November 8, 2023 • 31 mins
On this episode of Five to Thrive Live, our guest, anesthesiologist and integrative medicine physician, Dr. Rosie Sheinberg will empower you with ways to prepare for surgery. Dr. Sheinberg will also explain how to use integrative strategies after surgery to optimize recovery.
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(00:00):
Any health related information on the followingshow provides general information only. Content presented
on any show by any host orguest should not be substituted for a doctor's
advice. Always consult your physician beforebeginning any new diet, exercise, or
treatment program. Hello, welcome tofive to Thrive Live, a podcast about
(00:43):
thriving for those who have been affectedby cancer and chronic disease. I'm doctor
Lisa Schuler and I co host withmy good friend Carolyn Gazella. You can
find all of our past show podcastson iHeartRadio, Spotify, Pandora, iTunes,
Stitchard, of course on our websitethriveplan dot com. So I'm really
looking forward to tonight's show with doctorRosie Sheinberg. Doctor Sheinberg is an associate
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professor of Anesthesiology and pay Medicine atthe University of Washington. Prior to receiving
her undergraduate degree in biochemistry from theUniversity of California Davis, she was a
member of the Jeoffrey Ballet in NewYork City. She toured as a member
of the Phantom of the Opera anddanced for Carnival cruise lines. So she
was quite an artist She then earnedher m d. From Johns Hopkins.
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She completed her residency and performed afellowship in Cardiothoracic and pysiology at Johns Hopkins
Hospital. She joined the Johns HopkinsFaculty in twenty eleven, where she served
as the program director of the AdultCardiothoracic Antisysiology Fellowship Program until twenty sixteen.
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She completed a fellowship in Integrative Medicinethrough the Andrew Wild Program at the University
of Arizona in Tucson, and becameBoard certified and Integrative Medicine in twenty fourteen.
So before we start our conversation withdoctor Schinberg, I want to thank
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com. So we thank all oursponsors very much. Hello, doctor Joinberg,
Welcome to five to Thrive Live.Hello and thanks for having me here.
Glad to be here, you betso. I would love to hear
how you did such an about facefrom being a ballet dancer to anesphesiology and
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then after any physiology you went intointegrative medicine. Like, help us understand
your path. It's a little circuitous, but I promise that it seems to
make sense at least in my head, in my world. You know,
I grew up always wanting to bea ballerina and a dancer, and that's
what I did. And growing upyou naturally have inies and so you have
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encounters with doctors. So I wentto doctors when I had to go to
doctors. But I also started learningwhat I could do to sort of be
at peak health, peak performance,sort of optimize my body so I could
be the best dancer performer that Icould be. So, you know,
it's interesting. Actually, statistically,more professional ballet dancers ballet dancers go into
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healthcare than in sort of the generalpopulation, because I think there's a natural
interest in the body, not onlyfrom sort of how you can get it
to optimize, but then understanding whenyou get injured what you can do to
get back to health. So Ithink there's an actual connection there. Yeah,
and then I just always wanted tobe in this health and wellness world.
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So it's not like I went tomedicine and then came back to sort
of integrative medicine. I always wantedto be in the health and wellness world,
and I actually sort of struggled originallythinking gosh, what pathway would be
the best way to do that?And I thought of becoming a natural path
I thought of becoming sort of anm D physician, and I thought,
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you know, perhaps becoming the quoteunquote sort of you know MD Western medical
train it might help me bring theseideas to a broader population. Ultimately,
then going to do training like anatural path where at this point I think
there's more of a you're gonna getself selected people that go to a naturopath,
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and so I wanted to get toeverybody that I could, So I
went to the MD route, andYeah, then I just happened to fall
in love with anesthesia and then cardiacanesthesia, which is pretty much the opposite
end of wellness and prevention as youcan get, but goodness, I love
them both. I love that sortof you know, life saving end of
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it, and then I love thinkingabout the beginning end of it as well,
and the health and prevention. SoI knew I had always wanted to
go back and do the fellowship throughAndrew Wild's program at the University of Arizona.
In fact, at during medical school, I did a month long medicine
training there and really just knew Iwanted to go back and complete the loop
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when I was done, so that'swhat I did. Well, Yeah,
that's amazing, And yeah, soglad that you really have encompassed so much
such a broad continuum in your careerbecause it's given you a lot of authority
to speak about and to educate yourpatients about things like preparing for surgery,
which is our topic tonight. Solet's dive in. And first of all,
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I just want to ask why mightone think of ahead of a scheduled
surgery about doing specific preparations. Imean, is there really value in trying
to prepare yourself for sin It's sucha great question, And thank you for
bringing this topic because it's just somethingwe don't talk a lot about. People
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just sort of stumble into surgery whenthey sort of have to, and you
know, people feel like a lotof control is stripped away from them and
they don't really get to participate insort of their own optimal outcomes. But
in fact, it is a cruciallyimportant time to really get all your ducks
in a row, as it were, to optimize everything you can optimize.
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We know surgery is a big stresson the body. It's a big insult
to the body. We're invading thebody in ways we normally don't. So
to be ready to bounce back asfluidly as possible. That's the goal,
and that's why it's important to thinkabout it ahead of time, not after
it's already said and done. MOkay, So with that being said,
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what let's sort of categorize this first, Like somebody's let's say, has a
surgery on on their calendar, whatbroad areas of preparation can be addressed for
that person? Yeah, good question. So big areas that can be addressed,
and we already know, we alreadyhave evidence that these areas sort of
make an impact in how you willdo throughout your surgery, throughout your recovery.
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Are number one, kind of yourphysical strength, your muscle tone,
your muscle mass, your ability tosort of move around in life. We
know that people who have good muscletone, muscle strength, good exercise habits,
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that is a huge advantage. That'sone category nutrition. We can't talk
about, you know, anything inhealth and wellness without this foundation of nutrition.
And when your body is trying torecover, repair, build itself back
up, it needs building blocks andwhere do those come from? It pulls
from all the nutrients in the body. So nutrition is the second big broad
category. The third category is somethingthat I think has often been neglected,
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and that's the psychological preparation, becauseit's all about the stress rice response.
Being in that fight and flight sortof state before surgery, thinking about it,
worrying about it. You know,people try and write wills and do
things sort of, you know,in anticipation of badness happening. That stress
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creates a milieu of inflammation in thebody, a catabolic state where proteins and
building blocks are being broken down andutilized, rather than creating a nice reserve
and store and anti inflammatory state fromwhich to then repair after surgery. So
those, to me are the threebiggest categories kind of your physical muscular sort
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of physiologic tone, nutrition, psychologicalpreparation. M okay, so let's start
with nutrition. Actually this is notthe order you and in, but I
think that what do I eat iskind of the big thing that people think
about first. So what are kindof your top most important nutritional strategies?
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And maybe you can context this littlebit, like are we talking several months
in advance? A few weeks inadvance. You know, what's the timeframe.
Well, you know, I liketo use the you know, episodic,
you know, the episodic one timeof having surgery as a one of
those learning moments, one of thoseteachable moments for people, right, because
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the better you go in nutritionally,the better you you know, the better
you're set up for success after yoursurgery. So yes, I mean we
should all start eating healthfully at birth. And it's that, you know,
at a basis kind of what wethink of as ideally is this, you
want your body to be anti inflammatory, so anti inflammatory, whole foods,
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diet. The only particular thing thatwe think is a little bit different from
sort of any advice you'd give toanyone wanting to optimize their health through nutrition,
is we do our body utilizes andneeds a little more protein before surgery.
Now I hesitate saying that because Iwill say, from a vast majority
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standpoint, people are generally not deficientin protein. But it is something to
pay attention to because there are people, especially in the oncology world, cancer
patients who can be who can besort of protein deficient, elderly who may
not be eating sort of as muchor as balanced. So we have a
little bit elevated needs of protein aroundsurgical recovery, so that that is the
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only sort of caveat to a wholefoods, anti inflammatory style of eating with
lots of Again, all of thosenutrients that we think about are in the
rainbow of colors, so all ofthe rainbow colors of vegetables, whole grains,
clean proteins, that's what you wantto be eating, lots of hydration
water. So I want to diveinto this just for one additional question here,
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because this is a little bit confusing. So a lot of people,
let's say, listening to this willthink, Okay, I've got a stock
up on my protein and make sureI have my photonutrients in and then they're
told to facts before surgery overnight,so they're kind of in a depleted state.
I mean, is there any isthis changing? Is the literature supportive
of that? I don't know.Yes, So the literature does support that
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well. Okay, from an Westernbased evidence standpoint, what we are now
saying is that if you give someonea large carbohydrate load, it does mitigate
that strong hyperglycemic response that happens inresponse to the stress of the cortisol that
is being released during surgery. Sogenerally, you come into a surgery,
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you're fasting, you have the stressof surgery, your body releases cortisol,
you have glucose levels that go outof control, so blood sugars are higher
than normal, even in people whoare not diabetic, just because of that
stress response. So we are saying, and from the Western standpoint here,
here's a sort of what we understandis that if you give a big carbohydrate
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load, and in this day andage, that could be the recommendation to
drink an eight ounce gatorade in themorning before surgery. That is sort of
what we what we are telling patientsat this point. So technically the guidelines
are eight hours without food, butit's only two hours without clear liquids,
and clear liquids being water, teacoffee without any cream in it, anything,
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you know. Technically the old wayof saying that is any any liquid
you can see, you could reada paper behind it, if you look
through a glass, that's a clearliquid that you can have up to two
hours before surgery. So certainly hydratingbefore surgery is important at this point.
But yes, we are asking peopleto fast because having an empty, empty
stomach, does you know, doeslower the risk of things getting into the
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lungs and clothing problems under anesthesia.Okay, all right, good to note.
Okay, so what about you mentionedhaving good muscle tone and being you
know, fit and active is helpful. So that's a life you know,
not lifetime, that's a long termhabit essentially that you're suggesting once somebody has
a surgery scheduled, Let's say they'vebeen a bit sedentary, or perhaps they're
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going into surgery for a hip ora knee that's preventing them from being as
active as they would like. Whatdo you suggest to that point? And
should they in fact rest prior tosurgery. That's a great question. We
now know the more active and themore mobile people are before and immediately right
after surgery. These days of youshould rest, you should are done.
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The only time you should rest isif you are having active heart attack type
you know, ischemic symptoms. Evenif you're just having angina, you can
move around. And so we arenow finding that putting people who are even
sedentary into an exercise, strength trainingprogram, physical therapy even six to eight
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weeks before surgery makes a difference.So just because some hasn't been a lifelong
exerciser doesn't mean they shouldn't get anexercise prescription before surgery. Almost anyone can
do something. It should be tailoredtowards what they're you know, can do.
If they are, you know,having a knee surgery, We're not
going to recommend they start running andbicycling and things like that, but we
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could do other things with upper body, other ways of getting their heart rate
up, other ways of utilizing youknow, getting body strength and other body
parts at this moment that will stillbenefit them. M hm. And when
you say benefit, are you speakingspecifically about faster recovery, less fewer risk,
lower risk of complication, Like wherewhere's the benefit? Yeah, So
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as we start to categorize more andmore, you know, being very sedentary
and not very strong and mobile isone characteristic of what we're calling frailty,
right, and we're now having manymany frailty scoring systems. Malnutrition, whether
you're obese or things in low musclestrength, low cognitives reserve people with you
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know, decreasing mental function. Theoutcomes that we look at our mortality,
So your chance of dying within thirtydays within a year, your chance of
having a major or a minor complicationsepsis, a pneumonia after surgery, a
wound infection, things like that.So little and big outcomes are being affected
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by your physical fitness going in.Okay, all right, so yeah,
that builds the case, I wouldsay. Yeah. So an area I
know that you are personally very passionateabout is sort of the mind body aspect
of surgery preparation. And of coursemost people going into surgery are anxious about
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surgery. I mean they sort ofhave to relinquish themselves completely to the hands
of basically strangers, right, andin an environment that's unfamiliar to them.
So it's normal think for people tobe anxious when they're facing surgery. So
why is that a problem? Numberone? And number two? What do
you advise your patients to do aboutit? Yeah? First of all,
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anxiety absolutely, as you said,it's a normal and natural reaction because this
is unknown for them. Just becausemy office is in the operating room,
that's not where everybody spends their day. That's not everybody's happy place. So
I get that many of us likecontrol over our working environments. I think
that's part of the reason I'm anantithesiologist. I get I get full control
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over everything in that operating room,and so having to give that up as
a patient is very uncomfortable and verydisquieting. We know there are studies that
tell us that psychological factors distress iscorrelated with poor clinical outcomes. And we
know that the mind body reaction,so the physiologic reaction leads to insulin insensitivity,
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break down, a proteins catabolic state, exactly what you don't want before
surgery, now psychological preparation. Sothis anxiety, it's not something you can
just turn off the day of surgery. It's a muscle to build. If
all of us, you know,had a background that we were, for
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example, raised and we were Buddhistor Tibetan monks, and we spent eight
hours a day meditating, wouldn't thatbe amazing. They are experts that have
learned to turn in and they cancontrol. So this is where I love.
This is where integrative medicine and anesthesiaoverlap in the autonomic nervous system.
So I love talking about the autonomicnervous system. It's that stress response,
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right, It's the fight and flightversus the rest and digest system, and
in anesthesia, obviously when you're anxiouscoming in that fight or flight is really
activated. But what we are learningusing the mind body connection is that we
actually have control over the balance betweenthe sympathetic and parasympathetic parts of the nervous
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system. So that's what I likepatients to start practicing and learning for themselves
that they actually do have some controlover that. So I like some kind
of preparation, you know, thesooner the better. If someone has a
practice where they have already learned toturn inward and learn to enhance their relaxation
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by breathing, by yoga, bymeditating, many ways to buy biofeedback.
There's many ways to get at theautonomic nervous system. But if they haven't,
there is still time before surgery todo this and practicing something. So
I like pairing things together. Sopracticing guided visualization I think is super important.
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I'd love to talk more about thatin a minute. But adding the
deep breathing which directly connects to theparasympathetic you know, and enhances parasympathetic tone
when you start breathing deeply, andthen I love pairing that with another integrative
approach, which is aroma therapy.So you start practicing your deep breathing guided
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imagery, all while you're inhaling aparticular scent because we have these associations.
So later when you're in the preop area you're nervous, you can start
utilizing your aroma therapy and he putsyou right back in your bedroom or wherever
you happen, your living room,wherever you happen to practice. You're breathing
your guided visualization. Great idea,that's fantastic and that's allowable. Yeah,
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yes to you. Yeah, okay, so let's go back to guided visualization.
Yeah, so guided visualization. Igrew I was not only a dancer,
but I was actually a pre Olympicgymnast, and I had an amazing
instructor who in the eighties the Russianswere the best in the world at gymnastics,
and so he learned Russian so hecould translate their Russian gymnastics training manuals
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and then train us according to whatthey were doing. And one of the
things they were doing. This isthe days before we'd called it guided visualization,
but they were doing what they calledmental rehearsal. And nowadays no Olympic
trained athlete gets away without doing allof this guided visualization mental rehearsal. And
we know because they hook them upand do lots of studies that it creates
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physiologic change. The magic is whereyou have to translate it is. And
this is a reason like I needto I coach people with this because it's
not a passive process. You haveto use all of your five senses so
that you almost can't tell that whatyou're visualizing is not happening right now.
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It just feels like it could behappening right now because you're just feeling and
sensing all of the details. You'rehearing what would be around you, you're
smelling what you would smell. You'reseeing, you're tasting, you're touching,
you're feeling. So, for example, I'm not asking people just to say,
oh, yeah, I'm relaxing onthe beach, very relaxing. No,
what I'm saying is you can feelthe gritty sand underneath your toes,
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and it's hot because the sun's beatingdown on it. And if you dig
your toes under that surface sand,maybe you're by the water's edge, and
now it's cool and moist because it'snow underneath that surface, like you can
feel that temperature change with your toes. You're really smelling and inhaling and smelling
that salt air and listening to thewave crashes, you know, how slow
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or how fast they're coming in andcrashing, and hearing the birds that are
calling there. You know, maybethere's a pelican or two or some kind
of seabirds. So it's very muchan active process utilizing all your senses.
That's what gets that's what generates physiologicchange. So the idea again is that
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if we if one does this visualization, which they can generate their own,
as you said, and there aremany available on various free apps now as
well. They can listen to that, they can make sure they're relaxed,
they're breathing deeply, they have anaroma therapy sent so they're really in training
their mind to a state of relaxationwhich they can then reactivate in the pre
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setting and after surgery as well.Exactly. Okay, yeah, that sounds
really good. Now is this partof there's this thing, I don't know
if that's quite the right word,but this sort of movement I guess among
the operative community called Enhanced Recovery aftersurgery or eras. Can you describe that?
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And is this what you're talking abouta part of that? Yeah,
so ERAS came about, I don'tknow, twenty thirty years ago now,
but it is called enhanced Recovery aftersurgery. It is sort of a collection
of best practices. It's not anyone thing. It's not any one protocol.
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Every institution in implements sort of avariety of let's say packages. It
technically includes things in the preoperative state, the intraoperative state, and the post
operative state. And they are thingslike in the preoperative state, there's drinking
the gatorade thirty minutes before, there'sdoing an antibacterial soap scrub the night before
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surgery. Intraoperative, it might beputting a warmer over the body to keep
the temperature above thirty six degrees sowe don't get hypothermic. It might be
gold directed fluid therapy, specific antibioticrecommendations. Afterwards, it might be getting
people eating food by mouth as soonas possible, getting drains out as soon
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as possible, getting people up andmoving as soon as possible. So ERAS
has been this collection of interventions thatby themselves. They don't improve outcomes,
but as a collection they do.I think of it as almost like integrative
medicine light. They're speaking about theright factors. We're starting to think more
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broadly about patients, what can wedo to enhance the whole beginning, middle,
and end part of surgery. Butthey just don't use the entire toolbox
that we are trained for in integrativemedicine. So enhanced recovery does think about
some degree of psychological preparation, nutrition, and exercise. They may implement it,
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for example, by giving people Insureshakes to make sure they get enough
protein before surgery. Is that sortof a whole food's anti inflammatory intervention?
Probably not, But does it getthem sort of to the goal of X
amount of protein per day? Yeah? It does. So that's why I
think integrative medicine we think a littlemore broadly and holistically about these ideas.
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But eras is sort of our Westernmedicine attempt to get on board with a
complete perioperative plan for a pape.Yeah. Well, it's really wonderful that
there's concentrated effort in these areas.And I think that you know, the
additional you know, the deeper integrativestrategies that you're bringing to your work environment,
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and you know, I know you'reworking on some publications and so forth,
is really wonderful. So I justhave to ask, we have an
any anesthesiologist with us, you know, anesthesia so unusual, like you go
in and then the next thing youknow, you're out, but there's a
lot of thought that you're some partof your mind is still aware. Do
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you advise your patients anything about thatperiod of time, like, you know,
can they is it a time wherethey can sort of use power of
self suggestion or they just relax?Yeah, so I think it is a
great time. Often I don't thinkwe utilize it to its fullest potential.
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We get busy trying to get them, you know, on the bed,
monitors on, you know, readyto go. We all do a team
time out now and then before weget them to sleep. I think,
as a patient, what I wouldbe doing to optimize my outcome is that's
the time again, your sympathetic systemis going to be revving up unfamiliar environment,
it's cold, it's bright. Iwould be deep breathing, and then
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with or without the help of youranesthesia provider to coach you to start thinking
about again, either that visualization thatyou have been, that you created in
your your head, maybe something whereyou are fully healed and doing something you
love to do after surgery, forexample. Or sometimes we ask patients to
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go to their favorite vacation spot,or I ask them to think of their
loved one and how happy that lovedone's going to be the moment they walk
into the room after surgery they're goingto and they see that they're you know,
their person who had surgery is doingokay, oh that look of like
relief and happiness, And think abouthow much you love your your spouse,
your child, old, your parent, and how much they love you.
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So trying to get those positive feelingsin their body. So I try and
use the strongest association I can toget them back into their body and thinking
about that positive association positive affect intheir minds. So they start with a
parent's sympathetic tone going to sleep.Yeah, really great, great advice.
I think you've been very consistent insaying this, so the importance of it
(28:26):
should be evident. And so we'realmost out a time. I want to
give you thirty seconds to give usa last tip or thought and if you
have any website or social media thatyou'd like to share. Yeah, something
we hadn't talked about yet yet.I think acupuncture has such amazing data perioperatively.
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I'm also trained in medical acupuncture,so I will often add it to
my patient's plans. I wish itwere more accessible and utilized. We're not
there yet, but it is incrediblybeneficial right before after. I don't think
there's a limitation if you're someone whogets acupuncture, set it up as soon
as you're you know, out ofthe hospital, and do it routinely for
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you know, an intensive period aftersurgery to help your body recover. It's
beneficial. I think it's beneficial todo it ahead of time, to get
all of your meridians, everything sortof you know, as optimized as possible
before you even go in. TheOther thing I just want to say is
I want to make sure people feelempowered to tell their anesthesia providers what they
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would like. For example, ifthey because I have a lot of people
that you know, are doing someof the mind body things that are like,
oh, I don't want to Idon't want to ask them to say
anything positive one and going to sleeplike I'm embarrassed to do that, so
they're very quiet. I want toempower people to ask their providers to do
things that they believe would beneficial.If they want to have an aromatherapy,
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you know, little sticker sent togo in the room, ask if that
can be done. If they wanttheir anesthesia provider to tell them positive things
going to sleep and waking up,ask, So I want to empower people
to feel like they can contribute totheir own plan. Perfect, Okay,
and do you have a website thatour listeners can find you at? I
(30:12):
don't. I don't really have anactive GiB. All right, tell you
the truth. I am. Iam on on I guess the X website
now the old Twitter and at ourShinberg But yeah, yeah, perfect,
Well, gosh, doctor Schinberg,this has been a pleasure, and really
(30:33):
want to thank you for taking timeout of your I know, very busy
scheduled to join us. And thatdoes wrap up this episode of five to
Thrive Live Again. I want tothank our sponsors NFH, the professional supplement
line bridging the gap between nutraceuticals andevidence based medicine, cognizant set of Cooling
to help enhance memory, focus andattention. Immuse a post biotic for immune
(30:56):
support and doctor Orhiro's Probiotics award winningpre and probiotic formulas. And thank you
listener for joining us. May youexperience joy, laughter and love. It's
time to thrive everyone, Thanks againRosie and have a great night everyone.
Good night everyone, and thankfully mis
Any health related information on the followingshow provides general information only. Content presented
on any show by any host orguest should not be substituted for a doctor's
advice. Always consult your physician beforebeginning any new diet, exercise, or
treatment program. Hello, welcome tofive to Thrive Live, a podcast about
(00:43):
thriving for those who have been affectedby cancer and chronic disease. I'm doctor
Lisa Schuler and I co host withmy good friend Carolyn Gazella. You can
find all of our past show podcastson iHeartRadio, Spotify, Pandora, iTunes,
Stitchard, of course on our websitethriveplan dot com. So I'm really
looking forward to tonight's show with doctorRosie Sheinberg. Doctor Sheinberg is an associate
(01:07):
professor of Anesthesiology and pay Medicine atthe University of Washington. Prior to receiving
her undergraduate degree in biochemistry from theUniversity of California Davis, she was a
member of the Jeoffrey Ballet in NewYork City. She toured as a member
of the Phantom of the Opera anddanced for Carnival cruise lines. So she
was quite an artist She then earnedher m d. From Johns Hopkins.
(01:30):
She completed her residency and performed afellowship in Cardiothoracic and pysiology at Johns Hopkins
Hospital. She joined the Johns HopkinsFaculty in twenty eleven, where she served
as the program director of the AdultCardiothoracic Antisysiology Fellowship Program until twenty sixteen.
(01:51):
She completed a fellowship in Integrative Medicinethrough the Andrew Wild Program at the University
of Arizona in Tucson, and becameBoard certified and Integrative Medicine in twenty fourteen.
So before we start our conversation withdoctor Schinberg, I want to thank
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com. So we thank all oursponsors very much. Hello, doctor Joinberg,
Welcome to five to Thrive Live.Hello and thanks for having me here.
Glad to be here, you betso. I would love to hear
how you did such an about facefrom being a ballet dancer to anesphesiology and
(03:35):
then after any physiology you went intointegrative medicine. Like, help us understand
your path. It's a little circuitous, but I promise that it seems to
make sense at least in my head, in my world. You know,
I grew up always wanting to bea ballerina and a dancer, and that's
what I did. And growing upyou naturally have inies and so you have
(04:00):
encounters with doctors. So I wentto doctors when I had to go to
doctors. But I also started learningwhat I could do to sort of be
at peak health, peak performance,sort of optimize my body so I could
be the best dancer performer that Icould be. So, you know,
it's interesting. Actually, statistically,more professional ballet dancers ballet dancers go into
(04:26):
healthcare than in sort of the generalpopulation, because I think there's a natural
interest in the body, not onlyfrom sort of how you can get it
to optimize, but then understanding whenyou get injured what you can do to
get back to health. So Ithink there's an actual connection there. Yeah,
and then I just always wanted tobe in this health and wellness world.
(04:47):
So it's not like I went tomedicine and then came back to sort
of integrative medicine. I always wantedto be in the health and wellness world,
and I actually sort of struggled originallythinking gosh, what pathway would be
the best way to do that?And I thought of becoming a natural path
I thought of becoming sort of anm D physician, and I thought,
(05:08):
you know, perhaps becoming the quoteunquote sort of you know MD Western medical
train it might help me bring theseideas to a broader population. Ultimately,
then going to do training like anatural path where at this point I think
there's more of a you're gonna getself selected people that go to a naturopath,
(05:30):
and so I wanted to get toeverybody that I could, So I
went to the MD route, andYeah, then I just happened to fall
in love with anesthesia and then cardiacanesthesia, which is pretty much the opposite
end of wellness and prevention as youcan get, but goodness, I love
them both. I love that sortof you know, life saving end of
(05:50):
it, and then I love thinkingabout the beginning end of it as well,
and the health and prevention. SoI knew I had always wanted to
go back and do the fellowship throughAndrew Wild's program at the University of Arizona.
In fact, at during medical school, I did a month long medicine
training there and really just knew Iwanted to go back and complete the loop
(06:14):
when I was done, so that'swhat I did. Well, Yeah,
that's amazing, And yeah, soglad that you really have encompassed so much
such a broad continuum in your careerbecause it's given you a lot of authority
to speak about and to educate yourpatients about things like preparing for surgery,
which is our topic tonight. Solet's dive in. And first of all,
(06:35):
I just want to ask why mightone think of ahead of a scheduled
surgery about doing specific preparations. Imean, is there really value in trying
to prepare yourself for sin It's sucha great question, And thank you for
bringing this topic because it's just somethingwe don't talk a lot about. People
(06:57):
just sort of stumble into surgery whenthey sort of have to, and you
know, people feel like a lotof control is stripped away from them and
they don't really get to participate insort of their own optimal outcomes. But
in fact, it is a cruciallyimportant time to really get all your ducks
in a row, as it were, to optimize everything you can optimize.
(07:20):
We know surgery is a big stresson the body. It's a big insult
to the body. We're invading thebody in ways we normally don't. So
to be ready to bounce back asfluidly as possible. That's the goal,
and that's why it's important to thinkabout it ahead of time, not after
it's already said and done. MOkay, So with that being said,
(07:44):
what let's sort of categorize this first, Like somebody's let's say, has a
surgery on on their calendar, whatbroad areas of preparation can be addressed for
that person? Yeah, good question. So big areas that can be addressed,
and we already know, we alreadyhave evidence that these areas sort of
make an impact in how you willdo throughout your surgery, throughout your recovery.
(08:07):
Are number one, kind of yourphysical strength, your muscle tone,
your muscle mass, your ability tosort of move around in life. We
know that people who have good muscletone, muscle strength, good exercise habits,
(08:28):
that is a huge advantage. That'sone category nutrition. We can't talk
about, you know, anything inhealth and wellness without this foundation of nutrition.
And when your body is trying torecover, repair, build itself back
up, it needs building blocks andwhere do those come from? It pulls
from all the nutrients in the body. So nutrition is the second big broad
category. The third category is somethingthat I think has often been neglected,
(08:54):
and that's the psychological preparation, becauseit's all about the stress rice response.
Being in that fight and flight sortof state before surgery, thinking about it,
worrying about it. You know,people try and write wills and do
things sort of, you know,in anticipation of badness happening. That stress
(09:16):
creates a milieu of inflammation in thebody, a catabolic state where proteins and
building blocks are being broken down andutilized, rather than creating a nice reserve
and store and anti inflammatory state fromwhich to then repair after surgery. So
those, to me are the threebiggest categories kind of your physical muscular sort
(09:37):
of physiologic tone, nutrition, psychologicalpreparation. M okay, so let's start
with nutrition. Actually this is notthe order you and in, but I
think that what do I eat iskind of the big thing that people think
about first. So what are kindof your top most important nutritional strategies?
(09:58):
And maybe you can context this littlebit, like are we talking several months
in advance? A few weeks inadvance. You know, what's the timeframe.
Well, you know, I liketo use the you know, episodic,
you know, the episodic one timeof having surgery as a one of
those learning moments, one of thoseteachable moments for people, right, because
(10:20):
the better you go in nutritionally,the better you you know, the better
you're set up for success after yoursurgery. So yes, I mean we
should all start eating healthfully at birth. And it's that, you know,
at a basis kind of what wethink of as ideally is this, you
want your body to be anti inflammatory, so anti inflammatory, whole foods,
(10:41):
diet. The only particular thing thatwe think is a little bit different from
sort of any advice you'd give toanyone wanting to optimize their health through nutrition,
is we do our body utilizes andneeds a little more protein before surgery.
Now I hesitate saying that because Iwill say, from a vast majority
(11:01):
standpoint, people are generally not deficientin protein. But it is something to
pay attention to because there are people, especially in the oncology world, cancer
patients who can be who can besort of protein deficient, elderly who may
not be eating sort of as muchor as balanced. So we have a
little bit elevated needs of protein aroundsurgical recovery, so that that is the
(11:22):
only sort of caveat to a wholefoods, anti inflammatory style of eating with
lots of Again, all of thosenutrients that we think about are in the
rainbow of colors, so all ofthe rainbow colors of vegetables, whole grains,
clean proteins, that's what you wantto be eating, lots of hydration
water. So I want to diveinto this just for one additional question here,
(11:48):
because this is a little bit confusing. So a lot of people,
let's say, listening to this willthink, Okay, I've got a stock
up on my protein and make sureI have my photonutrients in and then they're
told to facts before surgery overnight,so they're kind of in a depleted state.
I mean, is there any isthis changing? Is the literature supportive
of that? I don't know.Yes, So the literature does support that
(12:13):
well. Okay, from an Westernbased evidence standpoint, what we are now
saying is that if you give someonea large carbohydrate load, it does mitigate
that strong hyperglycemic response that happens inresponse to the stress of the cortisol that
is being released during surgery. Sogenerally, you come into a surgery,
(12:37):
you're fasting, you have the stressof surgery, your body releases cortisol,
you have glucose levels that go outof control, so blood sugars are higher
than normal, even in people whoare not diabetic, just because of that
stress response. So we are saying, and from the Western standpoint here,
here's a sort of what we understandis that if you give a big carbohydrate
(12:58):
load, and in this day andage, that could be the recommendation to
drink an eight ounce gatorade in themorning before surgery. That is sort of
what we what we are telling patientsat this point. So technically the guidelines
are eight hours without food, butit's only two hours without clear liquids,
and clear liquids being water, teacoffee without any cream in it, anything,
(13:26):
you know. Technically the old wayof saying that is any any liquid
you can see, you could reada paper behind it, if you look
through a glass, that's a clearliquid that you can have up to two
hours before surgery. So certainly hydratingbefore surgery is important at this point.
But yes, we are asking peopleto fast because having an empty, empty
stomach, does you know, doeslower the risk of things getting into the
(13:48):
lungs and clothing problems under anesthesia.Okay, all right, good to note.
Okay, so what about you mentionedhaving good muscle tone and being you
know, fit and active is helpful. So that's a life you know,
not lifetime, that's a long termhabit essentially that you're suggesting once somebody has
a surgery scheduled, Let's say they'vebeen a bit sedentary, or perhaps they're
(14:11):
going into surgery for a hip ora knee that's preventing them from being as
active as they would like. Whatdo you suggest to that point? And
should they in fact rest prior tosurgery. That's a great question. We
now know the more active and themore mobile people are before and immediately right
after surgery. These days of youshould rest, you should are done.
(14:35):
The only time you should rest isif you are having active heart attack type
you know, ischemic symptoms. Evenif you're just having angina, you can
move around. And so we arenow finding that putting people who are even
sedentary into an exercise, strength trainingprogram, physical therapy even six to eight
(14:56):
weeks before surgery makes a difference.So just because some hasn't been a lifelong
exerciser doesn't mean they shouldn't get anexercise prescription before surgery. Almost anyone can
do something. It should be tailoredtowards what they're you know, can do.
If they are, you know,having a knee surgery, We're not
going to recommend they start running andbicycling and things like that, but we
(15:18):
could do other things with upper body, other ways of getting their heart rate
up, other ways of utilizing youknow, getting body strength and other body
parts at this moment that will stillbenefit them. M hm. And when
you say benefit, are you speakingspecifically about faster recovery, less fewer risk,
lower risk of complication, Like wherewhere's the benefit? Yeah, So
(15:43):
as we start to categorize more andmore, you know, being very sedentary
and not very strong and mobile isone characteristic of what we're calling frailty,
right, and we're now having manymany frailty scoring systems. Malnutrition, whether
you're obese or things in low musclestrength, low cognitives reserve people with you
(16:04):
know, decreasing mental function. Theoutcomes that we look at our mortality,
So your chance of dying within thirtydays within a year, your chance of
having a major or a minor complicationsepsis, a pneumonia after surgery, a
wound infection, things like that.So little and big outcomes are being affected
(16:26):
by your physical fitness going in.Okay, all right, so yeah,
that builds the case, I wouldsay. Yeah. So an area I
know that you are personally very passionateabout is sort of the mind body aspect
of surgery preparation. And of coursemost people going into surgery are anxious about
(16:48):
surgery. I mean they sort ofhave to relinquish themselves completely to the hands
of basically strangers, right, andin an environment that's unfamiliar to them.
So it's normal think for people tobe anxious when they're facing surgery. So
why is that a problem? Numberone? And number two? What do
you advise your patients to do aboutit? Yeah? First of all,
(17:11):
anxiety absolutely, as you said,it's a normal and natural reaction because this
is unknown for them. Just becausemy office is in the operating room,
that's not where everybody spends their day. That's not everybody's happy place. So
I get that many of us likecontrol over our working environments. I think
that's part of the reason I'm anantithesiologist. I get I get full control
(17:32):
over everything in that operating room,and so having to give that up as
a patient is very uncomfortable and verydisquieting. We know there are studies that
tell us that psychological factors distress iscorrelated with poor clinical outcomes. And we
know that the mind body reaction,so the physiologic reaction leads to insulin insensitivity,
(17:57):
break down, a proteins catabolic state, exactly what you don't want before
surgery, now psychological preparation. Sothis anxiety, it's not something you can
just turn off the day of surgery. It's a muscle to build. If
all of us, you know,had a background that we were, for
(18:18):
example, raised and we were Buddhistor Tibetan monks, and we spent eight
hours a day meditating, wouldn't thatbe amazing. They are experts that have
learned to turn in and they cancontrol. So this is where I love.
This is where integrative medicine and anesthesiaoverlap in the autonomic nervous system.
So I love talking about the autonomicnervous system. It's that stress response,
(18:41):
right, It's the fight and flightversus the rest and digest system, and
in anesthesia, obviously when you're anxiouscoming in that fight or flight is really
activated. But what we are learningusing the mind body connection is that we
actually have control over the balance betweenthe sympathetic and parasympathetic parts of the nervous
(19:03):
system. So that's what I likepatients to start practicing and learning for themselves
that they actually do have some controlover that. So I like some kind
of preparation, you know, thesooner the better. If someone has a
practice where they have already learned toturn inward and learn to enhance their relaxation
(19:26):
by breathing, by yoga, bymeditating, many ways to buy biofeedback.
There's many ways to get at theautonomic nervous system. But if they haven't,
there is still time before surgery todo this and practicing something. So
I like pairing things together. Sopracticing guided visualization I think is super important.
(19:48):
I'd love to talk more about thatin a minute. But adding the
deep breathing which directly connects to theparasympathetic you know, and enhances parasympathetic tone
when you start breathing deeply, andthen I love pairing that with another integrative
approach, which is aroma therapy.So you start practicing your deep breathing guided
(20:08):
imagery, all while you're inhaling aparticular scent because we have these associations.
So later when you're in the preop area you're nervous, you can start
utilizing your aroma therapy and he putsyou right back in your bedroom or wherever
you happen, your living room,wherever you happen to practice. You're breathing
your guided visualization. Great idea,that's fantastic and that's allowable. Yeah,
(20:33):
yes to you. Yeah, okay, so let's go back to guided visualization.
Yeah, so guided visualization. Igrew I was not only a dancer,
but I was actually a pre Olympicgymnast, and I had an amazing
instructor who in the eighties the Russianswere the best in the world at gymnastics,
and so he learned Russian so hecould translate their Russian gymnastics training manuals
(20:56):
and then train us according to whatthey were doing. And one of the
things they were doing. This isthe days before we'd called it guided visualization,
but they were doing what they calledmental rehearsal. And nowadays no Olympic
trained athlete gets away without doing allof this guided visualization mental rehearsal. And
we know because they hook them upand do lots of studies that it creates
(21:19):
physiologic change. The magic is whereyou have to translate it is. And
this is a reason like I needto I coach people with this because it's
not a passive process. You haveto use all of your five senses so
that you almost can't tell that whatyou're visualizing is not happening right now.
(21:41):
It just feels like it could behappening right now because you're just feeling and
sensing all of the details. You'rehearing what would be around you, you're
smelling what you would smell. You'reseeing, you're tasting, you're touching,
you're feeling. So, for example, I'm not asking people just to say,
oh, yeah, I'm relaxing onthe beach, very relaxing. No,
what I'm saying is you can feelthe gritty sand underneath your toes,
(22:04):
and it's hot because the sun's beatingdown on it. And if you dig
your toes under that surface sand,maybe you're by the water's edge, and
now it's cool and moist because it'snow underneath that surface, like you can
feel that temperature change with your toes. You're really smelling and inhaling and smelling
that salt air and listening to thewave crashes, you know, how slow
(22:26):
or how fast they're coming in andcrashing, and hearing the birds that are
calling there. You know, maybethere's a pelican or two or some kind
of seabirds. So it's very muchan active process utilizing all your senses.
That's what gets that's what generates physiologicchange. So the idea again is that
(22:48):
if we if one does this visualization, which they can generate their own,
as you said, and there aremany available on various free apps now as
well. They can listen to that, they can make sure they're relaxed,
they're breathing deeply, they have anaroma therapy sent so they're really in training
their mind to a state of relaxationwhich they can then reactivate in the pre
(23:12):
setting and after surgery as well.Exactly. Okay, yeah, that sounds
really good. Now is this partof there's this thing, I don't know
if that's quite the right word,but this sort of movement I guess among
the operative community called Enhanced Recovery aftersurgery or eras. Can you describe that?
(23:33):
And is this what you're talking abouta part of that? Yeah,
so ERAS came about, I don'tknow, twenty thirty years ago now,
but it is called enhanced Recovery aftersurgery. It is sort of a collection
of best practices. It's not anyone thing. It's not any one protocol.
(23:55):
Every institution in implements sort of avariety of let's say packages. It
technically includes things in the preoperative state, the intraoperative state, and the post
operative state. And they are thingslike in the preoperative state, there's drinking
the gatorade thirty minutes before, there'sdoing an antibacterial soap scrub the night before
(24:19):
surgery. Intraoperative, it might beputting a warmer over the body to keep
the temperature above thirty six degrees sowe don't get hypothermic. It might be
gold directed fluid therapy, specific antibioticrecommendations. Afterwards, it might be getting
people eating food by mouth as soonas possible, getting drains out as soon
(24:41):
as possible, getting people up andmoving as soon as possible. So ERAS
has been this collection of interventions thatby themselves. They don't improve outcomes,
but as a collection they do.I think of it as almost like integrative
medicine light. They're speaking about theright factors. We're starting to think more
(25:03):
broadly about patients, what can wedo to enhance the whole beginning, middle,
and end part of surgery. Butthey just don't use the entire toolbox
that we are trained for in integrativemedicine. So enhanced recovery does think about
some degree of psychological preparation, nutrition, and exercise. They may implement it,
(25:26):
for example, by giving people Insureshakes to make sure they get enough
protein before surgery. Is that sortof a whole food's anti inflammatory intervention?
Probably not, But does it getthem sort of to the goal of X
amount of protein per day? Yeah? It does. So that's why I
think integrative medicine we think a littlemore broadly and holistically about these ideas.
(25:51):
But eras is sort of our Westernmedicine attempt to get on board with a
complete perioperative plan for a pape.Yeah. Well, it's really wonderful that
there's concentrated effort in these areas.And I think that you know, the
additional you know, the deeper integrativestrategies that you're bringing to your work environment,
(26:12):
and you know, I know you'reworking on some publications and so forth,
is really wonderful. So I justhave to ask, we have an
any anesthesiologist with us, you know, anesthesia so unusual, like you go
in and then the next thing youknow, you're out, but there's a
lot of thought that you're some partof your mind is still aware. Do
(26:33):
you advise your patients anything about thatperiod of time, like, you know,
can they is it a time wherethey can sort of use power of
self suggestion or they just relax?Yeah, so I think it is a
great time. Often I don't thinkwe utilize it to its fullest potential.
(26:55):
We get busy trying to get them, you know, on the bed,
monitors on, you know, readyto go. We all do a team
time out now and then before weget them to sleep. I think,
as a patient, what I wouldbe doing to optimize my outcome is that's
the time again, your sympathetic systemis going to be revving up unfamiliar environment,
it's cold, it's bright. Iwould be deep breathing, and then
(27:18):
with or without the help of youranesthesia provider to coach you to start thinking
about again, either that visualization thatyou have been, that you created in
your your head, maybe something whereyou are fully healed and doing something you
love to do after surgery, forexample. Or sometimes we ask patients to
(27:40):
go to their favorite vacation spot,or I ask them to think of their
loved one and how happy that lovedone's going to be the moment they walk
into the room after surgery they're goingto and they see that they're you know,
their person who had surgery is doingokay, oh that look of like
relief and happiness, And think abouthow much you love your your spouse,
your child, old, your parent, and how much they love you.
(28:02):
So trying to get those positive feelingsin their body. So I try and
use the strongest association I can toget them back into their body and thinking
about that positive association positive affect intheir minds. So they start with a
parent's sympathetic tone going to sleep.Yeah, really great, great advice.
I think you've been very consistent insaying this, so the importance of it
(28:26):
should be evident. And so we'realmost out a time. I want to
give you thirty seconds to give usa last tip or thought and if you
have any website or social media thatyou'd like to share. Yeah, something
we hadn't talked about yet yet.I think acupuncture has such amazing data perioperatively.
(28:47):
I'm also trained in medical acupuncture,so I will often add it to
my patient's plans. I wish itwere more accessible and utilized. We're not
there yet, but it is incrediblybeneficial right before after. I don't think
there's a limitation if you're someone whogets acupuncture, set it up as soon
as you're you know, out ofthe hospital, and do it routinely for
(29:07):
you know, an intensive period aftersurgery to help your body recover. It's
beneficial. I think it's beneficial todo it ahead of time, to get
all of your meridians, everything sortof you know, as optimized as possible
before you even go in. TheOther thing I just want to say is
I want to make sure people feelempowered to tell their anesthesia providers what they
(29:30):
would like. For example, ifthey because I have a lot of people
that you know, are doing someof the mind body things that are like,
oh, I don't want to Idon't want to ask them to say
anything positive one and going to sleeplike I'm embarrassed to do that, so
they're very quiet. I want toempower people to ask their providers to do
things that they believe would beneficial.If they want to have an aromatherapy,
(29:52):
you know, little sticker sent togo in the room, ask if that
can be done. If they wanttheir anesthesia provider to tell them positive things
going to sleep and waking up,ask, So I want to empower people
to feel like they can contribute totheir own plan. Perfect, Okay,
and do you have a website thatour listeners can find you at? I
(30:12):
don't. I don't really have anactive GiB. All right, tell you
the truth. I am. Iam on on I guess the X website
now the old Twitter and at ourShinberg But yeah, yeah, perfect,
Well, gosh, doctor Schinberg,this has been a pleasure, and really
(30:33):
want to thank you for taking timeout of your I know, very busy
scheduled to join us. And thatdoes wrap up this episode of five to
Thrive Live Again. I want tothank our sponsors NFH, the professional supplement
line bridging the gap between nutraceuticals andevidence based medicine, cognizant set of Cooling
to help enhance memory, focus andattention. Immuse a post biotic for immune
(30:56):
support and doctor Orhiro's Probiotics award winningpre and probiotic formulas. And thank you
listener for joining us. May youexperience joy, laughter and love. It's
time to thrive everyone, Thanks againRosie and have a great night everyone.
Good night everyone, and thankfully mis
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