Thanks for having me, thanks for coming in early to our talk on Saturday. My name is Amar Patel, I'm a hand surgeon in Southern California and I'm here to talk to you about occupational injury. So two main questions, first off, why should we care and what can we do about it? Realistically, when we think about occupational injury, we think about the construction worker or heavy laborer that gets hurt at work. We also think about our typical worker's compensation patient who sits at a desk job with multiple injuries that don't always make sense and we also have to think about ourselves. We're high performance individuals, we push ourselves a lot, put ourselves in awkward positions and oftentimes ignore it. We tell ourselves these common things, we're going to work through it, we're going to deal with it, we have to go away and we're trying to obtain our goals so we keep pushing through everything which is maybe not the healthiest thing to do in hindsight. But it's something important. In the U.S., almost $200 billion a year goes through occupational injury and costs. Of that, only a quarter is from medical costs and the rest is actually from lost productivity. Being in healthcare, we're the third most likely profession to have an occupational injury and surgeons face unique occupational hazard daily. This is a claims report from Guardian Healthcare Insurance for Disability which everyone's familiar with here. If you look at the disability claims for both short-term and long-term, almost 30% come from injury alone, musculoskeletal, back, and then non-back. That's both for short-term and long-term disability. In fact, that makes them more disability claims than maternity, cancer, and oftentimes cardiovascular for both long-term and short-term. If you think about these four tenets here about what is for worker's compensation patients, for regular people, what's considered a high physical task or at risk, all four of these can actually are relevant to hand surgeons. Physical demands are high, long hours, awkward positioning with awkward instruments, and lack of ergonomic awareness. So what's the literature say? I'll be the first to admit that the literature's not great. It's all based on survey studies, but it is relevant to this talk. And whatever information we can gather from it, it's important. British general surgeons, about 80% attribute some sort of MSK pain to work, and the usual suspects are there, the neck, the low back, and the shoulder. Risk factors were inadequate table height, use of the microscope, and prolonged kyphosis during work. Of all these body parts, poor ergonomics was the one cornerstone that was relevant. Orthopedic surgeons, similar, 44% to 86%, back, neck, hand, and also specifically radiculopathy in this study. Interestingly, up to 10% of surgeons in this specific study actually pursued surgery for their problems, most commonly lumbar herniated disc and carpal tunnel syndrome. The two main problems that caused a higher Hodgkin's ratio for having an issue were arthroscopic procedures and procedures using loops, and as expected, very few surgeons have any formal ergonomic evaluation. Lastly, similar data in the plastic surgery literature, about 80% have an MSK injury. Use of the microscope for more than three hours a week was indicative of having a cervical or thoracic problem, and interestingly, hand surgeons were most prone to femoarthritis. Lastly, in the resident literature, and this is becoming more of a hot topic, almost 100% of residents attribute some sort of MSK pain to work, once again in the back and neck being most common. And especially this is becoming an important topic about callousness, work satisfaction, burnout, and all of these were relevant in terms of MSK pain. So what can we do about it? Probably the most important article that I could find on how to make your ergonomic setup better was from 2002 in the laparoscopic general surgery literature. They really talk about four things we can do at our workstation in the OR. The first one is operating room height. Here's a schematic. If you look from the elbow down to the floor, 80% or so should be the level where the operating room table is. The patient should be as close as possible to the surgeon to prevent overreaching or prolonged bending at the back and neck. The gaze angle. And the torso angle should be about 45 degrees. So this is, these are the same numbers whether you're sitting or standing or in a different position. So here's a good schematic where the person on the left has, you know, adequate table height, the gaze angles about 45 degrees. And on the right, everything's just done wrong and that's probably not the best position to be in. Some other changes they talked about in the same article that are not based on ergonomics, particularly in terms of positioning but having more ergonomic instruments, position changes, use of a stool or foot rest and short breaks. All these aren't always practical to do in short cases but especially for the longer cases we do, these are something to keep in mind. And I have no conflict of interest with these but these are some pretty cool ergonomic devices I saw at the meeting today and then in the past. Here's one for all of us doing wide awake surgery. If you're injecting a bunch of local on a patient you can use this ergonomic handle to get up to 60 cc's of local. Here's a bone reduction forcep for those small failings, metacarpal fractures that we may need to reduce with the right angle to kind of help your hand a little bit. This is if we're nice for assistance, more ergonomic handles for rakes and prongs and also an offset chisel. So this is like an angled acetone to get into small spaces more easily. This is also something that I've seen for the last couple years. Some of the vendors now are using these vertical gaze lenses for loops. So basically you can still look straight but still look down through the angle of the lens. I personally try this on. It's very, there's definitely a learning curve. I don't own any of these but some friends I know have them definitely do like it but it does take some time to get used to it. But it prevents prolonged kyphosis at the neck which is important. And lastly this is something I do use. I just kind of a back story. I had an emergency. bit, and actually got all my attendings at the Indiana Hand Center to buy them also. So this is a elevated workstation. So most of the time when we're using a laptop like this, I'm looking down, my neck's bent over. laptop, your desktop, and also even at a standing station, this keeps your gaze straight the whole time, that keeps your neck in a better position. Lastly, a couple more practical tips. I'm sure everyone here has or is considering disability insurance if they don't have it. We never know when we're gonna get disabled, and we're actually quite high at risk. If you look at the disability literature, the most common professional specialty to be disabled is a female dentist, and a hand surgeon is actually the sixth most common. So it's probably important that we protect ourselves from any disaster striking, and no one likes paying money for insurance, but this is probably the most important one. Ergonomic assessments at work, there's private industry that does it. I'm sure most hospitals have, probably now have some sort of avenue to get that done. And then exercise, stretching, massage, kind of things we're gonna do. Okay, I'm Tyler Pigeon. As Chris said, I'm from Duke and I'm going to talk to you about mindfulness cognitive training in surgery. So why is this topic important? Well, it's really an important topic because of the overwhelming stress of practicing medicine. I think all of us who practice medicine can understand that it's a very overwhelming and fulfilling Burnout is a particularly problematic in orthopedic surgery. And there's a variety of causes for this, increasing malpractice lawsuits, shift in pace and attitudes, we're no longer revered as much as we used to be, increased administrative workloads, which is baffling to me because if you look at a chart of how administrators have been hired over the last 50 years and how doctors have been hired, the administrators are outpacing us by hundreds of percent points and yet we still have to do all this administrative work. Increased clinical workloads, the dollar rate per RVU is going down, we have to work harder to make the same amount of money. Burdensome institutional policies, reduction in autonomy, and maintenance of certification, which is increasingly burdensome. And I know we're not all orthopedic surgeons, a lot of us are plastic surgeons. In that article they found lower burnout in older surgeons over 65, those that work only outpatient, those that only do hand surgery, no elbow or shoulder, lower commute times, performing less than 10 surgeries a month. There's also higher burnout in people that take replant call, which again, maybe don't have a lot of control over. Lack of control over workload, which I think we can attack, inefficient teamwork, and a poor work atmosphere. And burnout is a real problem, and it has real effects. From a physical standpoint, burnout has been linked to the metabolic syndrome and diabetes. It's been linked to myocardial infarction. Obviously, it's going to have mental effects, depression, relationships. Depression. Depression is a problem in orthopedic surgery. The depression rate in orthopedic residents is double that of... And I think one of the big problems is that there are barriers to seeking help, there's a stigma to seeking help, there's a fear of punitive action. effects on licensure, and risk of losing staff privileges. I know when I was filling out my staff. So what can we do in terms of helping ourselves? Well, one thing we can do is consider looking into mindfulness therapy. So mindfulness is awareness of where we are and what we are doing and being present in the moment. It's supposed to be a nonjudgmental look at what's going on and what's happening and how you're reacting to it. It's asking yourself to accept what's happening, not overreacting, not becoming overly emotional to what's happening, and finding a solution to what's happening. And having your thoughts and having your feelings and recognizing them without labeling them as good or bad. This enhances resilience. It reduces perceived stress through cognitive habits, and I think that's key is perceived stress. So you're not necessarily reducing the stress that you're experiencing. You're not going back in time and not having a 50-patient day with 30 people screaming at you, but you're reducing the stress that you perceived from that day. It improves affect, it improves executive function, and it improves performance. So mindfulness-based cognitive therapy combines mindful meditation, which is really stolen, or not stolen, borrowed from Eastern Asian religions such as Taoism and Buddhism, and it combines that with cognitive-based therapy. And again, the idea is to reduce the amount of stress that you perceive, not necessarily changing what's happening to you, but reducing how much you're perceiving that as a stressful event. And by doing that, you are increasing your cognitive load. So if your brain is spending less time worrying about the stress that you're experiencing, then you have more time to think about other things that you want to do, be that the physical tasks that you're doing, mental tasks that you have to do, et cetera. Therapy goals for mindfulness-based cognitive therapy, you want to see patterns of the mind more clearly. You want to identify a downturn in the mood early before it takes you over and reverse that downturn. Connections, you stop the connection between a negative mood and a negative thinking and physical manifestations, such as fatigue. So if you can realize what's happening to me right now is causing me anxiety and stop it there, then you're doing a good job. So again, rather than have the emotion and then feel a judgment towards that emotion, you're having the emotion. So, does it work? Well, there's a few papers out there that look at this specifically in the Health Care Center. Labarce et al. did an eight-week, two-hour program with health care workers, residents at UCSF, versus a control group, and their hypothesis was that mindfulness training would enhance cognitive habits that change how people experience and respond to stress. And what they found in their study group, which is the group that they intervened on, they had less perceived stress, they had increased mindfulness, and they had decreased depressive symptoms. They also had better executive function, increased working memory, and better motor skills. So again, by reducing the amount of stress your brain is perceiving, you can reduce the amount of stress that your brain is perceiving. And what they found was that the studies grew. If you want to get started on this, you can see all three of That was awesome. Let's do some meditation together in the surger's lounge this week. All right, so next is Eric Wagner, former basketball player, so a guy who's very into nutrition and currently a new expecting father, so brushing up on his nutrition for his family. All right, well thank you very much for joining us. I realize this is one of the less ideal times to wake up for a ICL, particularly on body, mind, and health, given 645 on the anxiety, but nonetheless, hopefully you at least learned a little bit, can take home some stuff. So I'm going to talk about nutrition, and it's really about just the overview of some of the recent studies out there, some of the recent recommendations, and some thoughts that maybe you can take back in your own life. Actually, before I get started, how many people in the audience have a specific type of diet, whether it's a named one or non-named ones they follow on a regular basis? Perfect. And then how many people have some sort of either program that they pay for or a coach that sort of helps them out with this diet? Perfect. Cool. All right, so nonetheless, so my disclosure is none are relevant to this presentation, but I should point you to some cool resources. So this was one of the more informative ones. So Harvard has this health of policy. I have no disclosures or relationship with them, but I think it's a really nice resource when it comes to nutrition and when it comes to some of the considerations of the actual scientific evidence around it. So you can find a lot about opinions, but there's some nice links to a lot of the studies on this group and this website, and I'll point to some of the ones that have been more recent. So in general, we're going to go through a lot of different kinds of considerations and go through at least some evidence on it. Definitely not going to cover everything out there because it's a pretty complex topic if you really delve into the details. So naturally, carbohydrates comes in many different forms. You have whole grains, and that's something that you hear over and over again. This is something that's nice. It gives long-term energy. It's something that you want to incorporate a lot into your diet in a lot of respects. This idea of fast versus slow carbs, this is a cool study for those of you who want to go into it and read it. It's a perspective, and it goes through a lot of different studies on this idea of fast versus slow carbs. You know, interesting enough, for weight loss purely, there's not a big difference. For energy, though, there is a big difference, and there's a lot more detail than I think we understood on this idea of the fast versus slow carbs and the details of just simply breaking down by refined sugars versus more involved. It's not quite that simple, and I think it's worth—for those who are really interested, it's worth reading that article. It's a cool one. Nonetheless, so here's some studies on looking at sort of interventions. So this is a study that was part of this Framingham offset that looked at changing refined to whole grains in a cohort versus ones that did not, and sort of had this observational study to see what happened. Simply, the only intervention in this cohort, this arm, was changing refined to whole grains, increased HDL, decreased triclostrides, and decreased abdominal adipose tissue. So subtle, subtle changes can have big impacts, as this showed. There's other parts of—if those of you who are interested, this Framingham offspring cohort, this whole study of cardiac and abdominal risk factors is a fascinating group and fascinating effort that was put together. Another intervention, so looking at a carbohydrate-restricted diet. So this group looked at—they were trying to integrate genetics in with it, so they looked at this sort of lean mass hyper-responder phenotype. So they're trying to understand impacts on certain people that maybe are either at risk or self-identify as at risk, and found that by restricting carbs in this group, so this group that potentially has a more aptitude to have a, quote-unquote, slower metabolism, it actually led to elevation of LDL and associated cardiovascular risk. So one of the first studies to really suggest that a carbohydrate-restricted diet alone is maybe not the best thing to do, and that it's a little bit more complex than just not doing carbs. Obviously, you don't want simple sugars. That's pretty clear. I don't have to put the evidence on that. You have a quick energy. You have a crash. It's something that's not as complex. So when you look at all the different options, it's not as simple as simple sugars versus not. There's lots of ways to incorporate a carbohydrate-restricted diet. There's lots of ways to modulate how much you do. I definitely don't think overdoing in carbs makes sense. There's good data to support that, but there's also pretty good data that just cutting it out complete maybe is not the best thing either, especially with regards to cardiovascular health. Fats, another interesting one. So saturated fats, you always hear about unsaturated, saturated, polyunsaturated, all of these different considerations. I'm not going to go into the science of why one's better than the other. Those of you who remember from your undergrad chemistry classes, hopefully you realize it has to do with how easy it is to break down. There's some cool studies on this. So with regards to saturated fats and different types of carbs as we were talking about, actually interesting, the higher the carb, the higher mortality. That's been shown. Like I said, it's a little more complicated than just purely high or low carbs, but nonetheless, that's been shown nicely. But interesting enough, those that had a change in saturated fats alone, not restricting calories, not restricting anything else, but changing unsaturated, saturated fats, had a lower mortality and a lower shirk risk to 10 years. So there's subtle changes you can make without just completely abandoning certain aspects of your diet that can have a big impact on your health. Avocados, one of my favorite things. So there's actually more than just this study. This is one of the ones I've used. But avocados, there is decent evidence to suggest that it doesn't necessarily help with weight loss, but it does help with health. This is one that talks about redistributing abdominal fat distribution. There's other ones that look at its effect on HCL. There's other ones that look at effects on triglycerides and whatnot. But avocados actually is a decent source of it, but it's not necessarily going to help with weight loss. So if that's your goal, that's not necessarily the right way to go about this. Just to kind of highlight there that a lot of this, the theme of this is not you have to go and eat 500 or 1,000 calories a day, and then you're going to be healthy. You can make substitutions, and these substitutions can add, and you can decide what you want to substitute and what you don't want to substitute. And also understand a lot of the energy, because the topic of the talk, even though there's not that good of evidence on energy after changing diet things, it kind of makes sense that the healthier diet you have, the potentially longer lasting energy you're going to have, the more sugar, less or minus caffeine, you're going to have sort of highs and lows throughout the day. Other cool studies have looked at how often you should eat, how much you should eat. This is pretty well-established, but nonetheless, I figured I should write this. I didn't put the study up there, but that website I showed you has it. Looked at, it's quote, having people judge their fullness from one to 10, and looked at sort of at various times throughout a couple-year period, their energy levels, both short-term and long-term, found that somewhere around five or six of feeling of satiety was a pretty good level that led to less swings of energy. So basically small meals throughout the day instead of two or three large meals. Lunch is actually the biggest one, although our colleagues in Europe might disagree with this. One of the biggest ones that was associated with crashes, more so than breakfast, more so, obviously dinner doesn't matter as much if it does, but that lunches are whatever reason with regards to how your body digests are harder to digest, lead to higher spikes in glucose. For whatever reason, lunch is not a good time to really overindulge yourself. With regards to figures, I kind of talked about this, but your brain really needs steady nutrients throughout. Many people who coach how to do standardized tests or how to study for standardized tests suggest that people have just snacks while they're studying throughout the time of doing this, the time of studying, because it maintains your brain level. This is something, so three large meals a day is not really the best way to maintain your brain nutrients. Beverage is one of our, or some of our favorite topics. So water, my MA brings this massive water bottle in every day because she wants to have a huge amount, drinks a huge amount of water, and there's actually data that suggests you can't actually drink too much water with the exception of certain medical conditions. That being said, I mean, I'm not saying you have to necessarily do that, but if you don't have water, it has been associated with dehydration. I didn't put the study in there, maybe I should have, but there's a cool study actually looks at brain activity and shows that dehydration is associated with lower rates of brain activity as well. Ideally, so they suggest maybe four to six cups, so a lot more than I think the average person drinks. Caffeine, one of my favorite things personally. There is a lot of interesting data on caffeine. I'll show you at least one of the more conflicting studies that's gone backwards away from what some of the original sites suggested. It helps with alertness. Obviously there's a crash. You don't necessarily want to do it in the middle of the night unless your body's really used to it. I will admit this is definitely one that I cheat on constantly because I do, I do like it. So this is kind of an interesting study. So up until now, up until this study, every single study had actually suggested that sort of regular coffee use was associated with improved cardiovascular function and that potentially people who had moderate coffee consumption had lower risk of stroke and heart disease and whatnot. This study sort of challenged that, saying that looking at this cohort, it actually wasn't the coffee that was helping. It was the fact that when people got diagnosed with hypertension or some sort of problem, coffee was one of the first things they cut out or decreased. Maybe there's a casual relationship rather than a cause and effect relationship. So coffee literature really is not well established out there. I'd love to, as somebody who loves coffee, love to say that it's great, it helps with your heart, all that stuff. I don't think we would totally know. There's not a lot of negative effects of it outside of the crash that you feel. So it's still kind of out there. Alcohol obviously is something in excess that's not the best. And as you remember from your chemistry classes, it is a diuretic. This is a great study. So up until this study, there were many studies that suggested that red wine would decrease cardiovascular events. And that probably still stands. This study actually sort of counteracted that, suggested that drinking might have an impact on—cardiovascular events might have an impact on aortic aneurysms. If you look at the details of the study, though, it's not as simple as that. So basically, their conclusions were cardiovascular events were lower in the people that had one to two drinks a day, but that somewhere between one and four drinks a day had higher risks of aneurysms and stroke. If you look into a little bit more detail, though, the ones that had a stroke and aneurysm risk also had higher blood pressure, also had higher BMI, also had higher rates of diabetes. And independently, when you sort of factor it all together, it didn't really bear out that alcohol was independently associated. So it's kind of like if you're drinking a lot, you'll probably have some other health problems that potentially are also contributing to those risks. So it's a little bit more complicated than just alcohol by itself. People do think, though, in certain individuals, like alcohol can be helpful, can be healthy for your heart, and not necessarily just red wine. It's maybe sort of a stress thing. Energy bars, there's really actually no good data, and there's actually studies suggesting that certain energy bars are actually harmful and processed and not something that should be regularly consumed. And then processed foods, this is probably the most clear-cut part of this talk. Without question, whatever type of processed food you're talking about is not good for you, and is clearly not good for you. And to the point, some of these studies even suggest that they should be outlawed by governments, and they are in some countries. So processed meats, associated with higher cardiovascular risk. No difference between red meats and poultry, though, in this. Everybody talks about red meats being bad. This study didn't suggest that. It was actually just the processed meats that had the issue. Once again, processed red meat, increased risk of dementia. Unprocessed red meat, no. It actually had a decreased risk of dementia. Actually, poultry, processed or unprocessed, was neutral. But the processed red meat was overwhelmingly an increased risk in this study. Systematic review shows that processed meat, higher risk of everything you can imagine. So this is not controversial. Processed food is not good. If you can cut out something, that's probably one of the better things cut out, particularly those of you who are looking at longevity. From a kid's standpoint, turning them to vegans or vegetarians has some, for sure, some life habits that would be potentially helpful, but it has been associated with nutritional deficiency. You've got to be careful with kids, and be careful how you modulate their diets. This is a wonderful, wonderful review. Every year they come out with sort of a new review of every 15 topics that are updating some of the prior ones. This is where I got a lot of the recent ones from. It's a really cool resource. There's lots of diets out there, lots of press on it, especially with Tom Brady and sort of the effects of his diet. Really not good evidence suggests any of these individually are better than others. This, from that original resource I did, does go through all the different diets and all the different advantages of some of the diets and review potentially what, if you want to make a change, and whatever reason you want to make the change for, some of the considerations around that. The American Heart Association actually came out and based off of a variety of data that the Mediterranean diet is the recommended diet, so not just a vegetarian, but actually incorporating a little bit of shellfish and seafood is good for your heart, and obviously based on whole grains, fruits, and vegetables. This is some of the data that they based that on, or some of the data. That second study actually is a really cool one. They looked at people that lived older versus younger in these relatively isolated populations that have little influence from the outside world, and found that the ones that had a relatively close to a Mediterranean diet were the ones that were living longer. This just kind of goes with the idea of some considerations that hopefully kind of summarize what we just talked about. It's not just about calories. It's actually about the quality of what you're eating, and that there is some interesting studies. The NIH actually broke a record in 2020 for the amount of money they've put towards diet studies and looking at effects on inflammation and telomere length and all this stuff. So there's a lot coming down the pipeline. One thing we do know, though, is diet is very important, and it's the quality probably as much as the quantity. So that's kind of just a good summary of goods and bads. A lot of this you probably already knew. Hopefully you learned a little bit, and there's a lot of stuff that I think we're still going to be learning about this. But I think if you can cut out anything, cut out processed meats, change unsaturated to saturated fats, look a little bit more into type of carbohydrate you're eating, and maybe avoid heavy drinking if you can. This is one example of a wellness coach or a wellness mentor. Chris, I believe you work with Greg? Yeah, perfect. So he can talk a little bit more about that. But I do think that is an interesting—if you're trying to make a change in your life in a lot of respects, this is helpful. This is something that's used throughout the industry. My sister, who is a lawyer, also has a wellness coach, not necessarily for diet, but for other areas of her profession. But these are helpful. They are utilized in all the other industries, and there's studies looking at all the professions like law, business, and engineering, and medicine. Medicine is the one that's used the least, but yet they have some of the highest rates of, as we heard, burnout and stressors. So it might be worth looking into this. My sister, I can say, absolutely loves it, and it sounds like Chris does too. Thank you all for your time. Reach out to me if you have any questions. I think we're going to change gears. This is a little bit lighter of a conversation, and I would say that in my wildest dreams, I never thought I'd be giving a talk on yoga at the Hand Society, mainly because if you've ever felt imposter syndrome, this is the moment. My disclosures are that I am not a yoga instructor. I have no authority on yoga. I'm a hand surgeon who happened to take a course in college about 15 years ago on yoga, and now I've found ways to incorporate it into my practice. The objectives of this talk are to give that 1,000-foot view of what yoga is, the benefits of yoga, the effects on burnout, and actually, we're going to go through a little bit of a breathing exercise. My wife, who's an art therapist, suggested that I have everybody lie on the ground, close your eyes, and practice. I took a college class in 2004. We were all required to take about three gyms at college. The disclosures that I made were that I was going to be a teacher, that I was going to still present, why yoga? There are so many benefits. That's great. How many people have ever wanted to practice, but there were some obstacles? All right, this talk's for you. Yoga over the past two decades has gained increasing popularity. It's deliberate breath control coupled with specific body positions that you can incorporate into your daily practice. There's mental benefits. There's physical benefits. And I think that, again, the stigma of yoga is that there are many barriers to yoga. Myself, I mean, many days I say, okay, I need to sweat today. It's too hard. Some people say it's too easy. I've heard every excuse in the book. This is for everybody. I mean, there are so many bad— I read an article recently that was talking about our priorities. Most of us would say that probably our top priority is family. Maybe the second would be religion, and somewhere down the list we go through the priorities and we talk about our career and our work life. How many of us could look at our calendars right now, based on your priorities, you could tell that your priority was family or religion as opposed to career? We all put our career items and tasks on our calendar, but we neglect those tasks that are related to our family and friends, or religion. One very concrete thing that I've done in my personal life is on Wednesday mornings, every calendar date in my log is 6.30 a.m., I do yoga. Even if it's for 20 minutes, if you have a task on your calendar, we're all type A, we're all overachievers, you do not want to fail that task. If you put it on your calendar, you're more likely to actually participate in that activity, do that activity, and that could be yoga or any other thing that you want to achieve. It's just a small way of focusing on a small goal weekly without feeling the burden of incorporating something new. That's just one thought. There are so many reasons, like I said, to incorporate yoga. Not only the physical endurance, it increases vascularity to your muscles, your organs, there's cardiovascular benefit. There's a lot more to it than that. Finding ways to de-stress. I think that, like I said, we're all here at 645. Burnout is a hot topic, especially post-COVID. We are all feeling the effects of burnout. Burnout centers on emotional exhaustion, which is perfectionism, self-criticism. We're surgeons. We take those two things with us every single day. Depersonalization is that sense of feeling Despite our many accolades, I mean, to get to this point. but also dissatisfaction for your patients. If you're not happy, you're I'm not gonna go through these studies, but there are so many studies that we've already talked about this one is probably the most tangible and Just incorporating yoga breathing in a small subset of people has actually yoga breath it's not coffee breath it's not garlic breath I mean it is you might have heard we can kind of go through that. Yoga breathing and the thought and the deliberate process of yoga breathing, it controls your cortisol levels, it's been linked to increased cognition, increasing the oxygenation to the prefrontal cortex, it calms the nervous system and it can improve overall digestion. So I think that because So a few last tips. Once you start downloading the app or you're getting into it, you will learn. And like I said, And there's a huge financial impact the cost of the health care burnout coping. So, Mayo put But they did a study looking at sprinters, and sprinters. which is kind of shocking. And then there's effects on muscle. who run. So again, it combats aging by doing cardiovascular fitness. And then we all know that it has beneficial effects on articular cartilage. I think we all have patients that come in every day and say, hey, I have some arthritis because I was a runner and I put wear and tear on my body, but that actually may not be true. Age-related changes in articular cartilage result in a combination of genetic and environmental factors. But we all think that the risk of OA increases with age, and we all know it does, but runners and joggers actually lost less cartilage compared to control subjects, so it actually may have predictive properties. And then cardio health and mortality, I mean, we're all trying to live longer and have higher longevity, right, but there are 250,000 deaths per year due to lack of physical activity. But there are higher rates of cardiovascular Avi's going to be doing the next talk. We went to a class together. If you look on the left at the 11 o'clock hour, Avi was number one in his class for actually calories on a bike. I was last. And I'll see if I can get this to play. This is him overhead squatting 185 pounds, which is just amazing. So with that, I'm going to introduce Avi to show us why he's an impressive guy. Thank you. But some of it is a little bit focused on neck and back strength, but really the concepts around why, I'm going to just start talking because this thing's taking forever, why muscle development is so important. And some of it does overlap with what you just heard from Chris here. I think the whole sprinter data you just presented was because sprinters are, I mean, I don't know if you've seen a sprinter versus a distance runner, but it's all muscle. So I think a lot of that benefit is probably related. Strength and muscle development come in a whole lot of different forms. And so this is kind of a broad sweep on the concept of being stronger. So what am I talking about? Why does it matter for your health? I think debunking some myths is super important, especially for those of us who have limited time available to do whatever fitness journey you want to go on. Benefits for overall fitness and wellness and a little bit of recommendations, actually some data-driven recommendations. So this can be what you want to do, and that's fine. Having lots of muscle, that's strength training. But honestly, so is this, right? The Cartman Beefcake, which I think is motivational for a lot of us. Just eat a lot of weight gainer and go and put on some mass. You can do a lot of toning, body-based movements. Those are all valuable push-ups, which, you know, honestly, if you only have a few free minutes a day, it's a really great overall way to develop muscle and strength on top of cardiovascular. Or you could do really complex push-ups, which I don't really understand how to even do that. But that looks hard, and if you could do it, it'll probably make you stronger. But, you know, the question is, if I run and do cardio stuff, like, isn't that enough, right? So I would say probably not. This is really actually a focus, at least in the beginning, on the benefits of as we age. So there's a position statement from the National Strength and Conditioning Association, which essentially says resistance exercise. So all of this falls into the category of resistance exercise. As opposed to moving your body weight, it's moving your weight and or a weight under resistance or load. It improves metabolic capacity of skeletal muscle. Essentially, if you're not exercising, your muscle's doing the work for you to help you burn calories. And actually, lean muscle is much more impactful in weight loss than just the cardiovascular exercise, because lean muscle works for you even if you're not working. It also complements the widely known positive effects of aerobic training and can mitigate the effects of aging. So super broad statements. What does that mean? So like I just said, trained muscle, especially lean muscle, burns more calories at rest. Strength training protects against metabolic syndrome. Eccentric loading is actually much better for developing flexibility than stretching, which I think is very important for those of us who, you know, may feel that mobility and flexibility are super important. Eccentric load, meaning essentially having the weight and resisting it going down or resisting against your muscles, is much better for increasing your flexibility. And it makes you more robust to illness. As we all know, muscle strength and muscle mass protected a lot of people against the side effects of COVID or the more impactful illness effects of COVID. And so that's an important thing to understand as well. So it makes you more robust and maybe helps you lean out. Fall prevention is super important, especially as we age. One in four women and one in five men over the age of 50 will have a fragility fracture. So that's some of the osteoporosis data. Oftentimes, those fragility fractures occur with falls. Mobility and muscle strength are more strongly correlated with falls. This is a focus on a cohort in China. But ultimately, as you might imagine, balance, the ability to recover and the ability to catch yourself will prevent falls that can be for many patients catastrophic. Stronger bones, we all again heard about bone health specifically. So it's the fall prevention piece, but also things that improve your bone mineral density. So bones under load, the turnover is higher. Bone density tends to be higher. But it also helps patients improving certain postural changes. For example, kyphosis can get better. Bone health gets better. Also, this LIFT MORE trial, where they have one in women and in men, essentially the concept of using strength training rather than just cardiovascular fitness, is really where a lot of this back, not only back pain and neck pain, but also then structural improvements and postural improvements comes from. So a lot of people say, you know, aren't things bad for my knees? Or doesn't deadlifting hurt my back? Or if I pick up weights, won't it hurt me? As best we can tell, that's all just form related. But no, the movements themselves are not bad for you. And in fact, squatting below 90 degrees is incredibly protective for not only your knee joints, but also for developing the tendons and ligaments around the knee and strength. So squats do not wreck your knees. I would highly recommend them if you want to put on a leg or core strength. Deadlifts are the same thing. Great leg, posterior chain, back, hamstring. It's actually really almost in many ways a full body exercise that people worry about it for your back. Now, I wouldn't go and put, you know, a thousand pounds on the bar out of nowhere, but the high load programs are necessary. Low load is incredibly valuable. It's the movement. It's going through the full range with engaging all those muscles that can not only be helpful and protective for you, but also can help reduce a lot of back pain as you build back and core strength, which I'll get to in a second. So, and that's the chronic back pain thing. There's a bunch of data that support that core and posterior chain is really much all a substantial number of back pain patients need to have their back pain decrease substantially, to have their back pain decrease meaningfully. So this comes back to that position statement again, where that muscle disuse is preventable and reversible. And that muscle use in the form of resistance training has, and I'm going to just list all these things, although you can read them yourself. It attenuates age-related adipose infiltration, improves physical performance, increases muscle fiber area, so some of those metabolic and strength benefits, improves muscle quality, metabolic health and insulin sensitivity, management of chronic health conditions, quality of life, psychological well-being, and extended independent living and reduced risk of falls and fractures. Now, I acknowledge that all of those studies have their own biases, and studying all this stuff is really difficult in a rigorous manner. But the fact is that if this is something that you're considering or haven't been considering, you might want to start considering it, because even a little bit of load or a little bit of resistance training can make a humongous difference on how your muscles function. Starting it at 35, 40, 45, 50 is what allows it to be impactful when you get into that more risky range for either fragility fractures, falls, or just the natural muscle atrophy of aging. So think about it. So age-related declines in muscle strength and power negatively influence health span independently of changes in muscle mass. So the importance of preserving muscle strength is just straight-up a mortality benefit. This was looked at in a 15-year cohort, and essentially adjusting for past medical history, health behaviors, strength training was attributed, at least 46% of decreased odds of death was attributed directly to the strength training component in this analysis. I accept whatever criticisms of this research you want, because it is not the highest rigor, but they did their best, and this is over a 15-year span, and the mortality benefit, essentially you're just harder to kill if you have some muscle mass, which I think is worth considering. So what can you do? So that's body weight, resistance bands, free weights, go to a HIIT class, whether you like CrossFit, F45, F3, F this, F that. It's like, there are so many options. It's about moving on a relatively regular basis, and moving against resistance on a regular basis. Efficiency is really important. The last few slides are focused on some really valuable data in the strength training literature on efficient training. So minimal dose resistance training does improve muscle mass, strength, and function. So this is a little hard to see, I'm now appreciating, but effectively going from multiple exercises per muscle down to two exercises per muscle group, if you synchronize them, same effect on muscle development, strength, and metabolic benefits. Going from a moderate frequency a week to slightly higher, meaning doing it more, but for shorter periods of time, essentially negates the problem of shortening your training. By getting multiple joint movements in shorter, higher intensity doses, essentially is the same as sitting in the gym for an hour and a half and doing each muscle six times independently. This is a 10-minute neck and shoulder strengthening program, so it's pretty simple. It's mostly row mechanisms and sort of a little bit of back extensions. 10 minutes and pain reduction, movement improvements. Again, for surgeons, I wanted to make sure we focus on this. I didn't get to hear Amar's talk, but I'm sure there was some of this. It's so important at, again, the early stages to get ahead of this. Make it part of your routine. If you're doing breathing exercises, there's ways to even use shoulder mobility and shoulder raises and shoulder movement as part of that, and that's something I do on stressful days, and it can be really helpful. If you have really little time to lift, I think this is guidance. Looking for bilateral multi-joint movements, so less isolation. You don't need it. You don't need to do the one-arm bicep curls for 15 minutes in front. If you like doing it in front of a mirror, you're more than welcome to. There is certainly the physique effect of strength training, which, you know, is well documented, but you don't need it. So multi-joint movements are really valuable. I also want to highlight what this has is between a 6 to 15 rep max range. What that means is if your max is 100 pounds, but your goal for, like, a 6 or 8 rep max would be around 60% of that. So the value in this is doing that lighter load at intensity volume. It doesn't need to be going out and hitting heavy weights if that's the thing. I think there's a big perception that when meatheads like me talk about it, that that's what I'm implying. I actually think it's totally the opposite. I think it's finding a way to move a little bit of weight, a little bit more than your body in one way or another, that can really have an impact on stimulating the muscle development that will then provide a lot of those health benefits. When you warm up, focus on what you're about to use muscle-wise. The rest of it comes with you as your body warms up. So people, it's okay to spend a lot of time warming up, but you don't always need it. Really only prioritize stretching if your goal is to be more flexible. Otherwise, as I said before, eccentric loading, essentially returning the weights back from whence they came, is a great way to start stretching and warming up. So once you're warm, get moving under load. The rest of it will come with it. So all those things can take what you might feel is an hour-long workout and really condense it down to about 20 minutes. And you get a great cardiovascular benefit if you condense these things. So I think it's doable for anybody. Thank you.

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