The Peter Attia Drive - #36 - Eric Chehab, M.D.： Extending healthspan and preserving quality of life

00:00:00.000 Hey everyone, welcome to the Peter Atiyah Drive. I'm your host, Peter Atiyah.

00:00:10.140 The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking,

00:00:15.600 along with a few other obsessions along the way. I've spent the last several years working with

00:00:19.840 some of the most successful, top-performing individuals in the world, and this podcast

00:00:23.600 is my attempt to synthesize what I've learned along the way to help you live a higher quality,

00:00:28.360 more fulfilling life. If you enjoy this podcast, you can find more information on today's episode

00:00:33.000 and other topics at peteratiyahmd.com.

00:00:41.440 Hey everybody, welcome to this week's episode of The Drive. I'm your host, Peter Atiyah. My guest

00:00:46.600 this week is one of my best friends from medical school, a guy by the name of Eric Shehab. Eric is

00:00:51.920 an orthopedic surgeon specializing in sports, but overall knee and shoulder. He's an assistant

00:00:57.120 clinical professor at the University of Chicago. We met obviously at Stanford and he went on to do

00:01:01.740 his residency in orthopedic surgery at the Hospital for Special Surgery, or HSS as it's known, in New

00:01:08.220 York City. It's generally regarded as the best orthopedic facility in the country, if not the

00:01:13.080 world. He did his fellowship with the New York Giants before settling in Chicago. He was also mentored

00:01:18.520 at HSS by a guy named Russ Warren, who anybody listening to this who knows a lot about, or a little

00:01:23.360 bit of, you know, about orthopedic surgery will understand the significance of that. Russ is

00:01:26.560 generally considered the godfather of sports medicine. This interview was also really informative

00:01:31.640 for me because I, as you know, think about longevity through the standpoint of living longer, but living

00:01:36.280 better. And a big part of living better is not getting hurt. And what I love about talking to

00:01:41.120 orthopedic surgeons, especially people like Eric, who are just so cognizant of what the demise looks like

00:01:47.260 at the end of life, is I think by understanding where people fail later in life, you can understand

00:01:53.520 how to mitigate that earlier in life. So we get into a lot of detail around the common joint injuries.

00:01:59.460 So what's going on with knee pain, especially from incorrect form in a loaded fashion. We talk a lot

00:02:05.060 about shoulder injuries, especially with weights being used overhead, elbow, wrist injuries, ankles,

00:02:10.620 what's going on with the Achilles tendon. Obviously we talk about lower back stuff, which for many

00:02:14.520 people is also, you know, I think it's almost impossible to get through life without at least

00:02:18.480 one lower back flare up. We revisit sort of my injury, which I've talked about actually in the

00:02:23.440 past. We talk about all the complications that can come from it. And we talk a little bit about

00:02:27.980 how you can decide when PT makes more sense than surgery, which unfortunately for lower back injuries

00:02:33.320 is almost always the case. We get into some of the real controversy stuff like meniscus surgery,

00:02:38.460 which some of you may be aware of. We talk about the origins of pain. So a lot of times people

00:02:43.280 present with joint pain, but it's not really clear is the pain matching the thing you see

00:02:48.500 on the MRI. And again, I have an example of where that was not the case. We get into PRP,

00:02:53.720 stem cells, sham surgeries, and all sorts of things like that. The other thing that probably comes

00:02:58.660 across though, not as maybe as much as I would have liked is Eric is probably one of the funniest

00:03:03.200 human beings I know. He actually sang at my wedding. And I think we even discussed that story

00:03:08.280 early in this episode, although I didn't get him to sing. So that's probably one drawback.

00:03:12.520 Anyway, the show notes will be linked to a ton of awesome stuff that follows up and goes deeper

00:03:17.740 on some of these things. And obviously if you want to learn more about Eric, that's great. But the

00:03:22.860 reality of it is this is mostly just a way to kind of help people think about orthopedic surgery

00:03:26.400 and more than anything else, these types of injuries and what we can do to prevent them.

00:03:31.020 So I hope you enjoyed today's episode and here we go.

00:03:36.860 Hey man, what's going on?

00:03:38.360 Not much. Good to see you. It's been a long time.

00:03:40.160 I feel like it's been two years since I've seen you in person and we did get to spend an hour

00:03:43.940 finding a place to record this. So that, that like gave us a good chance to catch up.

00:03:49.860 Where are we sitting right now?

00:03:51.320 We are sitting in my Wilmette office for Illinois Bone and Joint in Wilmette.

00:03:55.520 We're like, we're actually in a patient exam room, I think.

00:03:57.340 We're in a patient exam room. Yep.

00:03:59.040 It's like the only room we could find that didn't have an AC unit blaring or something like that.

00:04:03.620 Well, Eric, there's so much stuff I want to talk about, you know, mostly about orthopedic stuff

00:04:07.160 because in the spirit of sort of trying to live longer, you've probably heard me talk about it.

00:04:11.640 There's no point living longer if you're not living better. And a big part of living better

00:04:14.520 is your exoskeleton. And for a lot of people that you probably see, and certainly I see it to a lesser

00:04:20.920 extent, you know, once that quality of life deteriorates, meaning once they don't have the

00:04:25.100 strength, mobility, or freedom from pain to kind of carry out the activities of daily living,

00:04:29.500 you know, for many people, they don't actually care that much if they're going to delay their heart

00:04:33.040 attack by four years or something like that, it stops mattering. So, I mean, let's go back to the

00:04:37.780 beginning. There's so many goofy things I want to talk about. Did you grow up in New Jersey? I don't

00:04:41.400 think I knew this. Yeah, I grew up in New Jersey. I was born in Omaha and moved to New Jersey when I

00:04:46.360 was three. And is Bruce Springsteen still probably one of your favorite singers? He's my favorite.

00:04:51.460 Yep. There is this, I think I put it up on social media a little while ago, but there's this

00:04:55.320 awesome video. It was from 2009 in Madison Square Garden where Bruce Springsteen was playing with

00:05:00.260 Tom Morello. And my son, when he watches the video, thinks I'm Tom Morello. He doesn't get that I'm

00:05:06.340 not. And it's like, no, no, no, actually, daddy looks like him or he looks like daddy, but that's

00:05:10.120 not me. And he's like, what do you mean? That is you. And he's like, why do you know how to play

00:05:14.920 the guitar, but you never play at home? There's this one song, which we'll have to link to,

00:05:18.940 The Ghost of Tom Jo that they played together. It's like an eight minute thing with Morello doing like

00:05:23.200 a three minute guitar solo at the end that is out of control. But there's something about

00:05:27.900 Bruce Springsteen's voice that like, he might kind of be the coolest guy ever.

00:05:32.100 No, he's definitely the coolest guy ever.

00:05:36.600 How many times have you seen him live?

00:05:38.480 Five, six times. First concert I went to was Bruce in 84 at Brendan Byrne in New Jersey.

00:05:44.660 And it was as he was kicking off the Born in the USA tour. It was summertime. There were about five or

00:05:49.560 six of us. We were in eighth or ninth grade and it was great. Fantastic. And then I saw him,

00:05:55.680 I lived in Milan for a year. I was teaching high school and he was playing in Verona on Easter

00:06:01.040 Sunday. And he was supposed to play in an amphitheater in Verona that Guns and Roses had

00:06:07.360 played in like a month earlier and basically nearly tore the place down. And one of these amphitheaters

00:06:12.660 that had been there for 2000 years and sure enough, one concert and no more concerts. So he played in

00:06:18.100 the soccer stadium in Verona on Easter Sunday for about five hours. And I remember I was on a bike

00:06:24.780 tour. I was taking my bike through Tuscany. I was by myself on a mountain bike and it was Easter

00:06:30.500 Sunday morning. I was in Florence and there was the Easter parade. And I had this one ticket to Bruce

00:06:35.760 and I'm like, how the fuck am I going to get to Verona? So I ditched my bike someplace. I get on a

00:06:42.260 train of Verona. It turns out there were a lot of Bruce fans on the way and there were translations

00:06:47.180 of Bruce's lyrics into Italian, which I always wonder how like working on the highway and, you know,

00:06:51.760 drinking warm beer in the soft summer rain translate into Italian. But anyway,

00:06:56.760 and I get there and this show goes on as usual for about five hours. And I get on a train at

00:07:02.940 three in the morning from Verona, head back to Florence, pick up my bike around nine o'clock in

00:07:07.620 the morning and then keep riding because it was so pumped up and jacked up from having seen this

00:07:11.640 fantastic Bruce concert and just kept riding for the rest of the day. So that was one of my favorite

00:07:16.460 Bruce concerts was that in Italy. I saw him in Oakland with my wife, with Lynn, when we were

00:07:21.920 dating in medical school. And that was sort of tempered by the fact that she wasn't much of a

00:07:26.740 Bruce fan. My good buddy, Mark Pomerantz was at that concert too. Yeah. Is that right? Yeah. We're

00:07:32.260 up in Oakland, up in the nosebleeds. And then I saw Bruce most recently with Lynn, who now is a fan

00:07:38.020 in Milwaukee on his river tour. And he gives such a great show. The river tour is fantastic. And so he plays

00:07:44.780 the album and then he goes on for another two or three hours with just great songs. And he's so

00:07:49.600 good live. I saw him at Wrigley right after Clarence Clemens had died. And they had that

00:07:53.620 tribute where they, at 10th Avenue Freeze Out, they just stopped the music on when the big man joined

00:07:59.380 the band and they have a large shadow silhouette of Clarence from the Born to Run album. And it's

00:08:04.680 really moving. I mean, he must've done that about 50 times from his death to that concert, but it's still

00:08:11.000 very genuine and very moving. And the whole place goes quiet and then it erupts in sort of cheer and

00:08:18.100 laughter and tears as it was really moving. And that was what I think, it must've been four years

00:08:23.100 ago when he played at Wrigley. And yet I'm sort of a JV Bruce fan compared to my roommates in college

00:08:28.520 who go, my one roommate Owen had probably been to about a hundred concerts. And he tells a great

00:08:34.180 story of punching. This is the Owen that I know?

00:08:35.820 It's the Owen you know, yeah. He tells a great story of punching someone out on the Bruckner Expressway

00:08:40.080 on his way to the Bruce concert. So I'll let him tell that story.

00:08:43.860 He's not a successful New York executive.

00:08:44.960 Yeah, no, it sounds like the guy had it coming. So I don't really have any problem with that.

00:08:49.200 Owen was a, like, wasn't he a Navy SEAL or?

00:08:51.520 He was a Marine and he's now, he's now an undersecretary of defense for General Mattis.

00:08:55.680 He's a special ops and very busy guy.

00:08:58.060 Do you notice over time as you go to these concerts, like, does the fans seem older to you? And so for me,

00:09:03.700 Pearl Jam is the band that I've seen more than any other band. And I just saw them recently in Fenway.

00:09:09.140 And I got to tell you, it was the first time in a long time I've been in a concert where I had as

00:09:13.600 much joy out of watching the other people there because they were older than me, some of them.

00:09:18.420 But you could tell. So when 10 came out, I was maybe 17 or 18. But you can tell there were people

00:09:25.200 who were 30 when 10 came out and probably still found it amazing. And so now they're, you know,

00:09:31.200 in their late 50s and you can see the emotion in them when Eddie Vedder gets up there and plays

00:09:35.980 something that from 91 or something like that. So it must be the same with Springsteen,

00:09:41.060 but even greater because it's a greater time period.

00:09:42.760 Yeah. No, that's another funny thing when you're at Wrigley and you see the fans to your left and

00:09:47.140 your right and they're pretty old. And then you'll see some of them holding their 10 year olds. And

00:09:52.160 that's the fun part of it is that there's this sort of intergenerational thing. You have these

00:09:55.960 younger kids growing up loving Bruce because their parents love Bruce. And so, but yeah,

00:10:00.300 no doubt the crowd is older. It's funny you mentioned Pearl Jam. They opened for U2 in Verona

00:10:07.660 in 92. I was still in Milan and I saw Pearl Jam open for U2 on the Zouropa tour.

00:10:15.240 So you saw Pearl Jam, U2, and Bruce Springsteen in one trip to Italy?

00:10:18.880 No, no. Well, I lived in Italy.

00:10:20.500 But who lived in this? Oh, we were there for a year.

00:10:21.840 I lived for a year, but same venue, same and fabulous venue. And the lead guitarist for Pearl Jam was

00:10:27.320 licking his picks out like he does. Yeah. Mike McCready. I've almost caught a Mike

00:10:30.840 McCready pick once in DC. I was in the third row. I was like, that was my one shot at catching the

00:10:35.220 pick and I didn't. He also had a disposable camera and he takes pictures of the crowd. So

00:10:39.840 it'd be great if he still had one, that would be kicking an old school, but

00:10:42.760 the disposable camera out in the crowd. It was great.

00:10:46.840 We could spend the next two hours talking about music because we both love it so much.

00:10:49.720 The last music story I do want to tell though is, do you remember what you did at my wedding?

00:10:54.220 I hate to tell you weren't the first.

00:10:55.680 I still feel special. You should. I mean, you're the first that I use the buck teeth for,

00:11:00.040 but pretty much everybody's wedding, I've got up and sang with a band or whomever. And for whatever

00:11:05.300 reason, they let me do it. And I don't have any talent. I don't have a voice that's worth listening

00:11:09.740 to, but I certainly think I'm great. And I have a lot of verve and energy. And so at your wedding,

00:11:16.060 I sang a bruise. Yeah. Fire. Yeah. Fire. And I had my teeth in. So I was lisping

00:11:20.460 pretty badly. The, those buck teeth that make, yeah, we're going to explain what these are in a

00:11:24.640 moment to the listener. Yeah. So anyway, I had those Dr. Buck teeth in and sang fire to you and

00:11:29.100 Jill. And I could tell there was kind of like, what the hell is going on here among the whole

00:11:34.400 wedding crowd? And, but Hey, we were all in and it was great. And you had to, I remember that

00:11:40.100 I remember that wedding also talking to Conti because he was driving from, was it then that

00:11:49.040 he was driving from? No, he had just driven from Jason Pyle's wedding in Los Angeles to Boston in

00:11:56.560 30 something hours. Right. So he was planning to do it without stopping. Right. But his wife or I

00:12:03.300 wasn't his wife yet. He'd taken provisional, which is that. I gave him 400 milligrams of provisional,

00:12:07.140 800 milligrams of ibuprofen. And he said he was going to be fine. And I was like, that's crazy.

00:12:11.600 And she finally made him stop in Cleveland. Yeah. Yeah. And this was 36 hours to get to

00:12:17.000 Cleveland before she made him stop for eight hours before they finished the drive to Boston.

00:12:20.780 I asked him, I was like, you must've suffered like 24 hours. No, eight hours got up, drove the rest of

00:12:24.900 the way. Yeah. When you sang fire at our wedding, it was one of the most amazing things because it was

00:12:30.880 kind of like camp of a blank note. It was a Dan Flaherty, you know, the Dan band. Yes. It was

00:12:34.960 that experience because like at one point you threw in a couple extra fucks, like it was fucking

00:12:39.500 fine. Yeah. Yeah. Yeah. I did actually. That was so good. That's the part I love. Yeah. I wish I had

00:12:45.080 done something more with it, to be honest with you, because obviously it's been a great career for

00:12:48.080 that guy. I actually got to meet him at a party two years ago. I see you sent me the selfie. Yeah.

00:12:53.540 Yeah. Yeah. I just glued myself to him the whole night. I was like, I can't freaking believe I'm

00:12:58.080 sitting here with this guy. It's incredible. So where'd you go to college? So I went to a little

00:13:02.880 school back East. Oh, whereabouts? That's East of the Mississippi. Okay. What city?

00:13:07.100 Oh, I can't go city so quickly. It was in Massachusetts. Eastern Mass. Oh, so near Boston.

00:13:13.200 Near Boston. There's a little school outside Boston.

00:13:15.680 Boston College or no, that's in the city? No, no, no. Harvard.

00:13:20.660 So you were the first guy I met that took that to another level in terms of the complete

00:13:26.860 buffoonery of the too cool to say Harvard. Yeah. No, it always struck me as odd when people

00:13:33.440 couldn't say that they went to Harvard. And I remember being in the backseat of a car with

00:13:38.020 Duncan and his brother Hunter. And this dude is there with me. And I'm like, oh, so hey,

00:13:43.240 we're in school. And he starts out with Massachusetts. And I'm like, oh my God,

00:13:46.960 you got to be kidding me. So I play along with it. I'm like, oh, we're in Massachusetts on the west

00:13:51.760 side of Massachusetts or the east side of Massachusetts. He's like east side. And so he's so happy. He's not

00:13:56.440 coming out with it. And then finally, we withered down to Boston and then Cambridge and then Harvard.

00:14:02.500 He finally lays it on me. I was like, oh yeah, dude, I went there too. But I've got to admit,

00:14:10.720 very lucky to go. And there's not a chance in hell I'd go to a place like Harvard or anything

00:14:15.300 like that these days as my 16-year-old is going through this. It is a different world for college

00:14:21.340 admissions. And all the breaks that I had to get there, the door was still much wider open.

00:14:26.440 Than it is for kids today. It's just a different world, more international kids and highly more

00:14:32.580 competitive. They're much less wed to schools that they've used to admit to. They're much more open

00:14:37.940 and for kids all over the place. And all the words I think is a great thing, but it's just not the

00:14:42.100 same. I mean, there's no chance in hell I'd be in a school like that little school back east if I

00:14:45.720 were applying today. Well, we used to joke about this so much that it stayed with me forever. So even

00:14:51.900 when I left med school and wound up anywhere I would go thereafter, now I became, I was always

00:14:56.120 looking for the person who went to the little school back east. And so finally, so fast forward

00:15:00.640 maybe 10 years after we're done with medical school, I've got this friend, his name is David

00:15:05.980 Bataro, incredibly talented artist, could be talented at everything basically. And he went to that little

00:15:11.080 school back east and he thought that was the funniest shit on the face of the earth. And I said,

00:15:15.040 David, I need you to design little school back east t-shirts. So I want the sort of the Harvard

00:15:20.680 shield, but I need you to find the exact font that it normally says Harvard, but you have to just say

00:15:27.180 little school back east. And of course, David, because only David could do this, he probably

00:15:30.720 spent the next, I don't know, three weeks designing the font to make the t-shirt that I sent you.

00:15:36.580 Yeah.

00:15:36.700 So he made 10 of them because I had 10 friends who had gone to Harvard or whatever, or at least who I

00:15:41.140 thought would appreciate the joke. There were some who I didn't want to piss off too much.

00:15:44.220 So do you still have your little school back east t-shirt?

00:15:46.260 Yeah, of course I do.

00:15:47.240 Wow, that's so great.

00:15:48.520 I should have worn it during a reunion just a couple of years ago. That would have been good.

00:15:52.860 So did you know when you went to college, you wanted to go into medicine?

00:15:59.680 I had a pretty good idea. My mom is a nurse. My father, who I'm not, I didn't grow up with my dad.

00:16:07.460 When my mom and dad divorced, he went back to Lebanon and I really didn't hear from him until I

00:16:11.200 was 16, 17 years old.

00:16:12.380 How old were you when they split?

00:16:13.480 Three. But he's a physician and my grandfather was a physician. And so I always grew up around

00:16:19.340 medicine with my mom being a nurse. And the doctors that she worked for were terrific people.

00:16:25.360 I had a bunch of injuries as a kid. So I saw Dr. Taylor. I remember like it was yesterday

00:16:30.180 in his office for some of the knee injuries I had as a kid. So I was exposed to medicine

00:16:34.780 probably more frequently than most people. And so I had a pretty good idea, but I took a little bit

00:16:39.620 of a circuitous route after college where I taught chemistry and physics in high school.

00:16:45.420 But I did it overseas. I spent a year in Milan. That's where I saw the great concerts and

00:16:50.660 started an American school there, which was a terrific experience. And then came back to the

00:16:55.640 States for a year to a private school in DC called St. Albans and all boys school there. It's very

00:16:59.680 prominent, great preparatory school. And then went back overseas to Bulgaria of all places and

00:17:04.960 taught an American school there.

00:17:06.140 So these three years that you're teaching kids in high school, did you still think you

00:17:10.760 were going to go and do medicine or were you, is this a part of deciding if you still wanted to do

00:17:14.220 that?

00:17:14.540 No, I was pretty sure I was going to go, but it's interesting. The teaching was fun,

00:17:18.780 but I felt like there was more that I could offer, I guess. And I was basically a high school

00:17:23.320 chemistry teacher and enjoyed the kids and loved working with the kids. But I just felt that medicine

00:17:28.760 would be a better fit because I'd still be able to teach and still be able to help people.

00:17:32.820 But it was a little bit more challenging, I guess. It was just more up my alley. And I think it was

00:17:36.780 sort of a calling to go and do it. But the teaching was a great experience. It was a great

00:17:41.420 way to see the world. It was a great way to learn how to become an adult from college to earning a

00:17:46.180 living, getting a paycheck, paying your bills, paying back your student loans, and then directing

00:17:51.660 your life in a way that, you know, geez, I really want to make some of this. And so then you go back to

00:17:55.460 school. So that time off between college and medical school for me was invaluable in terms of

00:18:02.260 maturation. And it's hard to imagine. I mean, knowing me in medical school, I don't think I

00:18:06.220 was the most mature dude on the block, but believe it or not, it was still maturation.

00:18:10.700 No, you know, Conte and I actually did a podcast a while ago, which I just actually just came out.

00:18:14.540 And we talked a little bit about this, that there was just a group of us that became very fast friends.

00:18:18.680 And I think we were viewed externally as sort of these testosterone knucklehead guys,

00:18:22.960 but we all had this thing in common, which was it all kind of taken a bit of a winding path to get

00:18:26.960 there. And I think on the surface, while it looks like we were just a bunch of, you know, idiots,

00:18:31.940 I think there was, there was probably more to it. Yeah. Do you remember the last time you and I

00:18:36.360 interviewed? I sure do. It was me interviewing for med school. Yep. I was your student interview.

00:18:42.600 Yeah. That was my first interview. So I was beginning like the circuit and doing all that,

00:18:47.020 but it was also my first time in California. So I'd never been to California until that interview.

00:18:52.260 And Stanford was the only school I applied to that was not in the Northeast. And I remember

00:18:58.060 leaving there and I think I went either Duke or Hopkins or Hopkins Duke and sort of worked my way.

00:19:02.340 But I remember thinking, you know, in part, because I met you and I really connected with you

00:19:06.380 and in part, because I remember it was February and it was 76 degrees out. And I,

00:19:11.780 having grown up in Toronto and going to school outside of Toronto, it didn't occur to me,

00:19:16.960 even though intellectually, I understood you could live in a place in the winter where it wasn't freezing

00:19:20.620 to see that. I was like, wait a minute, this is, this is a different place. But when you went to

00:19:26.240 med school, my recollection is you, we kind of thought you were going to wind up doing internal

00:19:29.720 medicine or ortho. There was a bit of a toss up there, right? Yeah, that's right. I was undecided

00:19:34.460 pretty much until the 11th hour between internal medicine and orthopedics. And the appeal to internal

00:19:40.500 medicine was the idea that you'd have these long-term relationship with patients.

00:19:43.500 My guess is most people who are struggling between ortho and something, that other something is not

00:19:47.660 internal medicine. No, it's generally surgical for sure. I don't know. Maybe I shouldn't be

00:19:51.520 admitting this among my orthopedic colleagues. Well, there's a joke. And I remember when I was

00:19:56.540 going through my rotations, you know, you had sort of the attending and the senior resident or the

00:20:01.380 fellow and the senior resident, junior resident, all the orthopedic team walks into the patient's room,

00:20:05.360 you know, post-op day one. And the nurse says, you know, I think so-and-so might've broken out into

00:20:10.000 AFib last night and says, you know, so I'm going to call the cardiology consult. And the attending says,

00:20:14.540 come on, we're doctors here. Like, you're not going to call a cardiologist to tell us our own

00:20:17.880 patients in AFib, give me a stethoscope. And he reaches in his pocket, doesn't have one. He looks

00:20:22.080 back at the fellow, the fellow doesn't have one. He looks back at the chief resident, doesn't have

00:20:25.900 one, all the way down. Even the med student for the ortho rotation, not carrying the stethoscope.

00:20:30.140 So then he's like, yeah, just call the cardiologist consult.

00:20:34.180 Well, there was a sign in the general outside of the weight room that said ortho library.

00:20:39.780 And there's a stereotype, right? I mean, all the jocks go into ortho.

00:20:48.400 Yeah, no, it's a definite stereotype, but it's sort of an unfounded stereotype. I mean,

00:20:51.980 obviously there's some of it that's true. I mean, most of the guys in orthopedics are

00:20:55.960 athletes or have been athletes at one point, but it's a pretty thoughtful, especially it's not

00:21:00.680 simply bone broke me fix and that's that. And I'm really glad I made the decision I did. I mean,

00:21:05.300 I really can't imagine not going to the operating room, not seeing patients, not seeing sort of the

00:21:10.720 fruits of my actual work. I think being in internal medicine is for some people, it's great. For me,

00:21:16.940 I think it would have been ultimately a poor fit. So I'm very happy with the decision I ended up making.

00:21:21.560 I remember you let me read your essay for residency and you talked a lot about Bill.

00:21:26.800 Yep.

00:21:27.000 Who was Bill?

00:21:28.440 So when my mom and dad split, we moved back, my essay moved back. My mother's from New Jersey. We

00:21:33.960 moved back to the town where she grew up and it's a beautiful town near the shore called Rumson,

00:21:38.740 very well-to-do place, similar on par with Greenwich, Connecticut, some other places that

00:21:42.880 people hear about. And when we moved back, we moved down to a smaller street and across the street was

00:21:50.240 a guy, Bill Hensler, who was living with his aging mother. And he was a longshoreman. He had worked

00:21:56.060 on the docks. He'd been a caretaker. He'd been married three times, had kids, but had been estranged

00:22:01.600 from his daughter for a while. But anyway, he was our neighbor. And he took a liking to my mom and

00:22:06.880 my family and sort of ended up being over time a father figure to me. And like I said, I didn't

00:22:12.540 really have any contact, really had no contact with my biological father for between ages three and

00:22:18.200 16. And Bill was that role. He was that father figure. So the real turn of the relationship

00:22:25.640 actually happened in, I think, 1978, close to there, where my older sister, Karina, we were all

00:22:31.600 out playing in the street. And Bill at that time was an alcoholic. He was a World War II veteran.

00:22:35.480 And I think he had PTSD. And like many of the World War II vets, basically suffered in silence to some

00:22:41.260 degree. And his family, they were brewers in Newark. There was Hensler beer that was brewed in Newark.

00:22:46.200 And Bill passed out. And I think my sister was like trapped under his leg in the middle of the street.

00:22:51.400 And I mean, it was just a whole scene. And my mom said, hey, enough. And she took him to a place

00:22:56.400 called Carrier Clinic in New Jersey. And he sobered up in 28 days. And that's the last time he had any

00:23:02.800 alcohol to drink. And he was sober since. He came to all my Pop Warner football games. He would drive up

00:23:08.560 to St. Paul's in New Hampshire. I went to boarding school and come to some of those games there. And

00:23:13.080 he got remarried in 87. And I was his best man. And that was-

00:23:17.780 You would have been what, 18?

00:23:18.840 I was 18 years old. Yeah. And it was the honor of a lifetime to be his best man.

00:23:23.200 And we were very, very close. And part of the reason why I chose to do my training in New York

00:23:28.240 and leave California was so that I could be closer to home and closer to Bill. Because by that time,

00:23:31.900 he was in his late 70s. His health was failing. He'd had a cabbage.

00:23:35.540 A cabbage, for the listener, is a bypass surgery of the heart, coronary artery bypass graft.

00:23:39.880 So he was aging. And I just wanted to be closer to home. And then he died my fourth year of

00:23:45.340 residency about five days before my youngest son, JJ, was born. And those last six months were

00:23:51.100 rough for him. But I was very happy to be there. He actually broke his hip, which is an end-of-life

00:23:56.620 injury for many, many people. And it was for him. So he broke his hip in March. And it was actually

00:24:03.560 right after we had come back from Key West, Florida, where his daughter Annie lives and works.

00:24:10.140 And his daughter and he had been estranged for a long, long time. But his wife, Jay,

00:24:16.700 who I had stood up for at the wedding, she had gotten Annie and Bill back in touch. And they were

00:24:21.660 close. And they had reestablished their relationship. And so I had a week off from residency. And Lynn and

00:24:29.700 I decided to go to Florida. And our plans had fallen through at the last minute to be in a place

00:24:34.520 near Palm Beach. And so we said, let's go to Key West and let's bring Bill down to Annie. And

00:24:39.660 so we did. And then he ended up staying, planning for a week. He ended up staying for about six weeks.

00:24:45.060 And then he came back to New Jersey. And then shortly thereafter, he broke his hip.

00:24:48.960 And I went down to see him immediately in the local hospital in New Jersey. And they had him so

00:24:53.720 medicated that he couldn't talk. He wasn't him. And I said, this is not going in the right direction.

00:24:59.220 So I brought him up to New York to special surgery. And Matthias Bostrom, who's one of the greatest

00:25:04.680 guys at special surgery, did his hip, did his hemiarthroplasty. And then the nursing staff

00:25:10.600 really took a liking to Bill. And everyone really, you know, he's a hard guy not to like.

00:25:16.000 So he ended up staying for about two weeks in the hospital after his hemiarthroplasty for no other

00:25:20.860 reason than people liked hanging out with him, which is unheard of, right? I mean, and then, you know,

00:25:24.960 when I was on call over the weekend, we used to take call basically from Friday to Monday and be

00:25:29.860 in overnight. And so we would go up onto the roof on a nice day. And this was now in April,

00:25:35.380 weather was turning nice. And we went up on the roof on the sunny days and I'd hang out. My pager

00:25:40.520 would go off. I'd bring him back downstairs. And then whenever he had a minute, we'd go back up to

00:25:44.660 the roof. We'd cruise around. And then he got out of rehab. He went to home. He was on his own,

00:25:50.160 but he just got scared. And then he, I forgot to mention this. He ended up having a liver cancer,

00:25:56.500 HCC. So he had a hepatocellular carcinoma. So he was becoming cachectic. He was losing weight and he

00:26:02.980 was just becoming scared. And so the summer was sort of miserable for him. He was on his own at this

00:26:07.440 point. Jay had died about a decade earlier. And, you know, he went into hospice and about two days

00:26:12.960 later, he died. But Bill was probably the most giving and nicest person you could meet. He was

00:26:20.320 always quick with a laugh. He was a ton of fun. You know, when he'd come up to St. Paul's, he'd make

00:26:26.160 fast friends with all these other people. And again, you know, they'd be like, are you his

00:26:29.640 grandfather? He's like, no, he's just my friend. But he was that father figure that I otherwise

00:26:34.140 probably wouldn't have had. And he made all the difference in the path that I was able to take.

00:26:37.860 And so, you know, I did write my essay about Bill, partly because I just wanted people to know

00:26:43.240 who he was. You know, if I'm applying to be a part of your medical school, I mean, I didn't want to

00:26:48.680 just list my resume. That seems sort of stupid. I just wanted to give an insight. So I would talk

00:26:53.680 about, I think on that time, Jay, if it was my application for residency, Jay had passed. It was

00:26:59.620 about two months after she died. And I was at home for the summer. It was between my second and third

00:27:03.840 year of medical school. So I was in New Jersey. And I wanted to take him on a, just wanted to get

00:27:08.660 him away. So we went up to New Hampshire, like we had done when I was in high school. And we drove,

00:27:15.420 and when we drove, he called it a sponge tour. When he was younger, he talked with his buddies.

00:27:20.740 They would go on a sponge tour where they go from house to house and place to place and sponge off

00:27:25.420 their friends or their friends' parents. And so we kind of did that. We stopped in a few places and

00:27:30.540 then we went back to Cancad. We were joking in the car, Concord, New Hampshire, but the way

00:27:34.560 the folks in Concord say Concord is Cancad. That was something I'll never forget. And then we went

00:27:39.800 to Winnipesaukee where Mike Love, who's one of his family friends and who was one of my first bosses,

00:27:44.440 I bussed tables at Mike's restaurant in New Jersey. And Mike moved up to New Hampshire and opened a

00:27:48.860 restaurant in Moultonboro on Lake Winnipesaukee. And then he opened another restaurant in one of the

00:27:54.560 other lake towns off of Winnipesaukee called Love's Key. And so Bill and I saw Mike,

00:27:59.880 Mike insisted we stay with him and we really were sponging from place to place.

00:28:04.300 And so by the time we got back to New Jersey, about 10 days, two weeks later, we'd gone on

00:28:08.680 this nice ride and just had a chance to kind of normalize his life again. And that was in the

00:28:13.780 late 90s. And so I think that's what my essay was about, was this sponge tour that I had with a guy

00:28:18.120 who had just had a big loss in his life in a way of sort of healing through time and healing through

00:28:23.720 laughter and healing through just normal daily activities.

00:28:28.380 That's what sort of struck me about it. I remember this because, you know, I remember

00:28:33.060 going through, because you were a year ahead of me and I'm sort of putting that stuff into my own

00:28:36.680 thought at the time, which was like, what do I want to write about? You don't get a lot of space

00:28:40.060 to tell your story when you're making these applications. And I remember thinking this isn't

00:28:44.380 what you'd expect from a guy applying to orthopedic surgery. And there was some stuff in there about

00:28:48.920 ortho, right? Which was like returning functionality to people and things like that. But I was, I was very

00:28:52.840 touched by this story of Bill and yeah, I had forgotten until you mentioned it again, but that

00:28:58.220 you were his best man at the, you know, at the ripe old age of 18. I love that story. And your oldest son

00:29:02.700 is named after him.

00:29:03.520 He is. So my Will, we call him Will, is named after Bill Hensler and he was tickled pink about that. He

00:29:10.980 would have loved to have met JJ. I mean, sort of a Hellraiser character like Bill was. And I think

00:29:16.420 about life as somewhat serendipity and it is serendipitous that we happen to move into a house

00:29:22.160 across the street from this man and that we took such a liking to one another. And it was really all by

00:29:27.960 chance. And I sometimes think, would it happen in a day and age like we have today where everyone's

00:29:33.440 so suspicious of people becoming close? Anyway, the bottom line is, it was a great stroke of

00:29:39.520 fortune to know Bill. And I did write about him an awful lot because he was probably one of the most

00:29:45.620 meaningful influences in my whole life. Are you close to your dad today? No, no. I've seen my dad

00:29:51.360 probably a total of about four weeks. And, you know, it's funny you mentioned that because he's

00:29:56.300 recently, we were here in the office right now doing this interview. And so he's been sort of

00:30:02.520 raising hell through the office because I get calls from the hospital pager. I think your dad is on the

00:30:07.760 line. And then I get calls from my secretary. I think your dad is on the line. And we don't talk

00:30:15.120 very much. And he lives in Spain. He was in Beirut for the majority of the civil war during the 70s and

00:30:23.180 80s. And he refuged from Beirut to Spain in the mid 80s. And in 86 is when I saw him again. And he

00:30:31.480 was in a small town in Antignante and now lives in Alicante, which is a beach resort town about five

00:30:36.080 hours south of Barcelona. And I think he also suffers from PTSD. I mean, he was living in a war

00:30:42.660 zone and he's an OB guy. And, you know, he tells a story of having a woman on the table who he's

00:30:48.780 doing cesarean on. And then someone comes in with a machine gun asking to save his brother's life. And,

00:30:54.160 you know, he became somewhat of a trauma surgeon as an obstetrician. And that's a big leap. And,

00:31:01.080 you know, I just think it got too much. And he misses being at home. He misses Lebanon,

00:31:05.300 I'm sure of it. But the fact is, he's sort of anxiety riddled guy. We never really had a

00:31:10.660 meaningful relationship. So he got in touch with me again when he was hounding the office. I called

00:31:15.980 him and we talked for an hour. But I think the bottom line is he's at a point in his life where

00:31:19.700 he's not going to change very much. I'm probably not going to change very much. And it's hard to

00:31:23.740 bridge the gap. I wonder sometimes whether I want to expose my kids to that type of relationship with

00:31:30.780 their father. So I go back and forth on that. And then I did make a point of seeing him. The last time

00:31:35.940 I saw him was when I was engaged to my wife, Lynn. And I told her, look, you got to meet the gene pool

00:31:41.920 before you commit to this whole thing. Because he's a little nuts. So that was the last time I

00:31:47.660 saw him physically face to face. My sister ran to my oldest sister went to see him. And it was a real

00:31:52.580 brutal visit. He's starting to lose it a little bit. And he's just not fully there. So it's tragic.

00:31:59.220 It is. It's very sad because I think... Well, he was at Hopkins. He trained at Hopkins. He was one

00:32:04.800 of the foreign medical grads. He had gone to the American University. I didn't know that.

00:32:08.180 Yeah. He was at Hopkins. He did his OB-GYN. Is that where he met your mom?

00:32:11.220 He met my mom in Roosevelt Hospital in New York, where he was training. I think he was doing some

00:32:16.120 of his residency there. Or somehow they met there. I'm not sure if it was during his residency or

00:32:21.020 afterwards. But they met in New York. My mom was working as a medical assistant slash nurse anesthetist

00:32:25.600 at that time. She worked as a medical assistant her entire career. But I think about him and in

00:32:30.640 his mid-20s, he's got his whole life ahead of him. Everything's very promising. He's a young

00:32:34.780 medical student. He's becoming a resident and becoming a doctor. He has his family. And then

00:32:39.740 fast forward 10 years, it's all falling apart. He's lost his family. He's back in Beirut. He's

00:32:45.000 with his four kids. His wife gone back in New Jersey. He's in Beirut. And then he basically gets

00:32:53.380 burned out in Beirut during the war. And since then, really hasn't done much. He's taking care

00:32:59.780 of a few people locally in Spain as an obstetrician for some of the community that are refuged there,

00:33:06.260 essentially. But not really doing much. It's a derailment of his life at a time when things were

00:33:13.500 really looking very promising. And when I see him and meet him, I can see how that can happen.

00:33:19.540 And then I just don't want that for myself sometimes. So maybe I'm just turning a blind

00:33:23.640 eye to it. Yeah. Again, probably a deeper discussion that we could have off mic. But

00:33:28.620 I have so many thoughts about this, right? But I think that on the one hand, I have found myself

00:33:33.700 more and more empathetic to the situations people are in that on the surface might look like, well,

00:33:40.780 that's a cut and dry case of he left his family and X, Y, and Z. But you start to realize that

00:33:46.140 there are other bits of baggage that people are carrying with them that, you know, you can make

00:33:51.360 a wrong decision in a moment. And that decision can, you know, two people can make the same sort

00:33:55.720 of wrong decision, but one comes with far greater consequences. You know, one of the other people

00:34:00.040 I had on this podcast was a guy named Corey McCarthy. And it was a really, really interesting

00:34:04.620 discussion about his life and how he wound up in prison. And it made me reflect even more on how

00:34:10.860 close I could have come to going to prison too. Like when I was in eighth grade, the kid I looked

00:34:15.220 up to the most in high school and he took me under his wing. I mean, he really liked me and he was the

00:34:19.760 toughest kid in the block and blah, blah, blah. And you know, by the time I'm in 10th grade, he's in

00:34:23.960 11th grade, he's in jail for armed robbery. And I've always thought like, what if I was out with him

00:34:28.240 that night that he decided to do this really dumb thing and hold up a liquor store? Like you don't have

00:34:34.380 enough of a prefrontal cortex at that age to sometimes go, wait a minute, this is a bad idea.

00:34:39.280 Like in the moment that can seem like this is a great rush. Like we're going to get some money.

00:34:44.380 Now that said, you've brought up Lynn a couple of times. So I got to get one story out of you.

00:34:48.780 There's probably, if I had like top 27 Shayab stories, this one's on the list. So do you remember

00:34:54.780 your first date with Lynn? Now Lynn was one of our classmates. So you knew Lynn, but you finally

00:35:00.420 figured out a way to get her out on a date. Yeah. Our first date was a real winner.

00:35:03.900 So I finally sort of mustered up the balls to ask Lynn out on a date. We were going to go out to

00:35:11.840 dinner someplace. It was over Thanksgiving break. And my buddy, Josh Edelman was at the ed school at

00:35:18.000 Stanford at the time. And he called me up. He's like, Hey, Sid, some of my friends call me Sid for

00:35:22.900 Sid, Sid Walski from an old Budweiser commercial. And he's like, Hey, Sid, I totally forgot that.

00:35:27.120 He's like, I heard your mom sent you one of those hands. It's halftime at the Menlo-Atherton game. I'm

00:35:31.540 wonder if I can come over and have some of it. Like, Hey, Josh, I'm sorry, man. I got a date with

00:35:35.580 this girl. I really dig her. I can take her out to dinner. He's like, dude, dude, come on. I'll be

00:35:39.800 over in like five minutes. I'm like, all right, all right. So I call up Lynn. I say, Hey, Lynn,

00:35:44.000 I'm sorry. I got to cancel dinner. I've got, I got Josh coming over here to eat my ham, but you know,

00:35:49.680 maybe we can meet at the goose. Jesus Christ. I know, I know. Like that again, I mean, like what is going

00:35:55.500 through your mind in that moment? I'm just thinking I want to give all my ham to Josh. And so anyway,

00:36:00.180 and so she goes, are you kidding me? I'm like, no. And then she goes, okay. And I'm like, well,

00:36:07.520 do you want to meet at the goose? She goes, we're not meeting at the goose. You can pick me up when

00:36:10.500 we go to the goose. I'm like, okay. And the goose was the dive bar. You've been there many times,

00:36:13.920 but for those who don't know, it's a dive bar outside of Stanford. It's still there. It's still

00:36:17.320 up and running. Is it still there? Yeah. Same choice. First place I ever ate when I came to Stanford.

00:36:23.600 Yeah. No, you'll never forget it either. It's probably still working its way through you.

00:36:26.960 Yeah. And so Josh did come over. He ate most of the ham and then I picked up Lynn and we went to

00:36:34.520 the goose and we were talking and chatting across the table. And I don't know if I should talk about

00:36:39.860 this part of it, but I had gas and I was just trying to sniff it one way and blow it the other

00:36:45.940 way and just trying to divert it from getting near her nose. But I don't know. She says to this day,

00:36:52.300 she knew exactly what I was doing. I thought it was very subtle. So after that, I drove her home and

00:36:57.800 my car at that time was, this was 96 and I had an 83 Honda Civic semi station wagon with, where you

00:37:05.740 could see the road through the floorboards. I had sheepskin on the seats because they had worn

00:37:10.180 completely through. There was no radio and there was no air conditioning. And this thing was a,

00:37:14.760 you know, I bought it for like $1,300 and there's a story about selling it too.

00:37:18.180 So anyway, I took Lynn back and we're sitting in the car on the sheepskin and I asked her,

00:37:25.480 Hey, can I give you a kiss? And she's like, once again, are you kidding me? I'm like,

00:37:31.140 I'm like, what do you mean? Am I kidding you? She's like, why, why do you have to ask? I was

00:37:34.980 like, I don't know. I thought. And so anyway, we, we kiss very awkwardly and she bolts out of the

00:37:40.960 car. Good night. And she leaves and I'm like, Oh Jesus Christ. I really fucked that one up.

00:37:45.480 And so I get in the car. Cause you're sort of three strikes at this point. Yeah,

00:37:48.260 no, I'm beyond that. The blowing off the dinner for the money coming to get the ham and three

00:37:52.900 strikes. It's an awkward kiss. Like 27 outs. It's like a no hitter. So I'm leaving and I'm

00:37:58.780 driving. I'm literally like, I don't know, fourth of the way home. I'm like, fuck,

00:38:02.920 shit up, you idiot. So I turned the car around and I, this is the story. This is the best line.

00:38:08.940 So guys, if you've listened to nothing else in this story, this is the money line. Yeah.

00:38:14.920 So I knock on the door and she looks, she opens the door. She looks at me. I'm like,

00:38:19.880 Hey Lynn, I'm so sorry. I got halfway to the safe way. And I'm like, fuck shabby with it.

00:38:24.560 And so I turned around and I decided I just got to tell you how I feel. And she goes, well,

00:38:29.720 how do you feel? I'm like, I think you're hot as shit.

00:38:32.180 And I said, and I don't, I said to myself, if I don't care if I have to sleep on the couch

00:38:42.860 or in your bedroom, but I'm not going home. And she goes, well, you can sleep on the couch.

00:38:49.080 So strike, strike 10. And then to balance with you, things just sort of happened from there.

00:38:54.160 So, I mean, I mean, I slept at home that night. We did kiss and it was much better kiss.

00:38:59.160 And then, you know, things just took off and lucky me.

00:39:02.600 But that's the line. I mean, I think we're in a new era now. I still think that you're

00:39:06.940 hot as shit is not going to get you a me too offense. I don't know.

00:39:10.540 No, it shouldn't. I can't imagine why it could. It might.

00:39:13.300 I think it's reasonable.

00:39:14.580 Yeah. No, it's objectifying.

00:39:15.640 And it's authentic.

00:39:16.060 It's objectifying. It is authentic and it's sincere, but it's objectifying and it's using

00:39:20.120 swear words and stuff. So there's certainly something that could be me too'd about it.

00:39:23.200 I just love it. So you've alluded to it already, but just for those who don't know what HSS is.

00:39:29.680 So the Hospital for Special Surgery in New York is the apex facility for training orthopedic surgeons.

00:39:36.220 I mean, even though I wasn't interested in orthopedic surgery, even I knew what HSS was

00:39:40.040 from the first year of medical school, because if you wanted to do orthopedic surgery, you wanted

00:39:44.720 to go to HSS. So you end up there. But I mean, just for someone listening to this, what the heck

00:39:49.920 made HSS so special?

00:39:51.500 They had some giants in the field of orthopedics. And so number one, it was an all orthopedic

00:39:57.560 hospital. It was all orthopedics. And so they were a think tank of orthopedics and they were-

00:40:03.700 I'll let the oxymoron there slide on the think tank of orthopedics. I'm just kidding.

00:40:07.620 Yeah. So, but the development of joint replacement, that was a big, they played a big role in that.

00:40:15.260 Some of the giants in the field of joint replacement, Chip Ranawat, Tom Skulko, Philip

00:40:19.700 Wilson were part of it. The spine surgeons, I mean, every field within or every subspecialty

00:40:26.680 within orthopedics, HSS had a player in that field. And again, it's just a really unique

00:40:33.920 environment where the reputation of the hospital is well-earned and well-deserved. Patients come

00:40:39.080 from all over the tri-state area to get their orthopedic work done at special surgery. The

00:40:44.480 hospital will work now. We have 20 operating rooms for all the subspecialties. There were

00:40:48.620 20 inpatient operating rooms alone, all for orthopedics. So just through that incredible

00:40:55.000 volume, you can't help but learn just through osmosis. And they were very dedicated to resident

00:41:00.440 education. I remember one conference that we were getting a little bit scolded because not

00:41:05.320 everyone was showing up to conference. Obviously, it's funny when people scold that people are

00:41:08.700 actually there for not showing up, right? But anyway, I remember one of the guys saying, look,

00:41:13.440 we don't have to do these teaching conferences every morning. We'd be just as happy to crank up

00:41:17.020 the R's at 7.30 instead of 8.30. But they did do that. They would have these conferences every day

00:41:22.260 from 7.30 to 8.30 about some topic of orthopedics. And by the end of four years, again, simply by

00:41:28.440 osmosis, you'd absorb so much knowledge. And then the operative experience was second to none because

00:41:33.540 the operating rooms were humming all day long and sometimes well into the night. It was not unheard

00:41:38.580 of to do 10 joint replacements and be doing your last one at 10 in the evening. And that was the

00:41:45.640 ethic of the place was you took care of people, you did. There was no sort of end to it. And they had

00:41:52.000 an endless demand and an endless volume. And they still do. And they still have the same giants in

00:41:58.080 the field. They've developed some really young talent and influencers in the field.

00:42:02.160 Who were your mentors when you were there?

00:42:04.100 Well, there were several mentors, but Russ Warren, I would consider a mentor. I'm probably the,

00:42:09.660 not his pride and joy. He's had several, he's trained half the NFL team physicians and

00:42:14.460 he's been, he's still as prolific as he ever has been. And he's got to be pushing into his mid seventies

00:42:20.380 now. And he was a Vietnam war surgeon. It seems like all those, and you probably met him at Hopkins,

00:42:24.900 but these old time Vietnam war surgeons were just incredibly gifted, ballsy. They were just great

00:42:32.300 surgeons and they really knew how to take care of people. And I think their training in wartime was a

00:42:37.920 big part of that. So Russ Warren, for sure.

00:42:40.680 What did he specialize in specifically with an ortho?

00:42:42.940 So he, he's one of the godfathers of sports medicine and one of the earlier developers of

00:42:47.560 ACL reconstruction. And he was a pioneer in arthroscopy and arthroscopic reconstruction.

00:42:52.600 And he's written more papers than any orthopod alive and probably more papers than all orthopods

00:42:57.780 combined. I mean, he's been, he's, he, he never stopped moving and working. If he wasn't seeing a

00:43:03.600 patient, he was reading a research paper. He was coming up with an idea. And I remember one night

00:43:08.560 his driver, he had, I worked with him as a fellow with the giants when he, and he's still their team

00:43:14.300 physician. And he had a driver, Ernie, who would take him every place. And we had a late West coast

00:43:20.320 game. We got back to Newark at three or four in the morning and Dr. Warren would spend the night

00:43:23.920 above his office and then start seeing patients at 8am. And Ernie, he asked me if I want to lift

00:43:29.040 back. I said, yeah, that'd be great. Thank you. Cause where I live was two blocks down from the

00:43:32.100 hospital. And Ernie dropped off Dr. Warren. And then I was in the car with Ernie. I said, Hey Ernie,

00:43:37.300 man, how does Dr. Warren do it? I mean, he's always working. And, and I'm like, how do you do

00:43:43.340 it? He said, well, Dr. Warren takes very good care of me, but he once told me all I got is time

00:43:48.660 and I'm not wasting it for anybody. And when I heard that, it put everything into perspective,

00:43:53.420 the way Dr. Warren worked, the fact that he never let a minute go wasted. He was constantly either

00:43:58.300 taking care of patients or thinking of research. I remember on a West coast trip, he met with some

00:44:03.220 engineers at Stanford for a type of bracing. He just was constantly thinking orthopedics and

00:44:09.140 advancing the field. So he's obviously a huge influence and anybody who's ever worked with

00:44:14.020 him will tell you he's the number one guy. And then Dr. Palicci, Paul Palicci, who's another joint,

00:44:19.820 he's a joint replacement surgeon on a sports medicine surgery. Surgeon was the most gifted

00:44:23.860 joint replacement surgeon I've ever seen. He could do a total hip replacement in 45 minutes to an hour.

00:44:29.180 What do you mean? Skin to skin? Yes. And he just put in a perfect total lip every time. And he was

00:44:34.120 the doctor's doctor. He did anybody in the area, anybody in the hospital needed a hip replacement

00:44:39.020 was getting it from Palicci. I mean, he was just a very, very gifted surgeon and everyone knew it.

00:44:43.080 He's also one of the funniest people you can possibly meet, a big Bruce fan as well,

00:44:47.460 and a Bon Jovi fan. And it turns out Jovi played it. He had an honorary dinner and Bon Jovi was his,

00:44:53.100 you know, was playing at this, at this dinner for, in his honor. But Palicci, terrific guy.

00:44:58.640 And Wickowitz, Tom Wickowitz, who was the director of our fellowship, again, super good guy. Scott

00:45:03.720 Rodeo, who's the head team physician for the Giants now, who's a phenomenal research clinician.

00:45:09.800 And they're hard to find. The clinician scientists are sort of a dying breed, but Dr. Rodeo certainly

00:45:14.020 embodies that. And he takes terrific care of people, including my mom. And I don't know, I can go down

00:45:19.020 the list. I mean, well, before we talk about leaving New York, you spent a year with the Giants.

00:45:22.660 You did your sports fellowship. What did you learn there? I mean, it strikes me as an interesting

00:45:27.300 crash course of sports medicine because you're really seeing the finest tuned machines under

00:45:31.800 the greatest destructive forces. Yeah, that's a great way of putting it. So with the fellowship

00:45:36.740 that Dr. Warren had, he, Dr. Warren's fellowship, he picked two guys and you would alternate a week

00:45:41.840 at training camp. And so once the Giants opened training camp, that was also coincided with the

00:45:46.400 beginning of our fellowship just by, just by chance. And I grew up a Giants fan, like a rabid Giants fan.

00:45:51.040 And Bill Hensler was a rabid Giants fan. LT, the greatest linebacker of all time?

00:45:55.000 Yes, without question. And one of the greatest people. I mean, so Bill and I used to go to Giants

00:45:59.540 games. That was our thing. And one of my first Giants games was with Bill in 1983 when Scott

00:46:05.620 Bruner was the quarterback. And any Giant fan will remember this. When the Giants scored in our end

00:46:10.580 zone and they went up by three points against the Redskins and it was pissing rain. It was 32 and a

00:46:16.080 half degrees. I mean, I've never, you can't really be much colder than that. And then the

00:46:20.300 Giants kicked off and they squib kicked it. And so the Redskins got great field position with 40

00:46:25.280 seconds left. They get in the field goal position and Mark Mosley kicks his record tying consecutive

00:46:30.400 field goal. Then the Giants lose the coin toss. The Redskins get the, get the ball. They drive

00:46:35.260 in a field goal range. And Mark Mosley- And this is pre, this is like first score is going to win.

00:46:38.400 It is 83. And Mark Mosley kicks his record breaking consecutive field goal. And we go all home so

00:46:45.500 disappointed. And I think that was a game that Phil Simms hurt his knee and went out. But anyway,

00:46:49.480 Bill and I would go to all these games and actually the night before Bill died, there was a Giants game

00:46:53.360 on and we had talked about it. And, and we, like we always did. We'd, we'd call, you know, when I was

00:46:58.060 in New York or California or wherever, we'd talk every Sunday, talk about the Giants game. And I

00:47:02.840 remember talking about that game with Bill and then, and he knew something was up because that

00:47:07.220 following morning, he, that's when he died. And we were crying on the phone. I love you. And you

00:47:12.560 know, after talking about the game and the game was again, just another vehicle. So anyway, I had,

00:47:16.820 and I, Bill had taken me to Giants training camp when we were driving up to St. Paul's, I think one

00:47:21.640 time. And I was going up early for my own football camp as a junior in high school. And we stopped in

00:47:25.980 Albany for the Giants training camp where they would have it. And we hung out there for the day and

00:47:31.260 watched practice. And I remember that training camp. And now I'm coming back about a year and a half

00:47:36.160 after Bill died to Giants training camp. And it was a bizarrely emotional time. I never spoke with

00:47:41.740 the trainers, Ronnie Barnes and, and, and Byron Hanson and Steve Connelly about this. I mean,

00:47:46.160 they're three of the greatest guys. They're, they're, they're unbelievable practitioners and

00:47:50.480 caretakers of these athletes. But it was a kind of an emotional moment where I'm in training camp,

00:47:54.880 having all these memories of Bill thinking, man, he would be, he would love to be.

00:47:59.520 Can you imagine the pride he, he would be so happy, but okay. All that aside, the first thing

00:48:06.260 you do realize is that these guys are freak athletes, like beyond anything you can imagine.

00:48:13.880 They're so physically gifted. It is beyond belief. I remember I had a poster in my bedroom when I was

00:48:20.340 a kid of Jerry Rice standing in the end zone and he's holding the ball up and at his feet is a player.

00:48:27.240 I think it was someone in the Bengals and he's like got his ankles, but he's completely like

00:48:32.260 laying out and obviously failed in his attempt to stop Jerry Rice. And I remember one of my best

00:48:36.980 friends in high school who was himself a fantastic athlete. We were like sitting in my room one day,

00:48:41.580 sort of shooting the shit. And he, he said one of the most astute things ever. He looks up at that

00:48:45.440 poster and points to the Bengal laying prone. And he's like, do you realize that guy's a better

00:48:51.060 athlete than we'll ever be? Like the dude at the feet of the guy you're worshiping.

00:48:56.680 Well, the guys in the league are freak athletes. The guys trying to get into the league are freak

00:49:04.200 athletes. The guys at the top of the league are freak athletes. And it is a razor thin margin that

00:49:10.980 separates the guy who's a superstar in the league and the guy who's not in the league. And again,

00:49:16.800 that is such a narrow margin of, you know, this athlete versus that. They are all tremendous athletes.

00:49:23.620 So that's the first thing you recognize is just how fast, strong, powerful, gifted, graceful

00:49:30.640 all of these guys are.

00:49:32.000 And longevity matters. You know, I mean, Ryan Flaherty, who's a friend of mine that I do need

00:49:35.900 to get on this podcast at some point. I've talked about him in the past, but, you know,

00:49:40.020 Ryan is really the guru of speed training. And he does two things, basically trains guys in college

00:49:44.460 who were, you know, the top sort of 10 recruits that are going to go to the combine and do really

00:49:48.540 well. And then also trains guys once they're in the NFL. And he said to me once, you know,

00:49:53.200 the focus changes so much after the combine to what you care about. So when you are in college

00:49:59.900 trying to get there, it's all about performance at the combine and performance to get in the league.

00:50:04.120 And that predominantly comes down to speed. And then he said, but once you get in the NFL,

00:50:07.700 once he's working with these guys that are there, it's longevity. It's just don't get injured.

00:50:11.620 And he changes. The strategy is completely dedicated towards maintaining how long they can stay healthy.

00:50:16.320 And that's a huge challenge. It is so violent on the sidelines. It's very,

00:50:21.060 very difficult to really get a sense of how violent it is unless you're right next to it.

00:50:24.560 But the hits are massive. I mean, when they talk about it being like a car wreck,

00:50:28.840 it really is like a car wreck. It's an incredibly high energy collisions that happen over and over

00:50:34.680 and over again. I mean, the closest I've ever sat in an NFL game is probably 20 rows back in the end

00:50:39.840 zone. So you're far enough away. Like it's still great to be able to, you know, I was watching Barry

00:50:44.940 Sanders play the 49ers. That was like the only time I've ever seen Barry Sanders in person,

00:50:48.660 but yeah, I can't imagine where you're sitting on the sidelines, just even acoustically what that's

00:50:53.180 like. Yeah. I mean, I remember there was an interception once and the giants had thrown the

00:50:57.380 interception and, and then Chris knee, who was an all pro guard and Tom Coughlin's son-in-law,

00:51:03.180 as it turns out, he was married to Coughlin's daughter comes over and just wrecks this guy.

00:51:08.760 I mean, and it was right at, right in front of me and he flattened this guy and this guy got up,

00:51:15.080 but it was the most acoustically impactful. It felt like a sonic boom when this guy

00:51:20.220 popped him, like just really took him out. That's the other thing I think people

00:51:23.540 don't appreciate. I only appreciate this because I've seen them train how fast those linemen can

00:51:29.520 run. Like you look at this guy and you think, ah, he's 320 pounds. He's got a little bit of a belly.

00:51:34.660 He's probably not that fast. And he's going to run a 40 in like five seconds flat, if not four,

00:51:40.860 nine. Right. And then I couldn't run today if my life depended on it.

00:51:44.420 So they would do gassers. Coughlin had them do gassers where they'd go 50 yards across the field,

00:51:48.440 50 yards back. And you'd have to do it in 18 seconds, 16 seconds, depending on your position.

00:51:53.340 So I was like, all right, let me give this a try. And I wasn't as good a shape then as I had been,

00:51:58.740 you know, five years earlier, I'd sort of fallen off the, you know, once the kids came,

00:52:02.700 the wheels kind of came off, but, but I was trying to do the gassers and the lineman time

00:52:07.140 and it was very challenging. And these guys can motor. They are exceptionally good athletes. They

00:52:13.460 are big, but they're also graceful and they're strong and they're all of that. They're coordinated,

00:52:18.040 you name it. But the freakishness of the athletes is certainly something that sticks out.

00:52:22.700 The stress that these guys are under, I don't think people appreciate it. I mean,

00:52:25.940 people think about professional athletes just sort of coasting, they're making millions and

00:52:29.580 everything else, but that's not, it's not anywhere near the truth. And particularly in football where

00:52:33.920 they're really few and far between guaranteed contracts. So these guys don't see their money

00:52:38.700 unless they stay healthy and play. And there's so few games. I mean, I remember reading an editorial

00:52:43.740 a while ago that talked about, imagine we just took hockey, basketball and baseball and made it a 16

00:52:49.420 game season. Like think of what that would do to the intensity of every game, every play,

00:52:56.400 every game. So that's exactly what it is. It is intense. It's, and if you're in the league and

00:53:02.220 you know that the F, you know, you're fighting with everybody on your team for a position, you're

00:53:07.160 fighting with everybody in the league for your position, you're fighting with everybody out of

00:53:11.060 league, trying to get into the league for a position. It's an incredibly stressful environment

00:53:14.960 for a young 20 something year old to be exposed to. I mean, these guys are under a tremendous amount

00:53:20.640 of stress to just perform, keep their job, not get hurt. And it's an intensely difficult

00:53:29.020 situation. So that's certainly something that stood out.

00:53:32.900 What were the most common injuries? Like I remember reading, and this is almost assuredly

00:53:37.100 dated and no longer correct, but directionally I'm sure it's correct. But the median tenure of a

00:53:43.160 player in the NFL was like, you know, three to four years.

00:53:45.640 Yeah.

00:53:45.820 We hear about Tom Brady. I mean, it's great to talk. I mean, frankly, most of the players we know

00:53:49.620 about, you know, the great quarterbacks, you know, they've been around for a decade and you

00:53:54.220 sort of take that for granted, but that's not the norm.

00:53:56.800 Not even close. I mean, it is positionally dependent. The running backs have the shortest

00:54:00.220 careers. Linebackers have shorter careers, but they really, really, again, because everyone's

00:54:05.960 trying to get in the league, everyone in the league is competing and there's attrition. I mean,

00:54:10.480 these guys leak oil and they leak oil relatively quickly because of the violence of the game.

00:54:14.720 And it was funny. I remember at the combine, the combine, you'd examine the 300 participants who

00:54:20.500 were in the combine.

00:54:21.300 And would you actually examine everyone or would the giant say, Hey, look, these are the guys we're

00:54:24.780 most interested in go examine them.

00:54:26.480 It wasn't that they would cherry pick the players. They, they got a grade on everybody. So

00:54:30.520 all the 300 participants, they got a medical grade, but what would happen is the teams get

00:54:34.960 in groups of four or five and the docs groups of four or five. So the players are going to seven or

00:54:40.200 eight medical exams.

00:54:41.640 Undergoing the same physical exam seven or eight times.

00:54:44.060 Exactly. And if they had an injury history, obviously that would be what would be of interest.

00:54:48.540 The docs would share the information among the teams. They were, they were, you know,

00:54:51.320 very much working as a group of physicians trying to evaluate the medical care that these players

00:54:57.200 had gotten in the past. But I remember, I mean, all these kids coming through had something

00:55:01.740 and, you know, wrist surgeries for scaphoids, stability surgeries for shoulder dislocations,

00:55:08.340 ACLs, meniscus surgery. I mean, it seemed like more often than not, these kids had already had a

00:55:14.520 prior medical history or prior surgical history. And I said to Ronnie Barnes, I said, God, Ronnie,

00:55:19.860 all these guys are somewhat injured and leaking oil yet. These are the best guys coming through.

00:55:23.980 And he said, he said, they're all injured because they're the best guys coming through and they play.

00:55:31.120 And it's, it made me realize, boy, it's a very tough sport to play at a very high level without

00:55:36.140 exposing yourself to injury and that everybody gets hurt at some point. And it's usually those

00:55:41.100 injuries that slow you down just a little bit. That again, is that margin, that razor thin margin

00:55:45.940 of being a star in the league and being out of the league.

00:55:48.020 Do either of your boys play football?

00:55:49.600 My youngest does actually. JJ does. He's playing freshman football.

00:55:52.460 Does that worry you at all? Not just with everything, you know, but also with all the

00:55:56.300 CTE stuff we've since learned about.

00:55:58.040 Sure. It worries me like crazy. And, you know, he started playing football as he's probably the

00:56:02.460 only Jewish kid in the history of the world to leverage his bar mitzvah into a football spot.

00:56:07.380 Okay. I got to hear that story.

00:56:08.640 So yeah, he, he, he's in seventh grade and he was preparing for his bar mitzvah and he was hating it.

00:56:13.940 And he basically struck up a deal. He's like, you guys, let me play tackle football. You won't hear a

00:56:18.560 word about the bar mitzvah preparation. I'll just, I'm going to say a word.

00:56:23.180 And we, we took him up on the deal and he was playing in a weighted football league. So

00:56:29.060 125 pounds was the max. And they, everyone's acutely aware of, of CTE concussions, head injuries,

00:56:35.680 the way the game is coached has changed drastically among the youth level. And then when you watch the

00:56:41.080 games, it seems relatively safe. I mean, it's sort of kids bumping hips. It certainly doesn't seem

00:56:45.280 any more violent than the lacrosse and hockey that kids are playing at that age. And we let him play.

00:56:50.280 He, then he played again as eighth grade year. Cause he's a little bigger. And so again,

00:56:54.920 it was still a sized limited league. So he's a little bit more advantaged then. And then sort

00:57:00.120 of reluctantly he's playing as a freshman and simply because he loves playing the game. And we look at

00:57:05.180 the mentors who are his coaches and we have such admiration for his coaches. And we look at his

00:57:09.660 teammates and he gets an awful lot out of it. And I remember hearing a Curtis Martin's hall of fame

00:57:14.760 acceptance speech. Oh, which I will link to it, but it is beautiful. It's an awesome speech. So you're

00:57:21.000 better off listening to it. I don't know if you want me to spoil the punchline. Yeah. I mean, go

00:57:24.260 ahead and paraphrase it for the folks who don't want to listen. So Curtis Martin talks basically off

00:57:29.200 the cuff about football and his closing line was, and he came from very poor disadvantaged environment

00:57:37.180 in Pittsburgh and football gave him an Avenue. And he talks about all the dangers of the game.

00:57:43.820 And he's not certain whether or not he'd let his son play football or not. But he's, he says to

00:57:49.340 himself, if football can do for your kid, what it did for me, there's no question that I'd let you

00:57:53.740 play. I mean, that's fundamentally the punchline that there's a lot of pros and cons. You have to

00:57:58.700 weigh the pros and cons for your own kid and decide whether or not it's worth it. And for us,

00:58:03.880 we felt it was worth it. And I shit my pants nearly every game. I'm always worried about him

00:58:08.540 playing. But then again, I see the joy he derives from playing it. And it's hard to hold that now as

00:58:13.600 time goes on and the game gets faster and the kids get bigger. And, and he may decide this is for me,

00:58:19.380 or this is not for me. You know, we'll see how he develops. And he's still just a freshman and still

00:58:23.740 an underdeveloped freshman, but it is something we let him do despite Lynn being a pediatrician,

00:58:29.460 me being an orthopedist, and both of us being fully aware of the risk of playing because

00:58:33.560 in the end, we felt the benefits outweighed the risks.

00:58:35.920 Yeah. I don't know. It's tough. I was actually, as I was on the way over here to meet you,

00:58:39.280 I was talking to my brother and my brother's really into mountain biking and he keeps trying

00:58:43.660 to get me to do it. And I'm like, yeah, I just don't want to do it. Like I just, you know, just,

00:58:47.340 Hey, I don't need a new thing to get into, but also it's like, just don't, the risk of injury,

00:58:52.220 like I don't, even silly injuries. Like I don't want to break my wrist or do something like that.

00:58:55.520 But look, he's obsessed with it. And we have a mutual friend who he's much closer to,

00:58:59.880 who's a motorcycle racer and used to do a lot of road riding. And whenever we would be on road

00:59:06.280 rides, this guy was the best descender. Like because he had been racing motorcycles all his

00:59:10.880 life, he could, he could basically rip hell going down a mountain when all of us would be a little

00:59:15.440 more tentative and on our breaks and stuff. And this guy's name is Jimmy. And now Jimmy's got my

00:59:19.300 brother into something I didn't even realize was an activity, which is downhill mountain biking.

00:59:23.880 So they go to ski slopes in the summer and you ride, you take your mountain bike up the ski

00:59:28.540 slope and you just come down. And I'm like, my brother's like, I know what you're going to say

00:59:32.440 before you say it. So don't say it. I thought it was crazy too, but it is the fricking best thing in

00:59:38.040 the world. And I was like, you couldn't pay me to do that, Paul. What are you thinking?

00:59:43.400 Riding a mountain bike down a ski slope? Like, I don't know. I think I'm just a pussy. I mean,

00:59:49.260 I think at the end of the day, I took a trip with my buddy, Jim Barker from Telluride to Moab on a

00:59:55.280 mountain bike over the uncomparably plateau. But we were such novice rookies. We, we, we even like,

01:00:00.240 Hey, let's go mountain biking. Yeah. What do you want to do? Let's go to Colorado and go down some

01:00:03.920 ski slopes and, and barrel down on our mountain bikes. That's what we thought we were going to do.

01:00:08.440 Go have, we think it'd be fun. It's like Alpine sliding on a bike.

01:00:11.940 So let's talk a little bit about some of the nuts and bolts of orthopedic surgery, because I can't

01:00:17.120 imagine there's somebody listening to this who hasn't either personally, directly or indirectly

01:00:23.380 been touched by an orthopedic injury. And I don't know the right way to go through it, but why don't

01:00:28.560 we just start with the knee since that seems to be a pretty common joint that gets injured. Talk to me

01:00:34.840 about it through the lens of an engineer. What is the knee really good at? What is it bad at? If you

01:00:40.040 could be God for a day, what would you change? So, oh, that's a good question. So the knee is

01:00:45.240 incredibly good at bearing weight and supporting your weight. And it's incredibly stable for what

01:00:51.540 it's being asked to do, but it's an incredibly complex design with more moving parts. Every

01:00:57.440 degree of freedom is in, is in play with rotation, translation. So if I were God for a day, I would

01:01:05.340 make the ligaments, actually, no, I would make the cartilage immortal because the cartilage wearing

01:01:11.300 down in the knee is fundamentally what will slow people down. I see. So you're not going to save

01:01:16.500 the ACL tear, but you're going to save the knee replacements for arthritis. Correct. And the

01:01:22.180 cartilage is what, when that wears down, that's when people have pain. People can live without an

01:01:27.100 ACL. I've lived without an ACL in my left knee since I was 12 years old. And I was able to play

01:01:31.540 sports. Not many, not everybody can do it. So at 12, you tore your ACL. Yes. And you, at the time,

01:01:37.160 you could have had a cadaveric replacement. So at 12 years old at that time, I was casted for-

01:01:43.460 Or patellar tendon. It was in the early 80s. So, I mean, when I was 12. And so ACL reconstruction

01:01:48.740 was in its nascent. I'm not even sure anything was really being done on any sort of widespread level.

01:01:52.740 And if it was, it was being done through open incisions. And there was a five-in-one procedure

01:01:56.940 where you'd sling bits of the IT band around the knee. And certainly not what modern techniques

01:02:01.800 would be of reconstruction. Sometimes repairs were being done at the time that were failing,

01:02:06.260 basically trying to sew the ligament back together. And so you can live without an ACL and you can

01:02:11.400 live a very productive active life without one, but you will be prone to instability. And the

01:02:15.960 instability can wear down the knee. The repetitive giving out episodes can start wearing through the

01:02:22.000 meniscus. And then once the meniscus starts going, the articular hard cartilage starts going.

01:02:27.000 And once the hard cartilage starts going, the knee pain, the knee swelling, the limitations-

01:02:32.600 So let's talk about, let's describe the joint because now I'm realizing it's hard to do this over

01:02:35.160 audio, but you've got this thing called the tibia and it has a plateau and that's where the cartilage

01:02:39.820 sits, right?

01:02:40.740 On top of the plateau. Yes.

01:02:42.260 And then the other end of the joint is the sort of bottom end or the distal end of the femur.

01:02:46.180 That's kind of roundish.

01:02:47.480 Yes.

01:02:47.800 And it actually kind of looks more like a knuckle, right? Like it's sort of, yeah.

01:02:50.760 And there are two condyles, two knuckles to it.

01:02:52.720 Yeah.

01:02:52.800 Yes.

01:02:53.060 So you've talked about the cartilage, but then where does the ACL, MCL,

01:02:57.720 and menisci fit into that for the person listening to this?

01:03:01.620 So again, like you said, it's hard to describe.

01:03:04.180 And we'll put cool pictures up so people can kind of look and see this.

01:03:06.880 Okay. So the MCL is on the inside zone of the knee and it's actually a ligament that we consider

01:03:11.340 extra-articular. It's outside the joint capsule. And the MCL is a very stout ligament that controls

01:03:17.440 the knee from swaying side to side. So if you can imagine your tibia swaying out towards your hip

01:03:24.660 or back towards your other foot, the MCL controls that. The LCL, which is the lateral collateral

01:03:29.740 ligament on the other side of the knee and the outside zone of the knee has the same function,

01:03:33.500 but just in the opposite direction. And then the cruciate ligaments are crossing ligaments that are

01:03:38.400 directly in the center of the knee. And the anterior cruciate ligament is crucial for rotational

01:03:42.380 control of the knee. And when people tear their ACL, it's usually a rotational

01:03:47.220 injury that does it. And it's almost a near dislocation of the knee that occurs.

01:03:52.420 And so usually the outer part of the femur will rotate backwards and even come all the way off the

01:03:59.240 tibia and then rotate back. And as it comes off and comes back, that's where the tearing of the ACL

01:04:04.920 occurs. Why do people tear the ACL more than the PCL? PCL usually gets torn from a direct blow injury

01:04:11.800 from falling onto the knee, but falling specifically on the tibial tubercle. And it's not easy to do

01:04:17.200 that. I mean, most of the time you're falling more on your patella, but if you fall directly

01:04:21.020 on your tibial tubercle, you will drive the tibia backwards posteriorly. And that's what puts

01:04:25.620 the PCL on stretch and it gives out. But people do very well with a full PCL tear as long as they

01:04:30.820 don't have any other ligament injury in the knee. And plenty of the professional athletes, including

01:04:34.260 a few on the Giants had complete PCL tears who were functioning at that high athletic level.

01:04:39.060 So it doesn't have the same rotational implications when patients tear their PCL. They typically,

01:04:44.040 if they're having complication from a PCL tear, it's from the increased contact pressures that

01:04:48.500 happen in the patella because the tibia is now sitting back and it's pulling the patella into

01:04:55.160 the femur as it sits back. And that pressure between the patella and the femur is what gives

01:04:59.480 people disability from a PCL tear. And then, so where do the menisci sit?

01:05:03.420 The menisci sit on top of the plateau. They're rounded and they basically contour the flattish plateau

01:05:09.740 into a more rounded femur. So it allows for the contact pressures within the knee to be

01:05:15.320 distributed evenly, more evenly. And they're critical tissue structures, as it turns out.

01:05:20.380 It wasn't long ago that we were removing menisci without really any thought consequence. There was

01:05:26.680 no foreseen consequence of taking out the meniscus or even parts of it. And it's become very clear that

01:05:31.840 losing the meniscus is sort of the beginning of the end for most people's knees once they start

01:05:36.180 having meniscal tears. And it's far more likely that at a younger age, their cartilage is going to

01:05:41.600 wear down their hard cartilage. And so when a person gets a knee replacement,

01:05:45.540 the tibial plateau has that built-in little curvature up at the edges to mimic what the

01:05:50.440 meniscus would be doing sitting on the actual tibial cartridge. Is that necessary?

01:05:56.020 With a replacement. So the meniscus is also a stabilizing structure within the knee. And again,

01:06:02.080 it takes the flat tibia and makes it more rounded so that the femur fits in it. And that gives

01:06:06.360 some natural anterior and posterior resistance to translation. And losing that meniscus puts the

01:06:12.600 articular cartilage under a lot more pressure and it tends to wear down more quickly. Now there are

01:06:16.840 several other factors besides the status of the meniscus that leads to loss of that articular

01:06:21.620 cartilage, that hard cartilage that coats the end of the bones. But when people end up losing that

01:06:26.300 coating of hard cartilage on the end of the bones in the joint, that's the cartilage that we

01:06:31.020 really care about because losing that will lead to swelling and pain and difficulty walking and

01:06:38.240 feelings of instability and all the things that slow people down as they're trying to live a long

01:06:42.980 life. And that's where their health span and their lifespan start separating. As you, you know,

01:06:48.400 you've taught me this whole concept about lifespan and health span, but that's where it starts

01:06:52.120 separating when that articular cartilage starts wearing down. I tell all my patients, everyone's going

01:06:57.640 to lose their hard cartilage. That's not an if, it's a matter of when. And we all want to lose ours

01:07:03.440 when we're 150 years old. And the things that influence that are genetics, exposure to injury,

01:07:10.640 trauma, but also things that are modifiable, your weight, your exercise, things that really tend to

01:07:16.720 help. And so when people have knee replacement, the plastic that's put in between is really, again,

01:07:22.200 for stability and to distribute some force and to hold the knee in place. And there are different

01:07:27.320 designs with...

01:07:28.000 Is it still ultra-high molecular weight polyethylene?

01:07:31.320 It is polyethylene that's used. In hips, there's more cross-linked polyethylene to resist wear.

01:07:37.040 The knee replacements tend to fail because of loosening of the prosthetic from the bone. And one of

01:07:43.900 the things that can lead to loosening is particulate wear causing inflammation leading to a cascade that

01:07:49.460 eventually results in failure of the knee. And unlike changing the tires on your car,

01:07:54.860 when you have a new knee, it's not the same as the old set. It's not as durable. It's typically not

01:08:00.700 as satisfying. It's not as flexible. And so people don't have the same sort of euphoric outcome with

01:08:06.480 their second knee replacement, for instance, than they do with their first.

01:08:09.740 What's the typical expected or median expected utility out of a knee replacement? Again, it depends

01:08:16.060 heavily, I'm sure, on the age of the patient and activity level. But as a general rule, do you...

01:08:20.080 We don't necessarily give a number because it does depend on the activity. The younger a patient is,

01:08:24.580 the more active they'll be and the more likely they will loosen at an earlier age. And so for the

01:08:28.860 people who need the knee replacements the longest, people in their 40s and 50s will have the shortest

01:08:33.060 lifespan of the knee.

01:08:33.360 And so for the 40 to 50-year-old, you'll tell them just to set expectations,

01:08:36.260 you're probably going to need two of these in your lifetime?

01:08:38.480 It's going to need a revision at some point in their lifetime. But it's a significant difference in

01:08:42.580 longevity for the 50-year-old getting a knee replacement than the 65-year-old. And so we

01:08:47.320 try and kick the can down as far as we can down the road so that if patients end up needing knee

01:08:53.040 replacement, that it's going to be... Their knee replacement will outlast them and that they'll

01:08:57.360 only have one operation on their knee.

01:08:59.820 So it's not unlike the way you think about a heart valve.

01:09:01.940 It's the same.

01:09:02.640 The age and we use tissue versus mechanical, different situation.

01:09:06.200 Let's go back to some of the modifiable factors you talked about. So weight, how clear... I mean,

01:09:10.740 it's intuitively obvious. How clear is the relationship? Is it linear? Is it nonlinear

01:09:14.820 between...

01:09:15.580 It may be geometric. I mean, because every pound of weight loss up top is four pounds of weight

01:09:21.340 loss through the knee, which is walking. And it becomes amplified.

01:09:23.980 Wait, why is that? That's just the mechanics of the knee.

01:09:26.980 So your center of gravity and how that applies torque into the knee is part of the reason why

01:09:32.880 that body weight is amplified. So it's not just pound for pound. So when patients gain a pound,

01:09:38.000 they're putting four more pounds of pressure through the knee, which is walking six pounds

01:09:41.620 more with going up and down the stairs, eight pounds more with running. So it's a significant

01:09:46.420 multiplier. And there's similar multipliers with the hip and the back. And so we... It's so

01:09:52.240 interesting that you bring this up. We've been trying to help patients with these modifiable

01:09:55.560 factors for their knee and particularly their weight. And we started a program in our practice

01:10:01.260 called OrthoHealth, which is based off a lot of the work you do. And I don't know if you've

01:10:04.940 ever seen the webinar I give, but you're sort of an all-star in the webinar. And so is Lynn.

01:10:09.240 But we're trying to help patients sleep better, trying to help them manage their stress better,

01:10:14.560 try and help them eat better, and try to help them exercise more efficiently. I think people

01:10:20.240 exercise way too much, trying to get it all in, burn all... They have a concept of burning all the

01:10:24.940 calories as opposed to sort of activating their metabolism. And so we're trying with this group of

01:10:30.080 patients who are typically overweight, BMI over 30, 35, 40. They're pretty ill patients. They're not

01:10:35.940 just their knee that's bothering them. And trying to get them to turn their lives around a little bit.

01:10:40.260 So from an activity standpoint, is all things equal running harder on the knee than any other

01:10:45.900 activity a patient does?

01:10:47.500 It is harder and puts more strain on it. But the body reacts to this. There's... I think it's called

01:10:52.620 Wolf's Law, where the body reacts to stress. So the more stress that's put on it, the more bone that's

01:10:57.580 laid down, for instance. That's why we emphasize weight-bearing exercise for patients in their 30s

01:11:02.100 in particular, before they start losing bone, so that they can build up their bone density. And

01:11:06.400 so the body reacts...

01:11:07.860 When do you lose the ability to increase bone density through that activity?

01:11:10.980 It's usually around 30. And women have an accelerated bone loss in menopause. So the bone

01:11:17.520 building is occurring through the first couple of decades of life. And then from then on, it's down.

01:11:23.440 But there's a big, big decrease during menopause in bone density for women. And that's where

01:11:30.200 pharmacotherapy is directed during menopause.

01:11:32.820 Yeah. So all of the hormone therapy and all the exercise basically isn't to bring you back to where

01:11:37.300 you were when you were 30. It's to slow the decline.

01:11:39.040 Slow it down. Slow it down. Because it's an inevitable decline.

01:11:43.460 What is driving that? Is it osteoclastic? Is it...

01:11:47.580 Well, it has to be to some degree, because the osteoclasts are what are the... They're the cells that

01:11:52.060 resort bone. But how well understood is the why? Like, what's the evolutionary reason that we would...

01:11:57.280 We're not short of any of the minerals that are in bone. We could certainly get them exogenously.

01:12:01.440 Why in the world would we just decide to enter a catabolic state at the age of 30?

01:12:05.880 I don't have a clue. And I don't know whether for women, it's childbearing and building the

01:12:10.540 skeleton of the fetus. Certainly, there's a transient osteopenia of pregnancy that occurs.

01:12:16.060 But I don't have the faintest clue. And that's a fantastic question that people are trying to answer.

01:12:21.280 And pharmacologically, we try and slow down the osteoclastic function. We try and slow down the

01:12:27.260 speed at which the osteoclastic...

01:12:29.120 All right. And I use that term technically. I shouldn't have... I should have defined it.

01:12:31.940 So osteoclastic is the breaking down of bone. Osteoblastic is the building up of bone.

01:12:36.080 And they're the cells that do that.

01:12:37.340 Yeah.

01:12:37.940 And so the osteoclasts get inhibited by some of the pharmacotherapies,

01:12:42.400 the Fosamax, Bonivas, the bisphosphonates, that slow down and, quote unquote, build bone density.

01:12:48.480 But it's not necessarily building great bone. And so it's building denser bone, but there's

01:12:54.900 concerns that there may be fault lines in the bone, that it may not necessarily be more

01:12:58.920 torsionally resistant. It's not more tension resistant. So you see tension-sided failure of

01:13:03.820 bone with prolonged use of bisphosphonates. And so those are some of the atypical femur fractures

01:13:08.160 that you see. People get foot fractures with this. So it's not going to be the answer just

01:13:12.500 inhibiting osteoclasts to build healthier bone or to slow down the process of bone resorption.

01:13:17.660 And is there anything that's in the pipeline pharmacologically with respect to activating

01:13:22.480 osteoblasts?

01:13:23.820 Great question. Most of it is focused on osteoclastic inhibition. And there are thoughts

01:13:30.020 about bumping up osteoblastic production with magnetic fields. And that's what's the technology

01:13:35.780 behind bone stimulators for when patients have hard to heal fractures. You can use a bone stimulator,

01:13:40.520 which is an electromagnetic field that seems to be stimulating to the osteoblast. But there's always

01:13:45.780 concern that when you stimulate the osteoblasts that you may be provoking a cancer type situation.

01:13:51.500 Right. Because you don't necessarily know where you're directing them.

01:13:53.840 Right. And so we don't use these bone stimulators in patients with cancer. We purposely avoid that

01:14:00.820 to avoid stimulating out-of-control growth.

01:14:04.600 So if you're listening to this and you're not an athlete, so meaning you're like most of us,

01:14:08.100 your sport is life at this point. You exercise mainly to help you perform through life better as

01:14:15.160 opposed to play in the NFL. It's relatively easy to avoid the twisting injuries, but it's these

01:14:21.000 repetitive strain injuries. You know, the person who's riding the bike that doesn't have their

01:14:25.120 pedals and their cleats fully attuned correctly, or they're running, but they're doing it so

01:14:28.980 inefficiently. Or God, I see people that ride, you know, spend hours on ellipticals and their hips

01:14:33.660 are jacked because they're just in a lousy position. Is that the case or is that just my bias that I see

01:14:39.120 towards it? I mean, are you still seeing people our age that show up? Like, is it just as common to see

01:14:43.480 the guy who's playing pickup basketball and still tears his ACL through a torsional injury?

01:14:47.960 No, I share your bias. I do think people exercise incorrectly. And I think part of it is because

01:14:53.480 there seems to be such an emphasis on volume of exercise and the volume of exercise and intensity

01:14:59.400 or not intensity, but getting in your volume of exercise within an hour because of your sedentary

01:15:06.340 lifestyle for the other 23. I think that is what leads people to injury. They do too much repetition,

01:15:13.820 with poor form, like you're saying, exposing themselves to injury. So there's no question

01:15:18.240 that repetitive bad form will lead to injury. And especially under load. Correct. And then if you

01:15:24.120 have a torsional, if you just happen to be playing hoops and you happen to put your foot down on a

01:15:28.160 wet piece of turf or on someone's ankle and your knee twists, I mean, those are sort of freak accidents

01:15:32.540 that can occur at any point. And if you want to keep it as safe as possible and as healthful as

01:15:38.620 possible, then you should walk. I mean, walking will give you the cardiovascular benefits that most

01:15:43.120 exercises, most any other exercise will. And I think the Harvard School of Public Health has

01:15:47.260 done an awful lot of work at looking at walking and cardiovascular risk and near, you know, 30 to

01:15:52.340 40% risk reduction with walking. Yeah. I mean, you won't find many people that are more critical of

01:15:57.440 the Harvard School of Public Health, despite the fact that it is associated with a little school back

01:16:01.100 east. Yeah. I don't know the answer. My intuition is that those studies are so biased by the people who

01:16:06.340 have the luxury of being able to walk. Like, in other words, there may be too many healthy user

01:16:10.680 biases within those studies. I think, unfortunately, to get to do long-term clinical trials with

01:16:17.900 randomization here is going to pose a huge problem. It's not going to happen. So we are stuck with,

01:16:23.920 I think, some combination of short-term clinical studies that can show us measurable changes in short

01:16:29.400 terms, coupled with, I think, trying to do better epidemiology, which is, you know, that's sort of like

01:16:35.640 trying to make toilet water taste a little bit better. But yeah, I think I struggled with this.

01:16:41.600 I mean, yeah, my view is, and again, it's so unlike me to say this because it's so sort of hand-wavy

01:16:47.180 bullshitty, but I really do think that there is the less time you are sitting around, the better.

01:16:54.740 And I think in part, it's not just the benefit you get from walking around. It's the damage that's

01:17:01.000 done by shortening the hamstrings, by tightening the psoas and the hip flexors. Like, that stuff

01:17:06.180 starts to translate into these other things that set you up for orthopedic failure when you actually

01:17:11.580 are doing your one hour of activity or whatever it is.

01:17:14.860 Very well put. So when you have, again, a primarily sedentary life, but you're trying to make up for that

01:17:20.500 with one hour of exercise or two hours of exercises, I think that's the setup that leads people to injury.

01:17:26.220 Yet, people have jobs and families to provide for, and they are sitting around. And so then how can you

01:17:32.800 get them moving more consistently through the day? I do think that that sort of consistent movement

01:17:37.200 is what leads to better orthopedic musculoskeletal health. And it's not necessarily having to do an

01:17:44.220 hour of exercise a day. I think it's more generalized movement for the majority of hours of the day.

01:17:49.200 So I couldn't agree with you more. And I don't want to get into a thing with you of all people about

01:17:53.740 any sort of epidemiologic study. But I don't see a lot of patients coming to me who've injured

01:17:58.640 themselves walking. And I do see a lot- Oh, yeah. No, that I fully agree with. I think my question

01:18:03.540 is, I guess I'm not at a point yet where I know enough, even though this is a very high priority

01:18:07.880 for me to understand this, can walking be sufficient from a cardiovascular standpoint? In other words,

01:18:14.360 if you told somebody, all you got to do is lift weights and walk, but you can skip any of the high

01:18:18.140 intensity training. You can skip doing your Tabatas and med ball slams or Peloton stuff. There's like

01:18:24.680 a type of exercise that's still in the middle of those. I'm still trying to, I think, come to grips

01:18:29.360 with what the relative physiologic benefits are. Because the way I think about exercise, and like

01:18:34.380 all things, there's a Venn diagram, but there are certain exercises that we are doing where the

01:18:39.000 emphasis is on the exoskeleton. So maintaining muscle mass, maintaining functional movement,

01:18:43.780 maintaining bone density, and doing so free of pain. And then there are some aspects of exercise,

01:18:48.720 as you alluded to, where really what we're doing is talking about physiologic benefits.

01:18:53.120 We're talking about what it's doing to the microvasculature, what it's potentially doing

01:18:56.560 to the mitochondria, what it's doing with other hormones, for example, BDNF and the role that that

01:19:02.280 plays in the brain. I mean, I think you can make a pretty compelling case that there is no intervention

01:19:06.980 that has shown a larger impact in mitigating cognitive decline than exercise. And all avenues seem to

01:19:13.220 flow through BDNF and increased microvascular composure. So those are kind of like what I put

01:19:18.920 in this sort of exercise to reduce the risk of disease versus exercise to increase health span.

01:19:23.740 And then of course, the sweet spot is when they overlap. But then the question is, where do they

01:19:28.000 not? This is actually probably the thing I think about the most in my free time, is that particular

01:19:33.020 question. Yeah. So I try and ask the octogenarians that I see in my practice who look like they're in

01:19:37.200 pretty good health, who get around pretty well. And what's the secret? I ask as many of the older

01:19:42.480 people as I can, what's the secret? How'd you do it? I can totally see you doing this.

01:19:46.940 And, you know, commonly they're not saying, some people say, yeah, I've been working out every

01:19:53.000 single day of my life. Some people say I make all my meals. Some people say I just go for a walk.

01:19:59.900 And there's probably such a, you know, everybody probably has their fingerprint or their metabolic

01:20:04.600 footprint that for some people walking is sufficient. For some people it's high intensity

01:20:10.960 intervals that would be sufficient to extend their life. Yeah. And it's probably a function of what's

01:20:13.300 their sleep like? What's their, what's their nutrition like?

01:20:15.680 And so it becomes such a, you know, huge variable equation that you're trying to solve that I'm not

01:20:22.060 sure it's ever going to be solved. I hope it can be, but I do give the advice to patients because I

01:20:27.260 see a lot of injuries from people trying to overdo it. That, I mean, it really is important to start in

01:20:32.220 increments when you're just starting. It's very difficult to go from zero to 60 without exposing

01:20:36.760 yourself to injury unless you are 20 years old. Yeah. And that's an important point. I want to

01:20:41.000 come back to the joint stuff, but I, my patients will, they're pretty tired of hearing me say this,

01:20:45.720 but I always say sort of rule number one of exercises, you can't get injured.

01:20:49.240 Right. Because if you get injured, then, you know,

01:20:51.160 you're defeating the whole purpose. We've taken 10 steps backwards.

01:20:53.680 I don't want to put you on the spot because this is a question that I should have asked you earlier to

01:20:56.380 let you think about it, but top five exercise bad moves that end up coming into your clinic

01:21:02.580 for adults. Let's, let's take the, let's not talk about the high school and college kids who are

01:21:06.160 doing crazy sports, but. So probably the most common thing I see is knee pain and knee swelling

01:21:11.660 from excessive squats and lunges. And I understand the core benefits and the quad benefits of doing

01:21:17.260 squats and lunges, but like I said, it puts a lot of strain on the knee and some knees just aren't

01:21:22.100 ready to absorb that strain or don't have enough cartilage to absorb that strain, or most commonly

01:21:27.020 don't have enough muscle to absorb that strain. And so they come in with an overloaded joint that's

01:21:31.680 swollen, injured, and that articular cartilage has been put under too much pressure and it might be

01:21:36.080 failing. And do you get the sense that they're too anterior when they do these things, especially

01:21:40.320 on the lunges? I mean, the technique for a lunge is actually so counterintuitive because really a

01:21:46.740 lunge, the front knee should be under no load. The front leg should be all glute based loading.

01:21:53.420 And my guess is if you're, if you don't know that and you don't have a trainer who can put you in

01:21:57.820 the correct position, you end up being too far forward. You're going to load that

01:22:01.600 knee. Is that what you think is happening? Without a doubt. So, and they come in with

01:22:06.020 an overloaded knee, anterior knee pain from not using their glutes, from overly relying on their

01:22:12.480 quadriceps. And I mean, look, most of the trainers in our area are kids who like to lift weights and

01:22:19.380 they have their clients. And so I, I mean, it's really important, like you're alluding to,

01:22:26.120 to have a trainer who knows what they're doing because it makes all the difference in the world.

01:22:30.000 But I see a lot of patients for having trouble with their knees from repetitive squats and lunges

01:22:36.240 that are again, probably done with poor form, which is what we were talking about earlier about

01:22:39.480 repetitive injuries being a result of poor form. And then I see patients with shoulder injuries using

01:22:45.340 weights and again, being in significantly disadvantaged positions. And you know, when you're using weights,

01:22:51.500 you're, you're trying to, the ultimate weight training would be to activate the muscle without

01:22:56.240 loading the joint. And you can do that. You can activate the muscle and not load the joint when

01:23:01.960 you use very light weights, but enough weight that the muscle gets challenged to just even the most minor

01:23:08.780 degree, because once it's challenged, you can then over flex that muscle. You can voluntarily flex the

01:23:14.640 muscle beyond. So you need just enough weight to initiate the muscle activation and contraction.

01:23:20.820 And that's usually not very much at all. And then the joints not being loaded, the muscles being

01:23:26.720 activated, and you're getting a much safer workout. Do most shoulder injuries occur from loading the

01:23:33.240 shoulder above the plane of the neck? In other words, an overhead type resistance? I think so. I

01:23:38.880 mean, I can't say for certain, I'm not sure anyone can, but it seems that most people, when they come in

01:23:43.520 with shoulder pain, will have commented that the biggest problem has been that they're having trouble

01:23:47.360 with overhead. You know, they were doing an overhead press and it's usually a press over a pull. It

01:23:51.420 seems like the bench pressing, the military pressing, the inclines are causing a little bit

01:23:55.540 more trouble than for instance, the pull downs and the bench rows. So I think the, again, the joint load

01:24:00.440 is much higher when you're doing a press compared to a pull. So when patients are recovering from

01:24:05.400 shoulder injuries or have sustained shoulder injury, I, my sort of generic advice, sort of take home

01:24:10.400 advice is, you know, try and emphasize more of the pulls and the presses as you're recovering.

01:24:14.520 So what are the most common injuries you're seeing for elbows, wrists, hips, ankles, that

01:24:19.780 kind of stuff? So elbows and wrists are typically tendinopathies, again, tendon overload, tendon

01:24:24.500 inflammatory injuries. And I'm not sure whether they happen because of inflammatory changes or

01:24:29.600 just biologic and age related changes, blood flow related changes. So around the elbow in the

01:24:34.280 forties and fifties, I see, you know, endless, it seems like epicondylitis, which is tendonitis

01:24:39.360 around the, the forearm muscles that flex your wrist and straighten your hand or bend your wrist

01:24:44.260 and curl your hand. And those tendinopathies, whether they occur in the wrist, the shoulder,

01:24:50.740 the elbow, the knee, the ankle, I'm absolutely certain have the same biologic mechanism. And I do

01:24:57.360 think the blood flow to these tendons as they decline between the fourth and fifth decade of life,

01:25:03.620 that loss of blood flow, that loss of reparative mechanism is what leads to this sort of, again,

01:25:10.340 uniform biologic problem in these very joints. So I don't consider elbow lateral epicondylitis or

01:25:19.080 tennis elbow, golfer's elbow, that much different from shoulder tendonitis or impingement or that much

01:25:23.500 different from patella tendonitis or Achilles tendonitis. From a biologic standpoint, I'm pretty

01:25:28.480 certain they're exactly the same thing. And I think, again, the common pathway is probably loss of

01:25:33.800 microvasculature to the tendons. What about ankles?

01:25:37.400 Well, ankles. So ankles, again, it's usually the Achilles tendon. That's the key. To the foot,

01:25:42.980 it's the Achilles tendon. That's the key. With the foot, the most common sort of acquired problem is

01:25:49.060 posterior tibialis tendon deficiency, where there's attenuation and stretch of the posterior tibialis

01:25:53.640 tendon. And that's the tendon that supports the arch. And over time, that just starts getting

01:25:58.940 stretched out. As you can imagine, it's a mechanical issue. And unless it can keep itself in prime shape,

01:26:04.020 it's going to stretch out over time just due to the forces that it's under. And when it does,

01:26:08.020 the foot starts changing shape. The foot starts changing how it loads. And pain is the most

01:26:13.100 frequent presenting problem with a posterior tibialis tendon deficiency. And you can help

01:26:18.200 support that with orthotics. There are some very complex foot reconstructions that can be done to help

01:26:23.340 reconstruct the foot in such a way that the posterior tibialis tendon isn't playing as much of a role.

01:26:27.280 Those are difficult reconstructions to undergo. You're non-weight-bearing for six weeks strictly,

01:26:33.560 and then gradually weight-bearing. You're taking a big chunk out of your life. And you're definitely

01:26:38.800 knocking yourself down to build yourself back up again. And whenever you do that, there's always

01:26:43.820 a risk that you knock yourself down and you don't bounce. That's the problem with a lot of the surgeries

01:26:48.880 that we do is that we do set people back. And not every single person is going to bounce back

01:26:54.120 better than what they started. And that's sort of the challenge and the difficulty.

01:26:57.280 And what about the hip?

01:26:58.540 It's a simpler joint in the sense that it's a ball and socket. So it tends to just

01:27:02.240 wear down, not to oversimplify it. Now, there are some muscles around the hip that act like

01:27:06.680 that we're much more familiar with because of the accessibility of it, like the rotator cuff.

01:27:10.800 So a lot of the abductor muscles around the hip can act like a rotator cuff does in the shoulder.

01:27:15.400 But because of the, again, the weight-bearing nature of the hip, the congruency of the hip,

01:27:19.820 it tends to just wear down. And that labral cartilage, which is the soft cartilage of the

01:27:24.580 hip, can get frayed. But it's the articular cartilage that really makes a difference.

01:27:29.320 Now, there are some conditions around the hip that we can change the natural history to. It seems that

01:27:33.260 we can, where we can reshape the hip a bit so it's not banging into itself as much. That's called

01:27:39.080 femoroacetabular impingement. And that seems to be a place where we can make a difference in terms of

01:27:44.400 long-term outcomes of those patients by reshaping the hip to some degree. And labral tears, I think

01:27:51.380 the jury's out a bit. It strikes me as one of those things that's sort of a little bit like

01:27:54.780 lumbar disc herniation, where someone can have hip pain, you do an MRI, they've got a labral tear,

01:28:00.160 you're no further ahead than you were before. You don't know if that's the cause, right?

01:28:03.220 You're exactly right. So you and I can go on an MRI scan, and both of our hips are incredibly likely,

01:28:08.460 90% likely to have labral tearing on MR. And you put a 20-year-old in there, and it's not 90%,

01:28:14.100 but it's about 80%. So the odds are it's very high. So you're going to see some sort of labral

01:28:19.760 abnormality on an MRI on nearly everybody you put in. So then you're basically right where you started

01:28:24.040 from. You don't know much more than what you did. So a lot of people will be given the test of time.

01:28:29.120 They'll be put into physical therapy. They'll see if this remains an issue. And for those people who

01:28:34.000 fall out, then some type of correction can be helpful. But again, our experience with the meniscus

01:28:39.780 is kind of a good example of that, where having a meniscus injury on MRI is essentially, in a 40

01:28:46.980 or 50-year-old, isn't very meaningful. It's much more meaningful that if you suspect there's a

01:28:51.720 meniscus, that the patient hasn't been able to sort of write it on their own. They haven't been able to

01:28:56.700 use physical therapy or time to their advantage to get their knee right. And then those people will

01:29:01.600 typically benefit a lot from a procedure. Let's talk about this in a little bit more detail. So this is

01:29:05.680 still a kind of controversial area, or is the controversy within the, you know, esteemed

01:29:12.000 orthopedic surgery community no longer a controversy, but it's taking a while to trickle down to the rest

01:29:16.120 of us? So no, I mean, it's a funny topic. So Gina Colato wrote that article about how surgeons are

01:29:21.820 addicted to useless surgery. I don't know if you saw it. Oh, I saw it. I mean, I'm going to reserve my

01:29:26.660 comments on Gina Colato at this point in time. No, that's fine. But she's a little off base on this

01:29:31.320 one in particular. It's not the only thing she's off base on. Right, right, right, right. So there

01:29:36.000 was a paper that my buddy did. He's at WashU, Rob Brophy. He's a very accomplished researcher and

01:29:40.680 he's a great surgeon, great doc. And they did a study that was published in the New England Journal

01:29:45.540 regarding physical therapy versus surgery for meniscus tears. And the punchline was that there's

01:29:51.100 no difference between physical therapy and surgery. And so Gina Colato interprets that as,

01:29:56.020 hey, it doesn't matter whether you do surgery or therapy. So why are we doing surgery at all? We should

01:30:00.040 just do therapy for everybody. Well, it turns out in one of the arms of the physical therapy group,

01:30:04.640 there was a crossover to surgery for those patients who weren't getting better, but it was an intention

01:30:09.560 to treat models. So they were still counted. They were still counted, yep. They were still counted as

01:30:14.040 physical therapy. So the take-home message of the study wasn't, hey, it doesn't matter if you do

01:30:18.820 therapy or surgery, you'll end up in the same place. It's more, hey, look, it's reasonable to try.

01:30:22.600 It's reasonable to try both. Just to start with physical therapy and start conservatively,

01:30:26.080 but there are a subset of patients that will benefit from crossing over.

01:30:29.420 That's exactly right. That's exactly the message. And that's exactly what I tell my patients.

01:30:33.000 Hey, look, you have a meniscus injury. Odds are it's probably going to get better with therapy and

01:30:37.080 time, and you should play those odds. If, however, the odds aren't in your favor and you start having

01:30:41.620 pain or you continue to have pain and you're not getting any better in a month, let's go up your

01:30:45.440 knee, take care of your meniscus. What year was that paper? That was pretty recent.

01:30:48.700 2016. Yeah. Okay. We'll make sure we link to that paper because I think it'll be good for people to

01:30:52.500 see it. Again, we can go back and look, but do you remember off the top of your head or even,

01:30:56.980 nevermind that just clinically, what do you say to patients is how long a period of time do you want

01:31:01.340 to give them on the conservative approach before you cross over?

01:31:04.440 So I usually give it about a month or two, but when patients come in a month later saying,

01:31:08.780 yeah, I'm feeling a little better. I'll keep riding it out. Right. And even though they might

01:31:12.060 be just feeling a little better, there are other people coming a month later, feel a lot better.

01:31:15.800 I remember working with John Healy, who's an orthopedic oncologist at Sloan Kettering. And I mean,

01:31:21.320 he's really taking care of some very, very sick patients with osteosarcomas, chondrosarcomas.

01:31:28.160 They're younger, they're older. And he's an amazing doctor, an amazing surgeon. And he once made a

01:31:34.360 comment about people scoping for dollars. And I hate to think that that happens, but there's no

01:31:39.480 question that it happens. None of us like to think we're the ones doing it. But the fact of the matter

01:31:43.000 is that it has to happen. There has to be some pressures for people to feel like the arthroscopy is

01:31:48.140 the right thing to do, even though the data is pretty clear that someone walking into your office

01:31:52.380 with a degenerative meniscus tear probably shouldn't be scoped as a first line of treatment.

01:31:56.720 And so I don't know what's motivating that person, whether their past experience of their getting

01:32:00.440 better, which is again, tainted by the fact that they were probably going to get better whether

01:32:04.160 they did surgery or not. So that idea of doing useless surgery, the fact is I see where it comes from

01:32:11.440 because we kind of, as a group, can dig our own hole by making these decisions that are

01:32:17.320 whether consciously or not are being influenced by outside factors.

01:32:22.080 I think this is a really interesting point in medicine. And I struggle with this a lot

01:32:25.300 when you're not a proceduralist, which I'm not, the stakes are a little bit lower and the

01:32:30.080 opportunities are a bit lower, but I, I don't know if I've told the story before, but this was a moment

01:32:35.320 when I had a realization. So, so one of the things that a lot of people in my type of practice do is

01:32:40.100 they also sell drugs, meaning they can get a license to become a pharmacy basically, and they can sell

01:32:45.600 anything that's sort of compounded and it's, it becomes another profit center. So you can start

01:32:49.480 to sell whatever it is that you would be prescribing to your patients. So you get to make the money

01:32:53.140 instead of sending them to a pharmacy. And on the surface, that sounds okay. But the problem with

01:32:57.080 that is, and I realized it one day when I was really on the fence about two different therapies

01:33:02.560 for a patient and they were, they're different, but one of them is actually quite inexpensive.

01:33:07.860 It's generic. It's basically a free drug. And then the other one is not. Now I was sitting there

01:33:13.600 really wrestling with which one to put them on because of the age of the patient and a few other

01:33:17.960 factors. It really wasn't a clear cut case of which to do. And I remember thinking, holy shit,

01:33:25.100 if I were the one selling both of these, do I trust myself enough that subconsciously I wouldn't

01:33:30.700 lean towards the more expensive one because I would make $10 on the nothing burger one and I'd make

01:33:37.080 like $400 on the other one. And I, and I thought to myself, you know, don't be so sure. It's probably

01:33:43.920 a good thing that you don't actually have to make that. You don't have to think about that because

01:33:48.920 it's not to say that you're a bad doctor. If you fall prey, I think that's human nature or a bad person.

01:33:56.000 Yeah. And it's harder for you guys because you're proceduralists.

01:33:59.220 Yes. You get judged on this. You get judged on, you know, by the people like who write about

01:34:04.680 medicine, who like to sort of expose the surgeons as doing things that are unnecessary or the, you

01:34:10.580 know, the $50,000 diabetic foot that was talked about with Obama. I mean, this stuff is just so

01:34:16.180 crazy. I mean, the fact of the matter is most, if not the highest percentage of doctors are really

01:34:22.280 looking out for the best interest of their patient, but they're human, like you said, and they may be

01:34:27.800 influenced by other factors that have nothing to do with the best interest of their patient.

01:34:31.800 One of the things about orthopedics that I think actually makes it a little easier if done in the

01:34:35.900 right setting, and I'm sure this was the case at HSS, is it's so multidisciplinary that you have

01:34:40.840 these physiatrists who aren't getting paid to operate and yet they're still a part of the team that's

01:34:46.400 sort of saying, yeah, you know, this patient probably does do better with surgery. And so I

01:34:52.540 don't know how prevalent that sort of, that model is, but I've been lucky every time I've been

01:34:57.220 evaluated for a pretty, what I consider at least significant orthopedic injury. I've had the luxury

01:35:01.720 of not just having to talk to a surgeon, not that I can't talk to a surgeon, but it's nice to be able

01:35:07.280 to balance that with taking one layer of bias away. I think that's a great point. It's not easy to

01:35:13.620 find though. I mean, a lot of people don't even know. Exactly. Like HSS is one of the places where

01:35:18.080 you get lucky enough that you're going to be able to see a physiatrist. Yeah. Or non-operative sports

01:35:22.480 medicine. That's something that's been very prevalent. You know, labral injuries, you had a

01:35:26.520 labral injury, correct? I have a right shoulder labral tear that, you know, I was weeks away from

01:35:33.000 seeing all check for surgery at HSS. What's happened with it? So I was getting a massage with my

01:35:39.780 body work guy. And, you know, this thing had been dragging me down for probably been five years,

01:35:44.460 four years from 09 to about 13. And it was just getting worse and worse. And it got to the point,

01:35:48.280 you know, it started when I was swimming marathons. And so it was anytime I swam longer than six hours,

01:35:53.520 the pain became really unbearable to which any person listening to this is like, why are you,

01:35:57.780 what? Who cares? Right. Start swimming less than six hours. Okay. But the point is it very quickly

01:36:02.940 turned into if I swam two hours, it hurt. If it swam one hour, it hurt. Actually swimming just hurts

01:36:08.000 constantly. And, you know, you can do 50 pushups. Nope. You can only do 30 pushups. No,

01:36:12.700 actually you can't do one pushup. When it hit that point. So that was four years after the initial

01:36:16.820 injury. I, you know, I thought, okay, well, I got to go do something about it. So anyway,

01:36:20.500 so you and I spoke and you basically said, look, these are basically your two best guys in the

01:36:23.580 country, right? I forget the Neil. I'll check and Neil L. I forgot to mention that I'll check is also

01:36:29.720 one of those mentors. Yeah. I mean, a superb guy, great surgeon. Well, that's why ultimately I was going

01:36:34.500 to go to see. I'll check because, and also because I'm in New York, it was just easier to do. So I'm

01:36:39.320 seeing my guy and he's working on me and he said, you know, I know you have a labral tear. I mean,

01:36:43.100 I can read the MRI, but he goes, I actually don't think that's why you're, I don't think that's why

01:36:46.040 you're in so much pain. I actually think the pain is due to the fact that the labral tear caused you

01:36:53.020 to move differently. And over the past four years, you have changed the way you use this arm. And now

01:36:59.420 it's actually in your tricep, your deltoid, your subscapularis and your infraspinatus. And he said,

01:37:05.100 you know, the recovery from the labral tear is going to be brutal. It's you're in a sling for six

01:37:09.020 weeks. You're not going to be swimming for nine months. I mean, for you, that's a big compromise.

01:37:13.320 He said, I think in six months with manual therapy and PT, I can get you better. And I said,

01:37:21.020 okay, let's give it a try. And within three months, I was at 80% of baseline. And today I would say,

01:37:26.680 it's hard to say I'm a hundred percent because I've also aged. Like I, so you're dealing with

01:37:32.220 the declining curve anyway, but I, there's really nothing I can't do anymore. Like including like

01:37:38.700 any number of pushups or, you know, sort of any activity, I have to be careful with certain

01:37:42.860 things. So one thing I've learned how to do correctly is when I do pull-ups, which I love

01:37:46.640 doing, I never do a full dead hang without a scapular retraction. And so I'm always protecting my

01:37:52.280 shoulder. I don't do any overhead pressing activities. I do a lot of static over

01:37:56.660 head stuff. But yeah, I consider that, that along with the IT band injury I had that basically

01:38:03.620 ended me from riding a bike in medical school and almost ended me from riding a bike a second time.

01:38:09.600 And I was again, right, ready to have surgery on my IT band before this same guy was like,

01:38:14.520 actually, it's not really, I mean, yeah, your IT band is jacked, but it's because, you know,

01:38:18.640 the real issue is your glute meat and your TFL aren't firing correctly. And as a result of that,

01:38:23.860 your vastus lateralis and your quads are moving the IT band in an imbalanced way. And it was the

01:38:29.360 same thing. I mean, I think within two months I was better.

01:38:31.320 To have someone that skilled with evaluating balance and musculoskeletal balance,

01:38:38.560 they're few and far between. I assume they don't claim to be one of them.

01:38:42.100 Yeah. These guys are gods. And I'll tell you, just to give you the flip side of that story,

01:38:44.800 of course, this guy and now his protege, you know, really work with my patients. And that's,

01:38:50.300 you know, so, so what I basically do in my practice is try to find the people who are the

01:38:54.020 best and just figure out a way to utilize all of their time, you know, close down the rest of

01:38:58.540 their practice. They now, so, so, so Josh, who now basically only sees my patients, you know,

01:39:03.120 the flip side of that is I've sent patients there where after one appointment, they say,

01:39:06.540 this guy needs a shoulder replacement, like clear as day. Like I could, I could sit here and take a lot

01:39:10.640 of money from this guy for the next six months and do conservative therapy, but it's not going to

01:39:13.980 work. And so I've always appreciated people who had the ability from an out, totally unbiased point

01:39:18.740 of view. And that's working against his own best interest. The other thing though, that I will say

01:39:22.460 against this, and this is just kind of me on my soapbox about how I get a little pissed when people

01:39:26.320 sort of say all surgeons are incentivized. You know, it's like, you know, when you're a hammer,

01:39:30.060 everything's a nail. Great surgeons aren't looking for business, right? Like the great practitioners

01:39:35.820 are so overbooked, they don't have to do that. So, you know, in the case of this guy, his name is

01:39:41.620 Brian, Brian doesn't need any more patients. So it's easy for him when I send him somebody who he

01:39:46.480 thinks needs a shoulder replacement to say you need a shoulder replacement. And similarly, like I

01:39:50.480 actually sent a patient up to Stanford recently to get an aortic root replacement, an aortic valve,

01:39:54.860 and it was a huge operation. And he was a little reluctant to do the surgery. And he said, you know,

01:39:59.760 I'm a little worried because the surgeon says I need this operation, but you know, he's a surgeon.

01:40:04.260 And I said, let me give you a little secret about this surgeon. He's God. Like he doesn't need you.

01:40:10.220 Like he, he, he has an infinite number of patients who need his help, whether you are or are not one

01:40:17.060 of them. So I promise you this guy's, he doesn't make one more or less dollar as a result of your

01:40:22.380 existence. The recommendation to have surgery is because of the physiology of your disease.

01:40:26.820 But that said, I'm sympathetic to this. And I think it's, I don't have a good answer to it other

01:40:30.960 than this sort of multidisciplinary approach. I think there's something to be said.

01:40:34.040 When it's available to be able to be evaluated by more than one individual,

01:40:37.940 but that those individuals are working in your best interest, not their own. And that, that's,

01:40:42.800 that doesn't grow on trees. Yeah. Again, I like to think that most people in our profession are

01:40:48.480 genuinely working in the best interest of their patients. And again, I think it's the overwhelming

01:40:53.180 majority of physicians who do that, at least in my experience here. But there again, like you've

01:40:59.180 also mentioned, there are some unforeseen influences or unrecognized influences that affect all of us

01:41:06.240 because we are human and may be tainting our decisions in a way that may not be fully within

01:41:11.300 the best interest of the patients. So there are a lot of things in orthopedic surgery now that are

01:41:15.340 quite popular and, and they've become almost rampant and I don't have enough of a sense of their value.

01:41:21.460 So for example, like PRP and stem cells, like let's, let's talk about PRP for a moment. So

01:41:26.480 maybe just explain for someone who's listening to this, who hasn't heard of it, what is it?

01:41:29.980 PRP is a super concentrated portion of your blood. It's a platelet rich plasma. And the procedure itself

01:41:35.840 is quite simple. We basically take a needle, put it in your vein, take some blood out, and then put

01:41:40.720 that tube of blood into a centrifuge. And the heavy portions of your blood go to the bottom,

01:41:46.780 the lighter portions go up top, the platelet rich plasma is typically in the middle.

01:41:49.740 And you take the platelet rich plasma and you inject it into a knee, a shoulder, a tendon

01:41:55.260 for healing purposes. And the idea is that the platelets are rich in healing factors and VEGF

01:42:01.220 and platelet derived growth factors so that you can stimulate and accelerate.

01:42:06.160 Vascular endothelial growth factor. So another one of these growth factors that would promote growth.

01:42:10.000 So again, the idea being that you can accelerate healing, you can take the body's natural healing

01:42:14.360 responses and, and really supercharge them to some degree or super concentrate them to some

01:42:19.620 degree. So the studies about PRP are somewhat imperfect because there's, there's so many

01:42:26.300 different commercial preparations of PRP and there's sort of general categories. There's leukocyte

01:42:31.200 rich PRP. So high in white count, white cells is leukocyte poor.

01:42:37.060 Those were deliberate design choices or those are just methodology differences.

01:42:40.420 Yes. Yes. Design choices. And then again, several different types of preparations for PRP.

01:42:45.500 So you're dealing with a very heterogeneous starting point. And so one PRP injection doesn't,

01:42:51.860 isn't the equivalent of another PRP injection, but it's hard to really know whether PRP is making a big

01:42:57.080 difference in tendinopathies. Most commonly, it doesn't seem to be regrowing articular cartilage

01:43:02.660 when you inject it into a knee or a shoulder or an ankle or a hip. It may be helping to stimulate

01:43:08.220 tendon injury, but that's a very hard endpoint to measure because most of the time we're measuring pain

01:43:13.920 and function with that. And it might be getting better in the tendon because of the injection

01:43:18.980 itself and the VEGF and the, and the platelet growth factors are doing exactly what you are

01:43:24.020 hoping that they're doing. Or it might be because there's a placebo effect, or it might be because

01:43:27.440 you're resting because it's pretty sore after you get one of these injections. And, you know, again,

01:43:31.560 you don't really know the answer why, but the studies seem to demonstrate that PRP has a marginal

01:43:38.040 benefit for tendinopathies. It's not a make or break, which is why not everybody's running to get it,

01:43:43.500 which is why the insurance companies aren't typically paying for it.

01:43:45.560 And the end point for tendinopathy is pain or function?

01:43:49.440 Pain and function.

01:43:50.720 And the placebos used in these are what?

01:43:53.880 Saline, or they might be head to head with cortisone, or they might be head to head with,

01:43:58.520 if you're doing an intra-articular injection with the viscous supplements, the hyaluronic acid

01:44:02.520 injections. And each of these has their own limits too, by the way, of their own efficacy.

01:44:07.860 One of the challenges with this space is it's so nascent. And if I were going to make the case

01:44:13.900 that PRP is better than the studies let on, and I'm not making that case because I actually don't

01:44:17.680 know. But if you believe that PRP is better than the studies suggest, you'd probably also believe

01:44:23.160 that the reason the studies are under finding benefit is that they're underpowered because

01:44:27.760 of the heterogeneity and approach and the inconsistency in patient selection.

01:44:31.600 So I suspect that with all new procedures, if you had a crystal ball and you could look into

01:44:37.300 the future in a decade, you'd say, well, actually, we now know that a third of the patients we did

01:44:41.380 this on should have never had it. And so now you've reduced your patient population to a more

01:44:46.300 homogeneous. Because in medicine, it all comes down to the more homogeneous the population

01:44:51.380 you can treat and study, the better your outcomes are going to be. Now, in the end,

01:44:57.820 we're all heterogeneous. So yeah, the better your outcomes will be, but also the better your science

01:45:02.720 will be. Yes, that's my point. The better the science will lead to a better inference about who

01:45:08.280 to do it. But so it always makes me wonder, like, we're still in the wild west of a lot of these things.

01:45:14.340 And I do wonder if, you know, will this stick around long enough to get rigorous enough to

01:45:19.420 actually understand what are the patients that are best suited for this procedure? And is there a

01:45:24.440 way to standardize and optimize, really, the preparations and the technique? And where do

01:45:31.240 you think if one out of 10 is when it's starting and 10 out of 10 is when it's fully dialed, where

01:45:36.220 are we? Probably three out of 10. And we're still, I think there's a long way to go on the biologics.

01:45:41.540 But I mean, they are the most promising, intuitive avenue to go down. How do you think about it

01:45:48.100 personally when you're treating patients? So patients ask me every day about stem cells and PRP,

01:45:52.140 every single day. And I think the issue with stem cells is that we don't know why it works for the

01:45:58.040 people who it does work. But it doesn't seem to be working because it's regrowing their cartilage.

01:46:03.480 So that's the big issue. Now, it might be working as an anti-inflammatory. It might be working as a

01:46:08.560 placebo. And it turns out, as you're aware, the sort of the bigger the procedure, the better the

01:46:13.420 placebo effect. So the more you're digging, the more you're extracting, you are harnessing a larger

01:46:20.080 placebo effect. What is the placebo effect with that procedure? Is it viewed as about 15% benefit?

01:46:26.720 Because that's the all-in typical placebo benefit. Yeah, I couldn't give you the number. I actually

01:46:30.540 don't know the number. But I think with stem cells, there is a lot of promise. And I hope it works

01:46:35.840 because I'm going to need it myself. And we'll all need it. But right now, there are people who I think

01:46:42.660 are, particularly in the orthopedic form, are taking advantage of the fact that we don't have

01:46:49.040 great treatments for arthritis. We don't have any reversal for arthritis. We have ways of managing

01:46:53.880 arthritis and maybe slowing down the pace of worsening arthritis. But we don't have anything

01:46:59.220 that reverses the course of arthritis that turns your older knee into a younger knee, your older hip

01:47:05.200 into a younger hip. And the stem cells seems to be that sort of molecular fountain of youth that

01:47:10.340 people have glommed onto. They have this idea that they can regenerate their hip. They can grow their

01:47:15.780 native hip back to what it was when they were 20. And a lot of it, there is promise in this. There's

01:47:20.920 no question that there's promise in it. And the animal studies really demonstrate it. But for instance,

01:47:25.600 there's a local group that's doing stem cell injections here where they take a bone marrow

01:47:30.360 aspirate from your posterior iliac crest. They take a slurry of fat from your abdomen. They take some

01:47:37.320 PRP from your arm. They put it together and they inject it. And they charge $5,000 to $6,000 per

01:47:42.040 for this procedure, cash. And talk about incentives. I mean, they're highly incentivized to do this. And

01:47:48.480 they will have patients come back to them saying, I feel better. But again, there's no rigor. Are they

01:47:53.020 feeling better because of the placebo effect? Are they feeling better because there's an anti-inflammatory

01:47:56.960 effect, which you can get with cortisone for 25 bucks? Or what's really the deal? But I don't think

01:48:03.260 it's the cartilage we're growing. And when they do those injections, those preparations,

01:48:08.200 they're putting a couple hundred stem cells in. The studies that showed some benefit in rats and

01:48:12.640 small animals, it's about 10 to 20 million. So we're orders of magnitude off. And this is one

01:48:20.720 story I do tell my patients as well. I had a woman who said, I went to a stem cell talk. They offered a

01:48:25.880 free steak dinner. And I listened to the talk and I decided to sign up for it. And I ended up paying

01:48:31.060 $13,000 for three stem cell injections. For the steak?

01:48:36.120 Right. Exactly. Exactly. I'm like, how do you feel? And she's like, I feel a little better.

01:48:40.820 And she's like, what do you think? And I didn't have the heart to tell her, like you said,

01:48:43.680 that she paid $13,000 for a steak dinner. $13,000 or $1,300? $13,000 for three stem cell

01:48:49.260 injections. So these price tags that come with it are so exorbitant. And I think there's some

01:48:54.100 exploitation that's going on because again, we don't have the solutions and it doesn't take a lot of

01:48:59.900 anecdotes out in the community. Hey, I got this. I feel a little bit better. I feel better. I can

01:49:03.100 do things I couldn't do. And that's all great. But we don't know why you can't do the things that

01:49:07.280 why you now can do the things you couldn't do. Is it because the stem cell is doing what

01:49:12.400 is being advertised, growing new cartilage, or is it because of an anti-inflammatory effect or a

01:49:17.420 placebo effect? Are there randomized trials going on looking at this?

01:49:20.540 Yeah. And most of the time they show some clinical subjective benefit, but again,

01:49:24.640 not a single radiograph or MRI showing reconstituted cartilage.

01:49:29.720 And that's with not just PRP, but stem cells exclusively?

01:49:32.860 Correct.

01:49:33.260 There are RCTs that are ongoing?

01:49:34.920 There are randomized controlled trials. Now the randomization process might be a little bit...

01:49:39.560 Well, because I mean, this is the exact reason you actually have to have double blinding.

01:49:42.960 Yes.

01:49:43.580 So these have to be complicated trials.

01:49:45.780 Yes.

01:49:45.900 You're not doing this in Johnny's clinic.

01:49:47.320 And again, there's nothing that's come through that says we should be doing this at this point.

01:49:51.020 I struggle with this. I get a lot of patients that ask me about this,

01:49:53.440 and I've had probably half a dozen patients that have had it done and swear by it. And

01:49:57.080 sort of like you, I have a hard time sort of having a straight conversation with them because

01:50:01.220 deep down, I sort of think it's bullshit, frankly. But at the same time, I'd like to think I have

01:50:05.940 the humility to say I have no clue. And my first question is, is it doing harm? And I say that

01:50:10.360 specifically with the IV stem cells. So that's the one that I'm most skeptical of. So question one

01:50:15.500 is what's the probability of harm? And let's bracket harm as physical harm, financial harm. Like let's

01:50:20.620 actually break this thing out. And then we talk efficacy. In other words, you want to think about

01:50:24.920 it through the lens that you would think of drug development. Phase one, safety. Phase two,

01:50:31.620 efficacy. Phase three, effectiveness. I don't know. I hope that that level of rigor is being applied to

01:50:36.180 this because I do feel really bad. Like again, I don't know how wealthy your patient was that

01:50:40.940 bought the $13,000 stake, but boy, that would break my heart to think that that was a meaningful

01:50:47.620 chunk of change to her. Yeah. And in her case, she didn't get a big benefit. She felt a little bit

01:50:52.860 better. And she had a problem that pretty clear that it's a surgical issue. It's a surgical issue.

01:50:59.200 So, but she's doesn't want any more surgery. She really wants to try everything prior to surgery. And

01:51:04.120 so again, the do no harm part is, again, I don't discourage when people ask. I just try to steer them

01:51:10.800 towards one of the academic medical centers where they are doing trials so that yes, they may get a

01:51:15.660 placebo. Yes, they may get the stem cell, but they won't get fleeced. And eventually we'll get an

01:51:21.680 answer whether or not this is effective. You know, when we talk about placebo effects and particularly

01:51:25.600 in orthopedics, there was a recent paper published in the British JBGS, I think it was, regarding

01:51:32.060 subacromial decompression, which is a very common procedure used for shoulder pain, for shoulder

01:51:36.900 tendonitis and impingement. And for patients who don't have rotator cuff tearing, but have shoulder

01:51:41.500 dysfunction and pain. Traditionally, subacromial decompressions have been a procedure of choice

01:51:46.980 where you shave a little bit of the undersurface of the acromion, remove the bursa and allow for

01:51:52.180 more space for the rotator cuff to move. And it generally leads to pretty good outcomes. The results

01:51:57.060 of the surgery seem to be pretty good. Well, I was having dinner with a law professor at University

01:52:01.780 of Chicago, Todd Henderson, and the paper that was done looked at subacromial decompression versus

01:52:06.940 sham surgery. And there was no difference between the sham...

01:52:09.780 You tell people what a sham surgery is?

01:52:11.280 Yeah, you make the incisions, you don't do anything. So, and you blind it to the...

01:52:16.140 So it's a single blind. Obviously, the surgeon can't be blinded to a sham surgery.

01:52:19.640 Correct. But all the therapists and the patients, everyone downstream from the operating room is

01:52:23.640 blinded. And the results were the same between a sham surgery and the decompression, which would

01:52:29.840 speak to, you know, the decompression being worthless, except that both groups got better. And so when

01:52:35.860 both groups get better, his argument was the only ethical thing you can do as a surgeon is to offer

01:52:41.460 the sham surgery.

01:52:42.220 The problem is if you offer it as a sham, you might lose the benefit.

01:52:46.580 Right. So you can't do that. But then you are duping the patient, taking them to an operating room

01:52:53.000 for what they consider to be a procedure. That's a procedure when in fact...

01:52:56.300 Unless you explain to them that, look, the reason we would explain the equivalence of the sham to

01:53:02.820 the procedure is the post-operative care that you got. It's the PT, it's the... Or it's some

01:53:07.740 combination of the rest, the post-operative care...

01:53:10.700 The forced rest from the surgery.

01:53:12.080 The forced rest and the forced PT, because you're going to take PT way more seriously when you're in

01:53:15.940 a sling and you've had surgery.

01:53:17.600 Right. But then... So I will say that to patients sometimes with meniscal injuries,

01:53:22.160 hey, let's cut out the middleman. It's probably the rest and the therapy that's helping you.

01:53:25.800 So why don't we do that? But you are also withdrawing the placebo effect of the procedure,

01:53:33.620 what seems to be a placebo effect. Now, I do subacromal decompressions. I've done them and

01:53:38.620 I probably will still do them because I... Yet the science, that's a reasonable study of

01:53:43.940 randomizing patients and finding not much of a difference. And so... And these studies have

01:53:48.040 been done with meniscus surgery.

01:53:48.920 And how much better did the patients get? Do you recall what the absolute improvements were?

01:53:52.720 I don't know the absolute improvements. I don't recall.

01:53:54.840 Because that's the other thing that kind of has to be weighed into these things. I mean,

01:53:57.440 people who listen to this podcast have heard me sort of rant about the difference between

01:54:00.640 absolute and relative improvements. And those things have to be...

01:54:03.740 Well, they're relative improvements by definition when you're doing shoulder surgery. But it is...

01:54:09.420 Look, again, I thought that was a very interesting point. The most ethical thing you can do

01:54:15.780 is the sham surgery.

01:54:17.740 Let's talk about what I consider the elephant in the room when it comes to orthopedic injuries,

01:54:21.340 which is lower back injuries. I... I don't... You probably remember what happened to me in

01:54:25.280 meds. I totally remember what happened to you. You had a... You had a caudaquina.

01:54:29.120 Yeah. I mean, I had that free fragment, the L5-S1 free fragment stuck in the canal. I mean,

01:54:32.780 the whole thing was a disaster. I hate even talking about it.

01:54:34.360 And then you got infected afterwards too, right?

01:54:36.520 I did have a little infection after. The bigger issue is that he roped on the wrong side. The first

01:54:40.260 procedure he went... He did a left side... I did not know that.

01:54:42.900 It was a... Or he... Yeah, it was a left side injury. He did a right side of decompression and ding,

01:54:46.380 the right side of nerves. So I came out with a right-sided foot drop, even though I went in with

01:54:49.920 a left-sided injury.

01:54:50.920 Fuck, I did not know that.

01:54:52.200 Yeah, yeah. And had a bunch of redos. So it's something that's near and dear to my heart for

01:54:57.120 personal reasons, because I spent basically a year of my life recovering from a back injury,

01:55:02.460 three months of which I was debilitated, meaning I was... I couldn't move. My mom had to fly down

01:55:07.000 from Toronto to feed me. I mean, literally, I couldn't even make a meal. And my roommate,

01:55:11.900 Matt, was like... He's still a med student. It's not like... He couldn't sit there and feed me

01:55:15.960 and wipe my ass. So yeah, I'm still partially sort of traumatized, I think, from that. But also,

01:55:21.060 I now realize that it was... And I've talked about this in the past. It was the best worst thing that

01:55:25.220 ever happened to me, right? It was the worst thing that ever happened to me because it's just a year

01:55:27.840 of being hooked on opiates and all this other crap that comes with it. But it's also where you learn

01:55:33.580 how to move again. And in many ways, I think... I feel very fortunate now that that happened to me

01:55:39.460 when I was 27. I'm 45 today. Never really had a back issue ever since. Because it hurt for so long,

01:55:48.020 I learned how to redo everything that you wouldn't be able to relearn if you only had two weeks or a

01:55:53.980 month of pain. So for example, I learned how to sneeze while protecting my back. I learned how to

01:55:59.980 brush my teeth while bracing myself over the counter so that I'm not just completely placing

01:56:05.840 a torque on my lower back by bending forward. Little things. I remember a friend of mine was

01:56:11.880 over at my house and I was putting the dishes away and I put a fork in the thing and I did a squat to

01:56:18.820 bend down to put the fork in it. He's like, dude, what's wrong? Is your back hurting? And I was like,

01:56:23.880 no, it's exactly the opposite. My back doesn't hurt because I do this. Because I never get caught

01:56:29.860 picking up that piece of paper. Because so many people, when they throw their back out,

01:56:32.860 quote unquote, throw their back out, it's usually the tiniest insult that does it. It's not always

01:56:37.960 the, well, I was doing the 400 pound deadlift, right? So that said, you can't go far in life

01:56:44.540 without running into a friend, a family member, or a patient who's really suffering from lower back

01:56:48.900 pain. And I got to say, I'm not convinced that surgery is, there are clearly some amazing cases.

01:56:55.620 I've seen some spinal stenosis cases that, you know, the moment this patient comes out of surgery,

01:56:59.740 it's like, it's changed their life. But more often than not, I want to say, and maybe I'm biased

01:57:05.180 in my sampling, patients probably would get better without doing, you know, a lumbar discectomy,

01:57:11.200 for example. But again, that's now me speaking with a bias. I'm curious as to your thoughts on this,

01:57:16.540 even though I know you focus on joints and within the field of orthopedic surgery, this is sort of

01:57:20.820 like- It's a subspecialty. It's its own subspecialty, a spine. But, you know, look, you know more than I do.

01:57:25.660 So that's- You kind of go, if you go to an ophthalmology conference and you ask how many

01:57:29.940 people do LASIK, most of the hands go up in the air. And then how many would have them on themselves?

01:57:33.860 Most of the hands go down. If you go to an orthopedic conference and ask how many people

01:57:37.780 have done or would, or have done spine surgery, and we've all done it and we raise our hands,

01:57:42.240 how many people would have it on themselves? And the hands all go down. Because we see some of the

01:57:46.560 very poor outcomes that can happen with spine surgery and the difficulty that people can have with it.

01:57:50.940 And low back pain is ubiquitous. It's the number one reason people go to the doctor,

01:57:55.480 not the orthopedist, but the doctor. And- I didn't realize that.

01:57:59.440 Yeah. So it's the number one reason. And so when people have low back issues,

01:58:04.360 there may be mechanical issues, like you mentioned a slipped disc, which the majority will resolve with

01:58:09.120 time. But when patients have neurologic compromise, weakness, there tends to be a greater urgency to do

01:58:15.260 something about it. Especially cervical, right? Correct. And because it can affect,

01:58:19.920 you know, people's balance, people's ability to walk, not just their hands. And I can show you,

01:58:25.080 I will show you, my friend Nick Horgan moved to London and he was new to the area, new to the

01:58:32.060 healthcare system. And he calls me out of the blue. He's like, hey, hey, head. And that's what he

01:58:36.740 called me, head. I got a little problem here. And I got this disc and they're telling me not to fly

01:58:42.660 anywhere, not to go anywhere and have surgery on Monday. So I asked Nick to send me the worst picture

01:58:47.620 on the MRI that he could see. And he sends me the picture and he has this massive disc herniation

01:58:53.520 with signal within the spinal cord called myelomalacia, which means that he's getting

01:58:58.500 injury to his spinal cord and will lose neurologic function in short order. And I said to Nick, Nick,

01:59:05.900 do not fly like they told you. Do not go anywhere. You go into surgery when they tell you to,

01:59:11.020 and it's sooner the better. And he underwent a successful cervical decompression infusion.

01:59:15.660 And he had a vertebrectomy at the time and a big graft. And those type of spine surgeries are

01:59:20.260 life-altering and life-saving. And there are other spine surgeries where the problem isn't so dramatic,

01:59:26.440 but the intervention is so dramatic. And you've mentioned this to me before. You've sort of

01:59:31.100 introduced me to the concept of asymmetric risk, where when people are functioning 70%

01:59:38.520 and you do something as dramatic as a spine operation, you could take someone from 70% to

01:59:44.620 90%, but you could also take someone from 70% to 20%. You can really drop them out with a spine

01:59:50.080 operation. And because it's your core, it's your axial skeleton. And if things go awry there,

01:59:57.440 they go awry for your entire body. If I have a shoulder surgery where I'm trying to take someone

02:00:03.300 who's 80% functional and make them as close to 100% as I can, I'd probably knock them down to 20%.

02:00:10.580 And so again, if anything, they'll be a little bit worse or the same, but it's rare for when you're

02:00:16.800 working on the extremities to take someone way, way down like that. Can, but it's rare.

02:00:22.380 In the spine, it seems to happen more frequently. And again, you're taking people who are reasonably

02:00:26.700 functional, but not happy, happily functional and trying to make them better. And in the instances

02:00:33.360 where you don't, you can make them a hell of a lot worse. And it's kind of why I think joint

02:00:38.380 replacement is such a successful subspecialty in orthopedics. You have people who are 20 to 30%

02:00:43.300 functional. They can't walk more than four or five blocks without pain. They have pain all day long

02:00:47.380 while they're sitting. None of the anti-inflammatories are working. Their life is completely dominated by

02:00:51.940 their hip or their knee pain. And you do a joint replacement and you make them 70% functional.

02:00:58.340 And they're the happiest people you're going to meet because you make them, made them from 20%

02:01:02.020 functional to 70% functional. And you have an incredibly wide margin to improve them.

02:01:06.860 If you're in sports medicine where people are about 85% functional, I mean, you could do everything

02:01:11.500 except swim and do pushups, but you could do everything else in your life without pain.

02:01:16.240 And you're taking someone who's 80 to 85% functional, you're working with a very small margin.

02:01:20.960 And so it's a harder, it's harder to get the satisfaction that you can get.

02:01:25.220 Yeah. There's just, there's so much more downside than upside.

02:01:27.620 There's the potential. But again, because with the work that sports medicine surgeons do,

02:01:34.380 you rarely make someone from 80% to 20% yet in the spine, because it's the spine,

02:01:39.240 you can take someone from 80% way down. So I think that's, I'm not sure if that's making sense.

02:01:44.840 I hope it does make sense. What, what can people do? You know, obviously like you're my

02:01:50.940 go-to guy for any orthopedic question. Like I'm always calling you and I'm always sending you

02:01:55.300 MRIs on my patients and stuff like that. And you're always like, okay, what city is this person in?

02:01:59.560 And you're always a phone call away from like the best person in that city, or if they're willing

02:02:04.140 to go see the best person, period. You know, in that one case, we got really lucky that person

02:02:08.500 had a foot injury, needed an ankle replacement, and the best guy in the country happened to be one

02:02:13.280 of your partners. So that's, that's really nice. But you know, your connections through HSS

02:02:17.200 has always been great. But, but the average person listening to this doesn't get to call you up and

02:02:20.900 doesn't get to say, Eric, here's my MRI, tell me what to do. So it's hard to ask because if it's

02:02:27.200 anybody that is your friend or family, you're going to be able to do this for them. But if there's

02:02:30.740 someone you can't help, but you want to give them sort of the guiding principles of how should they be

02:02:35.240 screening orthopedic surgeons? What questions should they be asking before some of the more common

02:02:39.940 procedures? How would you navigate that?

02:02:42.280 Well, I think you alluded to it earlier with your friend who, you know, doesn't need the business

02:02:46.560 or that patient who was having the aortic root replacement. Volume does speak volumes. I mean,

02:02:51.900 when surgeons have high volumes, that's probably a generally a good sign. Now there are some

02:02:56.260 surgeons who have high volumes because they're scoping for dollars or other things, but in

02:03:00.760 general, it's a reasonable rule of thumb that they have a good volume.

02:03:04.160 So let's talk about a couple of procedures. If you're getting your knee replaced, how, you know,

02:03:08.520 I, and I, this is how, when we were trying to find the best surgeon to do my friend's aorta,

02:03:12.940 this was a big question, right? It's like, you don't want someone who's doing one of these a month.

02:03:16.560 So with, with a knee replacement, what do you consider the volume number above what?

02:03:21.360 Boy, I would want it to be 200 for a week, somewhere in that range. High volume is considered,

02:03:28.000 by the way, greater than 30 in some of the studies, which is once every other week,

02:03:33.140 but the high, really high volume guys are doing several a day.

02:03:36.160 Wow. And so you're saying, so someone who's doing four of these a week, 200 a year,

02:03:40.220 that's basically, that should be all they're doing pretty much, right?

02:03:42.280 They'll be doing that in hip replacement, you know, between four to 600 surgeries a year,

02:03:46.740 that's an incredibly high volume surgeon. Those are the HSS type numbers. You know,

02:03:50.820 those are the people who are going to be really at the top of the game again.

02:03:54.560 And that already introduces something interesting. You said, if studies are considering anybody over

02:03:58.600 30 to be high volume, you've already seen a great heterogeneity now in the studies.

02:04:02.980 Right. Because there's a huge spread between 30 and 400. Right. So, but I think the volume of cases

02:04:09.740 that are done, obviously just asking around and seeing what other people's outcomes have been,

02:04:15.320 have been really helpful. And you want to pick a surgeon who's not going to run from their

02:04:19.600 complications because we're all going to have complications. And again, human nature does play

02:04:23.460 a role. And, you know, no surgeon likes complications. It's, you don't feel good about

02:04:27.500 yourself when your patient has a complication.

02:04:29.380 It's one of the most interesting dynamics between a patient and a physician, because

02:04:33.660 the patient feels horrible because there's been a complication. The physician feels horrible

02:04:38.200 because if they're even remotely honest with themselves, they realize that something,

02:04:43.420 whether it was entirely their fault or some combination of things, something that they did

02:04:47.860 led to this. And yet the natural tendency is to run, not because you want to abandon the patient,

02:04:54.060 but because you can't stand facing the fact that this happened.

02:04:57.040 Well, there's a shame that's involved. I mean, when you have a complication,

02:04:59.960 you definitely feel completely responsible for it. And you know that shit happens, things happen,

02:05:05.960 but you feel responsible. It is your fault. I mean, you can't get around that. And you sometimes want

02:05:13.440 to cower away from it. And that is your first instinct to some degree to just, you know, bow away from it.

02:05:18.860 But obviously when you're choosing a surgeon, everyone's had complications. And the surgeon you want to have

02:05:23.220 is someone who steps up when there is a complication. You know, we've always been taught, you know,

02:05:27.480 keep your patients close and your complications closer. And I try and do that. I mean, I've had

02:05:33.060 patients who've had infections. I've had patients who've had outcomes that weren't expected.

02:05:37.180 And they're the ones that I obviously remember the most. I can't help it. There's an emotional

02:05:41.460 component to it. But I try and be available in every possible way that I can be, both emotionally,

02:05:46.920 being able to just call me, text me directly. And I don't like to put barriers between my patients in

02:05:53.040 the beginning. But for anybody who's had a complication, I try to create zero barriers.

02:05:58.760 I try to make it as seamless as possible. So you want to have a surgeon who has a reputation

02:06:04.080 of, you know, being someone who will deal with complications. And I don't know how you find that

02:06:10.660 other than my word of mouth. Yeah, I was just about to say, because there's really,

02:06:12.300 those are two interesting traits, right? Well, you're not going to advertise your complications,

02:06:15.640 right? Yeah. And it's something I think that patients have a hard time asking physicians

02:06:19.260 about. I don't have a hard time. You know, if I'm, when I'm talking to the cardiac surgeon who

02:06:23.440 was going to operate on my friend, I didn't have a hard time saying, all right, let's talk about the

02:06:26.740 complications. Like how many of your patients get AFib after surgery? How many re-bleed? How many

02:06:30.420 re-dos? Boom, boom, boom, boom, boom, boom. What's your 30-day mortality? But, you know, I came from

02:06:34.420 that world so I can talk in those terms. But for patients, is it okay to just say, hey, what's your

02:06:39.960 infection rate? What's your re-operate? What's boom, boom, boom? I think you absolutely should do that. I mean,

02:06:44.260 and the surgeon who can't answer those or doesn't want to, that's probably a harbinger of something

02:06:48.640 worse. I agree. I think most people worth their salt welcome those questions or happen to answer

02:06:53.060 them. A surgeon who welcomes a second opinion, yeah, please, by all means. I think that's someone

02:06:57.380 that, you know, you don't want someone to be like, who shies away from having a second opinion. I think

02:07:03.040 that's a red flag for sure. So volume, the humility to answer questions about complications,

02:07:08.440 the willingness to participate and have second opinions. I mean, those are three pretty good rules of

02:07:13.340 thumb. Yeah. I mean, generally, someone who's embracing those is concerned more about your

02:07:18.320 best interest than anything else, is concerned about themselves, and is more concerned about

02:07:22.120 your outcome, your best interest. But look, choosing a surgeon is really difficult. There's

02:07:26.620 no metric. I mean, you can go on to health grades, and you'll see some of the people that, when we're

02:07:31.200 in the know, who we see operate, who have great outcomes, who are gifted surgeons, have terrible

02:07:35.960 health grades. I feel like health grades should be taken away. I got to be honest with you. I think

02:07:39.760 there is no benefit to that service. And I don't say that disparagingly about health grades,

02:07:44.680 because I think they're doing anything wrong. I think it's a beautiful idea.

02:07:47.460 I'm not sure it translates into directing people to the people that they're in patients.

02:07:51.160 It absolutely categorically does not. It is a collection. You know, you're just going to,

02:07:55.400 it's a bunch of extreme selection.

02:07:57.540 Yes. Great way of putting it. And it's like, well, my kids are huge fans of South Park,

02:08:03.040 and it reminds me of the Yelper special episode. But I know. I mean, I'm a real people reviewer.

02:08:10.180 Yeah. Yeah. Anyway.

02:08:11.140 We'll link to that, I'm sure.

02:08:12.820 You should. It's unbelievable. But it's an imperfect, there's no perfect metric for who's

02:08:18.880 the best doctor. There's just like, you know, Tom Brady is drafted in the sixth round of the NFL.

02:08:23.860 And there are a lot of metrics for measuring athletic performance of how these guys are going to do.

02:08:28.480 And 32 teams made the same mistake six times over when Tom Brady was drafted 199. And they have 40

02:08:38.260 yard times, they have tons of film, they have, you know, pretty much every metric you could want,

02:08:44.860 and they still don't get it. Now let's take that in the medical world, where you don't have 40 times,

02:08:50.660 you don't have how many times you can bench, you don't have any game film. And it's,

02:08:53.900 in the best of circumstances, it's incredibly difficult to measure elite performance or predict

02:09:00.260 elite performance. And then you throw something in as complex as the medical world, it's even more

02:09:05.120 difficult. So it's very hard for patients to figure out how to select the best surgeon.

02:09:11.660 But then ultimately, it comes down to trust. I mean, I think, again, there's a big trust element,

02:09:16.580 and you have to trust that that person sitting across from you who is proposing to do a procedure

02:09:20.940 that's quite invasive, that you trust that they have your best interest, that they're going to do

02:09:24.840 a good job for you, that they're going to be there when you need them. And so there's a lot

02:09:30.280 of intuition that goes into it. I know that you're one of those surgeons who doesn't shy away from the

02:09:35.640 complications. And of course, the irony of it is, being so good, you have fewer of those complications,

02:09:41.580 but then you're kind of all in when they're there. I'm guessing the toughest complications are the

02:09:46.600 ones where they're occurring in people who have lost a non-trivial amount of function when it's

02:09:52.220 all said and done. Meaning, it's one thing if, God forbid, you have an infection and that means

02:09:57.100 there's an extra two weeks where you need an antibiotic and you have to be an inpatient and

02:10:00.520 there's a bunch of inconvenience. But in the long run, it's going to be the way it was before or

02:10:04.420 better. But have you had those complications where either through the complication or just the

02:10:10.480 bad luck of the disease, they're worse than when they started. And they can't do something that

02:10:16.840 they could once do before. Yes. And it's very difficult. And it kind of leads into something

02:10:22.240 that I wanted to speak with you about and the idea of coping. And from a surgeon's standpoint,

02:10:27.600 when you have people who have complications, you still have the next person who needs a similar

02:10:31.840 procedure and you have to be able to cope with the fact that you had a complication in one patient

02:10:36.200 and move on to the next and do the best you can for them because you feel it's the right thing.

02:10:39.720 And that's not easy to do at all. For a patient who has a complication that has left them with a

02:10:45.060 deficit, coping becomes a big part of it. Our role as physicians is to help patients adapt and cope

02:10:53.080 with their new reality. And helping patients focus on what they're able to do as opposed to what they're

02:10:59.140 unable to do is a big part of helping them cope. And if you can change the mindset, hey, from I no longer

02:11:06.920 can do this because of the complication, I no longer can do that because of the complication too.

02:11:12.100 I'm still capable of doing this. I want to do this. Can I do this? More of a, again, focus on what

02:11:18.020 you're capable of doing as opposed to incapable. Then I think you can help patients adapt to a new

02:11:23.600 reality that, again, there's a better acceptance and a better way of coping.

02:11:27.620 And it's not just complications. It's sometimes even without a complication, you know, the person

02:11:32.600 has an injury. The natural history.

02:11:33.340 Yeah, the natural history of the disease.

02:11:34.920 Yeah, the natural history can be just on a downslope. And again, trying to help patients cope with that

02:11:40.980 limitation. And again, I think it's so critical to help people focus on what they're capable of

02:11:46.620 doing as opposed to incapable, what they still have ahead of them as opposed to what they've lost

02:11:50.980 from behind. And again, it's very difficult. I mean, you've been in that situation when you've been

02:11:56.140 laid up and thinking about all the things you were unable to do and now what you were able to

02:12:00.400 recapture. But some people don't recapture, but still have to look forward to what they can do.

02:12:06.520 And I kind of was exposed to this coping idea through the care of a family member who has a

02:12:15.440 form of cancer that requires ongoing treatment. And this family member, through this illness,

02:12:21.980 I was exposed to a physician at Dana-Farber, one of the leading cancer centers, who's a breast

02:12:27.420 oncologist, Eric Weiner. And Dr. Weiner was the recipient of a Lifetime Achievement Award

02:12:33.640 in breast cancer treatment. And he gave a lecture. It's the McGuire Memorial Lecture in San Antonio in

02:12:41.240 2016, I believe, 2016, December of 2016. And he talks about the state of breast cancer and research

02:12:48.720 and developments and reasons for hope and reasons for optimism. But he also, for the last 15 minutes,

02:12:55.280 he tells a very personal story about his own interactions with medicine and what he feels his

02:13:02.380 primary role is as a physician. And fundamentally, he believes it's our role to help patients cope.

02:13:09.160 Whether it's with an illness, whether it's with an injury, whether it's with a psychological,

02:13:14.100 it's about coping and helping patients manage and helping them continue to live their lives

02:13:20.720 so that they focus on what they're capable of doing. Again, he delivers it such a powerfully,

02:13:26.840 and I don't want to spoil it. I really want people to listen to this. I think everybody who wants to be

02:13:31.060 a physician or is a physician should listen to it. I think anybody who's receiving medical care

02:13:35.200 has an ongoing issue should listen to this. It's an incredibly inspiring message that he gives.

02:13:41.020 Again, his own personal example is tremendous. And his message is spot on. And so I see many

02:13:48.860 patients who are in knee purgatory, I call it, who aren't ready for joint replacement,

02:13:53.380 who don't have a bad enough, aren't at that 20% to 30% point of dysfunction that they would benefit

02:13:59.160 from a knee replacement. If they're sort of 60% functional and you give them a knee replacement,

02:14:03.520 they're 70% functional. They're not typically happy with that because they have to go through hell

02:14:07.080 to get it. So in that knee purgatory, sort of 60% to 70% functional, where we don't have a lot of

02:14:13.000 options. It really is the emphasis on treatment and management is on coping.

02:14:18.100 Let's take an example of that. So the athlete who's in knee purgatory probably can't run anymore.

02:14:22.700 Yeah. Well, the athlete usually isn't in knee purgatory. It's usually someone my age or above

02:14:28.300 is in knee purgatory with a degenerative condition.

02:14:30.980 Yeah, that's right. I'm so used to calling patients athletes because I try to get this idea of like,

02:14:34.660 everyone's an athlete. You're an athlete when you're 90. You're an athlete for life. But yeah,

02:14:37.840 I see your point. Okay. So this person could be a 45 year old who's been athletic and all of a sudden

02:14:44.180 now she just can't run anymore. She used to be able to run marathons and now the 5K trot with her

02:14:51.500 daughter at school is unbearable. Right. And then we don't have a lot of treatment options for that

02:14:55.440 person surgically and they are 45 years old. So you want to get them to 55 or 65 as we talked about

02:15:00.680 earlier. Or if you, you know, I want to get them to a hundred. Well, no, but yeah, no, no, I'm saying

02:15:04.400 you want to get them to there to do the joint replacement, but the long, long view is to get

02:15:08.040 them to a hundred. You want to get them to a hundred and still mowing the lawn. Right. So coping is

02:15:12.420 somewhat of, of managing the expectations of what you will be capable of doing, but also not setting

02:15:18.380 limits, allowing patients to try the running and allow sort of the joint or their problem to limit

02:15:24.920 them as opposed to you imposing any artificial limits on them. So I draw a graph where I talk about

02:15:29.920 thresholds and, and, you know, above this threshold, if you're developing pain or swelling and below the

02:15:34.660 threshold, you're not, you want to be up against that threshold with your activity level as much

02:15:38.720 as you can be. And you can modulate your threshold. You can strengthen your leg. You can lose weight.

02:15:45.280 Even the person who weighs a hundred pounds and loses five pounds is going to benefit from weight

02:15:49.440 loss. If they have a painful lower extremity joint. Well, it's interesting. I'm glad you bring that up

02:15:52.800 because I was going to ask you about that. And then we got off and I forgot about it. So even me,

02:15:56.420 you know, I'm not overweight, but if I lost 10 pounds, presumably it's going to be a little

02:16:00.980 easier for me. Yeah. Things will feel better. And I feel the same thing. I know when my knee,

02:16:04.600 I almost know my weight by the pain of my knee. I can gauge it that precisely because I know what

02:16:09.280 weight I feel good and don't have pain and what weight I don't. But there's typically a threshold

02:16:13.320 that's kind of a binary issue. And so again, I try and get people to, to, to do what they can

02:16:19.060 and then let them know that they can modulate that threshold through effort. I mean,

02:16:23.760 really through strengthening, through weight management and through education. And the more

02:16:28.580 you learn about your condition, your illness, your injury, the better you'll be able to cope

02:16:33.780 with it. Period. And what are some of those things that you will recommend to those persons? So,

02:16:38.840 you know, that 45 year old mother, who's a star athlete, great runner, you know, probably played

02:16:44.440 tennis in college, whatever. Do you say if they keep hitting that threshold so often, do you just

02:16:50.480 say, look, I want you to try swimming or biking? Of course. Yeah. Yeah. Yeah. And again, if people

02:16:55.480 are focusing on what they can do versus what they can't do. So if she's focused on what, okay, I can

02:17:00.380 swim and I can bike as opposed to, I can't run anymore. That mindset makes a huge difference in

02:17:05.320 managing that and coping with that. And so helping to cultivate that mindset is a big role of what we do

02:17:11.200 in terms of, again, helping patients cope. It's not a biologic, it's not an injection,

02:17:17.300 it's not a cure, it's not a Jetson's approach to good health of being able to take this pill and

02:17:22.180 you're okay, or take this injection and you're okay. And we're not pursuing the molecular fountain

02:17:26.640 of youth through this approach. But on the other hand, you can help people still live better and

02:17:31.760 move better if you can focus on what you're capable of doing as opposed to what you're lost.

02:17:38.240 Yeah. And this could be especially valuable if by switching to a different track, you can slow the

02:17:43.760 decline. You know, one of the fears that I have in the, in that type of a patient is

02:17:48.800 they stop running because it just becomes simply too difficult, but they don't replace it with

02:17:55.140 something else. And all of a sudden they have a really precipitous decline in their physical

02:18:00.280 quality of life. Now look for a 45 year old to get sedentary doesn't mean that much, but by the time

02:18:05.420 they're 65, the difference between them having pivoted to a new sport or having done nothing

02:18:10.880 becomes enormous, especially for that woman. Cause in five years, she's going to go through

02:18:14.640 menopause and she's going to have another accelerator thrown onto it. And, and, you know,

02:18:18.400 these are the things that really, this is the problem that keeps me up at night. You know,

02:18:22.380 I was leaving my building the other day is in New York and I came out and I saw a guy who, you know,

02:18:28.800 I recognize cause he's in the building and he was in one of those sort of motorized scooters.

02:18:33.060 And I was just coming back from the gym and I was sort of running up the stairs cause I live on the,

02:18:38.540 you know, whatever fourth floor. And there's a part of me that kind of felt guilty. I was like,

02:18:42.460 God, I can't believe like there's ever a day that I bitch about anything. When I just ran past a dude

02:18:49.060 in his motorized scooter and ran up the stairs. And I thought, you know, he, he didn't look that old.

02:18:54.540 He's probably 75 truthfully, you know, maybe 80, but look in today's world, I, you know, that's just

02:19:00.200 not that old. And yet he, you know, he has to get a doorman to hold the door open. He can't go

02:19:05.020 through the revolving door, not that going through a revolving door matters. But the point is like,

02:19:08.960 I thought, boy, once, once you get to that point, like what would you give to go back in time? If

02:19:15.520 somebody says, look, man, go back to when you're 45 and do these seven things different, you'll be on

02:19:21.160 a different trajectory there. And I wonder how much of it is this, this adaptability that you talk

02:19:27.500 about, which is, Hey, you can't run great. You're going to learn how to ride a bike. Can't do that.

02:19:32.900 That's fine. You're going to learn to do X, Y, or Z. Or even again, changing the technique.

02:19:36.800 Oh, of course. Right. Right. And so whether it's barefoot running or, or getting an analysis of some

02:19:42.300 sort, getting lighter on your feet, taking shorter strides, I mean, whatever it is that you can do.

02:19:46.080 20 pounds and right. And so aging is such a big part of what we treat in orthopedics. And we do a

02:19:56.700 tremendous job with, with traumatic injuries and the traumatic injuries that don't involve the joints.

02:20:02.040 Again, we do a terrific job with those. We can realign the bone. We can get the bone to heal.

02:20:06.960 We can get people's function restored. The injuries that involve the joints specifically into, you

02:20:12.480 know, into the intra-articular portion of the knee or the hip, the ankle, or any of the joints,

02:20:18.980 we have a much harder time. And those are the injuries that linger for a lifetime. So a long bone

02:20:25.120 fracture in the middle of the femur, you'll pretty much recover from, or in the middle of your tibia,

02:20:28.640 you'll pretty much recover from and not have much of a deficit if any. But the moment you have an

02:20:33.080 intra-articular injury to the joint, it puts you on a different trajectory and, and how to sort of

02:20:38.580 manage that trajectory and, and keep it as close to what it would have been had you not been injured

02:20:43.660 is obviously one of the goals and difficult to do. But then also when that trajectory prevents

02:20:49.560 people from doing what they want to do, having them focus on what they're still capable of doing,

02:20:53.620 I think will help them cope because if they keep thinking about the trajectory they were on and

02:20:58.480 compare that, that the trajectory that, that they were on to the trajectory that they are currently

02:21:02.860 on, that can be a tremendous source of frustration. And so in the end, if they can just focus where

02:21:08.320 they are and realize what they're capable of doing, I think that's a big part of just preserving health.

02:21:15.340 And that fall must be, you know, bringing it back full circle to the guys in the NFL that you worked

02:21:20.540 with, that's gotta be one of the greatest deltas between the, the, the former track of performance

02:21:27.420 and the current track when these guys retire. Well, you see all those horrible videos of like

02:21:31.800 Earl Campbell and these tremendous athletes who are aging so prematurely and so difficultly,

02:21:37.640 and they really have no quality of life and they, and, and, but you ask them if they do it all over

02:21:43.580 again, the majority of them will say yes. Yeah. It's so funny. I was, I was actually just thinking

02:21:48.080 about that today on a totally different tangent, but I was in my hotel and there was a silent

02:21:52.260 auction going on and it was a picture of Muhammad Ali with the Beatles and, you know, I'm a big boxing

02:21:56.700 fan. I remember I was up, so I go up my lobby, I'm up, I'm shaving and, uh, cause I wanted to look

02:22:02.300 good for you. You do. Thank you. And I remember thinking to myself, God, you know, from night about

02:22:08.860 1960 to 1980, Muhammad Ali had about the most recognizable face on earth. You could argue that no athlete

02:22:16.160 existed on a larger stage than Muhammad Ali in those two decades. And yet he, in many ways,

02:22:21.960 he died very prematurely. I mean, he died, you know, a few years ago, but given how magnificent

02:22:27.500 his star was, all that he could have continued to have done, you know, his quality of life really

02:22:33.820 began to decline precipitously in the mid eighties. And I remember thinking to myself, like, so he was at

02:22:39.600 his best from age, you know, 18 to 38. If someone waved a magic wand and said to me, you could have

02:22:46.340 that life from age 18 to 38, but then it's going to be a pretty quick decline. Would you take it?

02:22:51.840 I guess for me, the answer is no, but I realized that having never been there, I don't know what

02:22:56.500 that high would actually be like, but I, I think I'm just such a conservative person who's mostly

02:23:01.900 optimizing on the back end of life. Perhaps that's wrong, but it gave me a great sense of sadness to

02:23:08.040 think about what would it have felt like to have been Muhammad Ali when you were 60 and to realize

02:23:14.420 that you were once the most gifted physical specimen that ever walked the face of the earth.

02:23:19.480 And now, you know, you couldn't tie your shoes. And similarly, as you said, you look at these guys

02:23:24.500 who are in their mid fifties, who were an enormous part of our lives growing up watching football and

02:23:31.780 now even ignoring the CTE issue, which is its own separate tragedy, but just the orthopedic injury

02:23:37.720 that I don't think gets enough attention. I mean, I think CTE is very important. I'm so,

02:23:41.840 I mean, nothing makes me happier than to see the attention that is getting,

02:23:44.720 but we don't see a lot of these guys whose brains are intact, but whose bodies are destroyed.

02:23:50.180 Yeah. And look, I'd never had a brightly lit star like that, but I played sports and I had a great

02:23:55.400 time doing it, but I'm carrying around the injuries now that I sustained then that aren't

02:23:59.700 going to go away and affected my quality of life and what I'm capable of doing. But I can't dwell on

02:24:05.120 what I wish I could be doing at age 50. I have to really focus on what I'm capable of doing now

02:24:10.340 and maximizing it. And in essence, not giving a shit what gave up. And I have to say, I, even for

02:24:17.620 the, for the sort of small time, you know, good times that I had with athletics and where it's left

02:24:24.140 me now, I still want to trade it. And this is like the small time stuff because I, it led me to a group

02:24:29.480 of friends and a long list of memories that I wouldn't really trade for anything. So I, I guess I would

02:24:34.240 still make that deal. You know, if I could take back that one cut that tore my ACL, or if I can

02:24:38.940 take that, that, that one, you know, jump that tore my rotator cuff, I mean, sure I would do it,

02:24:45.060 but if I had to give up everything else, so I wasn't exposed to that risk to do it, I don't think

02:24:49.480 I'd do it. It makes sense. And so it's a great question that you ask. I mean, I always admire

02:24:53.560 the way you ask questions. You ask the best questions. I remember one time you asked, I wonder what

02:24:58.460 the first human being thought when they ate an avocado.

02:25:05.460 When, I don't even remember asking that. What was the context? Were we eating avocados?

02:25:09.880 No, you and, you and Lynn were talking about health. And I think Lynn was talking about some

02:25:14.580 of the community health projects that she's doing. And you said, yeah, you know, I often think about

02:25:18.580 what the first human must've thought when he ate an avocado.

02:25:22.720 Yeah. Cause I love avocados.

02:25:23.320 I'm like, who the fuck thinks of these questions? But these are, these are great questions. And I

02:25:28.000 actually just said this to my kids. I was like, Hey, the people who really make the world different

02:25:32.320 aren't the people with all the answers are the people with the questions. So, you know, think,

02:25:36.660 think about some things that, you know, how can I change this? What, why does it work this way?

02:25:40.820 If you're asking the right questions, you'll be making a difference. It's not necessarily that

02:25:44.880 you have to have the right answers. You always ask them. Great questions.

02:25:49.720 Speaking of questions, I will wrap this up because I'm, I'm really excited that tonight is my first

02:25:54.760 Yom Kippur break fast. I've only had a handful of these two, by the way.

02:25:59.940 When you told me that I had the opportunity to join you for that tonight, I stopped eating a day

02:26:04.360 and a half ago in anticipation of this. So normally I would easily go 18, 24 hours without eating, but

02:26:09.520 this time I'm going 36 hours cause I just can't wait. Do I get to wear a yarmulke by the way,

02:26:14.760 or is that not cool? This is a non-yarmulke Yom Kippur. It's a pretty low key. It's my in-laws

02:26:22.060 who are terrific. It's one of their very close friends who Lynn and I have become friends with,

02:26:26.660 and she's been hosting it for the last, I think eight, nine years that we've been here.

02:26:30.220 But they know I'm coming.

02:26:31.180 They do know you're coming, by the way. I did send an email saying, I know this is not my place to

02:26:34.680 invite a buddy, but can I invite a buddy? And she's like, of course, she's great. You'll enjoy it.

02:26:38.980 And I, I'm going to enjoy it. This is the first time I've actually fasted for Yom Kippur and I

02:26:43.000 haven't eaten since, you know, six o'clock last night, which is a new for me.

02:26:47.080 Fantastic. Isn't it amazing? It works.

02:26:48.780 Yeah, it does. I feel pretty good.

02:26:50.200 Evolution at its finest. Last thing before we go, you alluded to it earlier and it's,

02:26:55.580 I can't believe we haven't given more lip service to it during this discussion, but

02:26:59.100 you introduced me to probably one of the three most important sort of parlor tricks of my life,

02:27:05.500 which are the Dr. Buck's. So how did you, and by the way, just for the listener,

02:27:10.220 and we're going to link to it, of course, it's Dr. Buck, B-U-K-K. In medical school,

02:27:15.720 you were walking around with the Buck original. I became pretty obsessed. By the time I was in

02:27:20.120 residency, I had at least five. I had the Buck original, I had the cow catcher, I had the speed

02:27:25.080 teeth. I still remember all of these things. I only, I think I had the gnarlies, but my Owen,

02:27:32.040 our undersecretary of defense, was the one who introduced me to the Buck teeth.

02:27:36.840 And I wish I could say I'd come up with it, but Owen was the one who introduced me to it. And

02:27:40.220 remember he had to bite into the styrofoam cup. Oh my God.

02:27:43.140 Photocopy it, send it to him, and then you get your pair of bucks.

02:27:47.760 And back then, like they were 40 bucks. I don't know what they cost today, but at the time

02:27:51.460 for me to go and blow. No, that was a massive chunk of change.

02:27:54.660 It was a huge chunk of change. Yes.

02:27:55.720 When I was dropping, because I'd be buying multiple copies of these, like I wanted at least

02:27:59.960 two of each of them because I wanted to keep them everywhere. And I don't know if you know this

02:28:04.600 story, but when I got to residency, this is kind of a ridiculous story. Makes me sound like I'm more

02:28:11.920 of an idiot than I am. I would wear the bucks everywhere. And I had convinced the entire pediatric

02:28:18.840 tower at Hopkins, which is called CMC, that there were two Dr. Atiyas. There was-

02:28:24.720 The one with the good teeth.

02:28:25.940 The one with the bad. And we were twins. And when we were kids, our parents wanted us to get braces,

02:28:31.420 but Peter, me, I did. And my brother, I forget what his name was, Patrick, he didn't. We're

02:28:38.740 identical twins. We're the same in every way. We're both now doctors at Hopkins. But when you

02:28:43.160 page Dr. Atiyas, you got to be careful because you don't know which one's coming. It could be the

02:28:46.420 good teeth or the bad teeth one. And I was so egregious in my desire to do social experiments with

02:28:52.920 these things that, like the day I got to Hopkins, when we were doing orientation and filling out our

02:28:57.340 forms, I found the dental clinic. And I went in with my teeth and I said, hey, I just, hi, my name

02:29:02.820 is Peter Atiyah. I'm the new dental fellow. Did you guys get my records? And you cannot believe the

02:29:09.380 discomfort in that room. Because they're so real, right? Like they're so, like if you're listening

02:29:14.360 to this and you are even half curious what we're talking to, sight unseen, just go buy a bunch of

02:29:20.320 bucks. And I don't think you could be more amused for 40 bucks. No. So you remember Ellen from medical

02:29:27.500 school? Yeah, yeah. So she had a faux pas party. You might've been there. I don't know if, I can't

02:29:31.540 remember. I might've been, I might've been too inebriated to remember. So I had, I had the bucks in

02:29:36.220 my pocket and I show up at her faux pas party and she's there. I said, hey, Ellen, we're in their

02:29:42.220 kitchen. I take the milk out of the refrigerator and I start drinking from it. I put the milk back.

02:29:47.440 I lift up my leg. I let one rip. And Ellen goes, it's a fashion faux pas party. I'm like, oh.

02:29:58.200 So anyway, I had my bucks in later on and I was, I was talking to someone and I, you know, when you,

02:30:03.660 when you flash the smile, you have to keep your lips pursed, but once you flash the smile,

02:30:07.540 the look on people's faces is priceless. And you taught me the look. Yeah. You just,

02:30:11.860 it's, it's, it's the sort of shy coy. Yeah. And then you flash those teeth and oh my God.

02:30:16.080 Owen taught me the look. I have to say, he's sort of the buck master. And then when I would take a

02:30:20.680 bite out of something like a piece of the ham, I'd purposely have pain. Oh God. And you know,

02:30:25.520 are you okay? Oh, I'm okay. And so Lynn was at the party and she goes, oh Christ. She goes,

02:30:30.920 she goes, she goes, I overheard someone say, yeah, yeah, I saw him and he seemed okay. But then he

02:30:35.980 smiled. Oh, that's not the worst of it. He's at the dental school.

02:30:40.140 So I would, I got to the point where I would wear these, there was probably a three year period where

02:30:46.700 I wasn't not wearing them. I couldn't go more than 12 hours without putting them on. And it drove

02:30:51.520 everybody in my life nuts. Yeah. Because the very first time I met my wife's father and grandmother

02:30:57.800 and brother and sister was at like Easter, you know, one year, right. Or whatever. Like after we'd

02:31:03.540 been dating for six months or something like that. And as we're driving over there, she's begging me.

02:31:08.360 She says, please, Peter, I know you want to put the teeth in, but just don't. And I was like, look,

02:31:14.560 Jill, you gotta let me be me. Like you gotta let me be me. I gotta put the teeth in. And she's just,

02:31:21.160 she's like, fine. I'm not even going to, I'm not even going to acknowledge it. So we get there,

02:31:25.100 put the teeth in and her dad is a really shy, he can't make eye contact with me. Like he gets one

02:31:31.520 glimpse of this and he is in pure discomfort mode. He's just, oh, uh, uh, you know, like not

02:31:37.380 looking me in the eye and trying to talk to me and it's super awkward. So we're sitting down to

02:31:41.020 dinner. They're still in and it's artichoke is the appetizer. And her grandmother's legendary.

02:31:49.280 Italian grandmother makes these amazing artichokes and she's unfazed by my buffoonery. She just,

02:31:55.400 she just, it hasn't registered that it is that unusual. And so she picks up a big leaf of the artichoke

02:31:59.560 and she goes, look, Peter, this is how you do it. And she yanks it out with her teeth. And I'm like,

02:32:04.420 oh, I got it. Okay. Let me do that. And I, and her dad at this point is under, like he's beside

02:32:11.200 himself in discomfort. How did Jill contain it? How did she not like spill the beans? Well,

02:32:16.680 because at this point we've been dating six months, she had seen every minute of it every day. Like

02:32:19.940 she just like, this was like, it was more just annoyance with this. And then her brother figures it

02:32:25.400 out and he can't take it. So he gets up and walks away and he's laughing. And then

02:32:29.180 finally, like I come, I decide, she says, look, she pulls me aside and she goes,

02:32:33.340 you're not leaving here without coming clean. So you can do it on your own terms,

02:32:36.700 but you're coming clean before we leave. So I do. And her grandmother says what everybody has said

02:32:43.020 when I come clean, which is, yeah, we couldn't understand how your parents had the money to help

02:32:48.900 you go to college and loss or whatever medical school, but you never got braces. Oh, okay. It makes

02:32:54.800 more sense now. Right. You remember, remember Carlos Corvero? Oh yeah. I put the bucks in when

02:33:00.860 he was my chief resident at UCSF. We were rounding in the ICU and I was presenting a patient and he

02:33:08.380 was in town a couple, like two years ago when he was telling the story and goes, dude, I was looking

02:33:12.960 at you with those fucking teeth and I'm trying to remember what you're saying about this patient,

02:33:17.840 but I'm just focused on your fucking teeth. I'm like, what's wrong with this guy?

02:33:23.200 Anyway, I used to do experiments. They are an incredible, incredible device. Yeah. Yeah. And

02:33:29.280 so I remember when I was interviewing for residency, cause that's at the time that most I'd ever flown

02:33:33.540 in my life because you were doing a, you know, a round trip every weekend basically. And I, it wasn't

02:33:39.180 purely randomized, but I would just decide on one leg of the trip with the teeth, one leg of the trip

02:33:45.680 without the teeth. And I wanted to know how I was treated differently. And I got to tell you, I was

02:33:50.180 treated differently. When I walk around without the teeth, the flight attendant was nice to me and

02:33:54.520 she wanted to talk to me and blah, blah, blah, blah, blah. When I had the teeth in nobody, everyone was

02:33:58.780 so uncomfortable around me and I felt like a second class citizen. Well, again, you, you asked all the

02:34:04.160 good questions. What's life like with the teeth? What's life like without them? We should do a second

02:34:10.060 podcast just on the teeth. Yeah. We should do it a video podcast. Yeah. Yeah. For sure. I also,

02:34:15.160 I would get to the point where I liked the way I talked with the teeth cause you, you, you, you get

02:34:20.040 a different talk. You sort of have a funnier way of talking, which I love. Yeah. Your S's are a

02:34:25.220 little bit more prolonged. You got to work around it. Yeah. Yeah. And it got to the point where in

02:34:29.360 residency, I would wear them during surgery under my mask, even though nobody could see it just because

02:34:34.900 I liked the way I talked with the teeth in. That's a little fucked up, but I love it. I, I, I never

02:34:41.120 warm it. The best part of this story is at my engagement dinner, which you were at, weren't

02:34:48.220 you the night before the wedding? I mean, you didn't get there in time. I don't, I don't think

02:34:52.220 I was actually. Or not an engagement. What's the night before the rehearsal, rehearsal dinner.

02:34:56.000 Yeah. The rehearsal dinner. The best part of it is total surprise to me. Jill shows up with a set

02:35:01.960 of teeth. Of her own. Yeah. And you know which ones she went with? No. Which were the funniest

02:35:06.700 snaggletooth. She went with you to man. All one word. You know, the you to man. That's good. That's

02:35:13.980 great. Good for her. That's fantastic. Eric, thank you so much for setting aside three hours on a

02:35:20.020 Wednesday afternoon or whatever it is here to talk about this stuff. I know that, you know,

02:35:25.140 for many people listening, we probably didn't even scratch the surface of some of the really deep

02:35:29.060 questions. But I also think that we gave people probably a really good overview of this,

02:35:32.760 this profession of yours, which is in many ways, probably one of the few professions that deals

02:35:38.900 disproportionately with health span versus lifespan. So much of medicine is really geared towards

02:35:43.780 how do you extend life? But orthopedics is one of these professions that, that certainly

02:35:48.940 disproportionately thinks about how do you maintain that quality of life? And, you know, I wish everybody

02:35:53.020 could be lucky enough to have an orthopedic surgeon like you. My hope is that unfortunately that while

02:35:57.380 that's not likely or real, you've given people some metrics by which they can at least evaluate

02:36:02.340 their own doctor. No, hey, Peter, thank you. I love, love talking to you anytime. First time I've

02:36:07.440 talked to you with headphones and a microphone, but you know, we're very lucky to be able to do what

02:36:11.240 we do. We have a medical degree. We have a means of helping people and we see a window into people's

02:36:18.000 lives. It's a very privileged view. And, you know, I, you take that responsibility incredibly

02:36:24.240 seriously. I like to think I do as well. And I admire all the work that you do. You do incredible

02:36:29.600 work for so many people. And many of the principles that you're have advocated over the years, we've

02:36:35.220 adopted in our practice to try and help people. And so your legacy and your, your, your tree spreads

02:36:42.980 far and wide and helping lots and lots of people. So I, again, my, I have an incredible amount of

02:36:48.020 gratitude to you personally for how you've influenced my practice and my ability to help

02:36:52.700 patients again, cope with their conditions and their injuries and live their life to the fullest.

02:36:57.680 So it's a great opportunity, a great privilege, and it's always great seeing you at any time,

02:37:01.980 but thank you for allowing me to share my perspective on, on my profession.

02:37:05.980 Well, thank you, Eric. And that, that feeling is mutual. My appreciation for you is as deep as

02:37:09.720 yours is for me. Thank you.

02:37:10.660 Thank you.

02:37:40.660 Longevity, science, performance, sleep, et cetera. On social, you can find me on Twitter,

02:37:45.680 Instagram, and Facebook, all with the ID, Peter Atiyah, MD. But usually Twitter is the best way to

02:37:50.940 reach me to share your questions and comments. Now for the obligatory disclaimer, this podcast is for

02:37:55.640 general informational purposes only and does not constitute the practice of medicine, nursing, or other

02:38:00.640 professional healthcare services, including the giving of medical advice. And note, no doctor-patient

02:38:06.380 relationship is formed. The use of this information and the materials linked to the podcast is at the

02:38:11.820 user's own risk. The content of this podcast is not intended to be a substitute for professional

02:38:16.360 medical advice, diagnoses, or treatment. Users should not disregard or delay in obtaining medical

02:38:21.860 advice for any medical condition they have and should seek the assistance of their healthcare

02:38:26.000 professionals for any such conditions. Lastly, and perhaps most importantly, I take conflicts of

02:38:31.800 interest very seriously. For all of my disclosures, the companies I invest in and or advise, please visit

02:38:37.800 peteratiyahmd.com forward slash about.

The Peter Attia Drive - January 14, 2019

#36 - Eric Chehab, M.D.： Extending healthspan and preserving quality of life

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