Episode 11: Dr. Rosanne Sheinberg, MD on Preoperative Care: What to do Before & After Surgery
Show Summary:
Dr. Sheinberg is an assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine. Her areas of clinical expertise include anesthesiology, cardiothoracic anesthesiology, medical acupuncture and integrative medicine. Dr. Sheinberg serves as the director of Integrative Medicine for the department of ACCM and has been board certified in Integrative Medicine since 2014.
Join us for a conversation today about optimizing perioperative care, the care before and after surgery. If you or someone you love is undergoing surgery in the future, this episode is for you!
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Full Episode Transcript:
SPEAKERS: Dr. Andrew Wong, Dr. Rosanne Sheinberg
Welcome to the Capital Integrative Health podcast, a podcast dedicated to transforming the consciousness around what it means to be healthy and understanding the root causes of both disease and wellness. I am Dr. Andrew Wong, co-founder of Capital Integrative Health, an integrative practice committed to expanding access to holistic root cause medicine to the global community.
Today we are excited to be joined by Dr. Rosanne Scheinberg. Dr. Scheinberg is an Assistant Professor of Anesthesiology and Critical care medicine at the Johns Hopkins University School of Medicine. Her areas of clinical expertise include Anesthesiology, Cardiothoracic Anesthesiology, Medical acupuncture, and Integrative medicine. Dr. Scheinberg serves as the director of Integrative medicine for the Department of Anesthesia and Critical care medicine at Johns Hopkins and has been board certified in Integrative medicine since 2014. Join us for a conversation today about optimizing perioperative care. The care before, during, and after surgery. Surgery doesn't have to be scary. There are things you can do to improve your recovery times, improve clinical outcomes and overall improve your experience with surgery. If you or someone you love is undergoing surgery in the future this episode is for you.
Dr. Wong
Welcome, Dr. Scheinberg to the podcast so great for you to be here today.
Dr. Scheinberg
Dr. Wong thank you so much pleasure is mine. It's great to see you again.
Dr. Wong
Yes, you too Rosie. And I think we met just for the listeners and apart from our time at the University of Arizona Integrative Medicine fellowship where we just had a great time there you know it's mostly a distance learning fellowship but there were three weeks of residential fellowship so we can talk about that in a minute. But first of all, just for all the listeners here Dr. Scheinberg, what motivated you to pursue medicine?
Dr. Scheinberg
Oh, good question. So I think you know interestingly so I became, I was very heavily into gymnastics and dance growing up. I was you know sort of at that pre-olympic level and also you know very high level in ballet and in those pursuits you really develop a natural interest in the body. It's the tool of your trade. High potential for injury and overuse injury so there's a lot of contact with the medical community. So I think, I always wanted to be involved in sort of health and wellness in some capacity just because of my experience you know in dance and gymnastics growing up.
Dr. Wong
And the medical system and the doctors and the practitioners you went to probably helped you out a lot too so that you're able to continue with dance and gymnastics, is that right?
Dr. Scheinberg
Yep, that's right Andy, it did. You know growing up in these areas like I went to a doctor if I needed to go to a doctor, and then I also did other things to stay really at the top of my performance and you know staying healthy and well you know nutrition was really important in being able to perform at the top sleep was important we learned early on sort of stress reduction things to help us get through competitions and performances and the nerves through that so it always made sense to me that there that you kind of dipped into both worlds of the health and wellness arena you know the kind of standard medical treatment as well as sort of more complete wellness world you know to achieve whatever goals you had you know to kind of be at peak operating capacity.
Dr. Wong
Yeah and we're gonna I think this is gonna connect to later with perioperative medicine here but I have a question from you know with you growing up and doing dance and gymnastics, is that did your coaches ever or maybe you found this yourself doing some sort of visualization before performances and you know practices even?
Dr. Scheinberg
Yeah, I had an amazing gymnastics coach growing up and in the 80s the Russians were the best in the world at gymnastics and so he learned Russian so he could translate their Russian training manuals and utilize some of their you know training techniques that they were using like utilizing to create world-class athletes in gymnastics at the time. And part of that was they did what they called at the time mental rehearsal so they did use kind of visualization techniques and you know using perform you know kind of visualizing your performance and different components and so I did. I learned that early on where I think it wasn't commonplace in athletic training like it is now.
Dr. Wong
Right and I think we all know this you know there's the functional MRI studies from Harvard that show that there's you know, if you imagine playing the piano versus playing the piano it lights up the same air of the brain so you can use that and probably guide imagery visualization for performance. But also for you know before a surgery and we know that you're an Anesthesiologist at Johns Hopkins and so kind of just wanted to get more into that how did you get into anesthesia and then how did you get into more integrative medicine as well?
Dr. Scheinberg
Yeah, good question. So going through med school I tried to keep an open mind. I sort of enjoyed everything that I did. All the different medicine subspecialties and you know along the way and when I got to anesthesia. What I particularly liked was this combination of things. One was that it's all the (I love), so I was a biochemistry undergrad so I love sort of the underlying thinking about like the mechanisms of how things work and anesthesia puts that into practice in real-time. So if I'm you know giving a drug for example it's going to go through a certain pathway and have a physiologic effect and I get to see that in real-time. I've always called anesthesia medicine for the impatient and yes I am a self-admitted, I'm an impatient person. I'm not good at waiting for things so I think in medicine you tend to have to wait for results where you prescribe medicine and someone has to go out and fill the prescription and then actually take the medication and then come back in a few weeks and report how things are going well. Anesthesia sort of does all of that physiology in a compressed time frame. So I enjoyed that aspect of it the direct pharmacology aspect. I liked that it is there's a lot so it's a real good combination of thinking the kind of the medicine the machinations and the thinking about pathways and how to keep people safe and you know how to get through a surgery with the physiologic changes but also doing. So we have a lot of hands-on procedure-type things where I'm you know I can put bypass cannulas in the neck and you know a lot of big IV access. I'm doing nerve blocks and epidurals as well as different airway management techniques. So, also procedure based so that part I enjoy as well. The one of the big roles that I enjoy in anesthesia is that you know a surgeon is kind of the hero of any patients you know when they have a surgical experience they're the one they remember their name and they look to really fix a problem that they have. And I feel like the anesthesiologist role is kind of the unsung hero role. I think there's a lot that people don't know about that happens while they're asleep under anesthesia and there's a lot of you know stress and physiologic manipulation on the body that happens and so I think our role is that really the protector role. I mean if you, if I take away someone's ability to do all the life-sustaining things that one normally does for one's self breathing blood pressure regulation temperature management if I were having surgery I would certainly want someone I trusted to take over that role and be very diligent about protecting me while I couldn't protect myself and so I love being in that role.
Dr. Wong
Certainly. Surgeons make you know to do the surgery but anesthesiologists make that surgery possible and smooth you know almost like a conductor but then you're playing the violins making everything smooth that's how I kind of see.
Dr. Scheinberg
That's right! It is pure codependent you know team-based relationship absolutely without the other.
Dr. Wong
So it sounds like you love you know connecting also the right and left brains you know together with the procedure base the analytical side the instant gratification is you know amazing with the instant results you see from you know administering a medication and seeing that person you know I think stabilize etc. on you know heart rate blood pressure etc. So that's great! And then how did you find out about and get into integrative medicine and why did you decide to go through the Dr. Weil fellowship that we both went to?
Dr. Scheinberg
Yeah, so I think it actually is almost a reverse thinking process that's always the question well, “How did you get into integrative medicine?” But I think that's what led me into medicine in the first place you know going back to my days in dance and gymnastics. I knew I wanted to be in this health and wellness world. And so in fact, before I was thinking about medical school, I was actually thinking about a pathway to become a naturopathic physician and which is a different training pathway you still get sort of your doctor designation but your toolset really becomes non-pharmacologic, non-surgical agents so (you really) your bread and butter is really thinking about how do lifestyle components, how do different botanicals and herbs and supplements help someone become well stay well deal with different pathologies and then you know my thinking process was a certain subset of people in our country or in this world will go to a naturopath. I thought maybe I could bring those ideas of underlying health and wellness to a broader population of people if I had the “credentials” of a western medical degree behind me. So ultimately that's actually what led me to go to medical school.
Dr. Wong
Yeah, I think I have a similar pathway too just thinking about health and wellness from a very early age as well and just knowing that's why I wanted to go to you know into the healthcare field to be of service you know for people. And in a way that brought in to access. But certainly, I know that you know and I'm curious actually if you've, at Hopkins have you also interfaced with lots of different other practitioners, naturopathic doctors, acupuncturists, specialists in the medical field because you've worked with a lot of different specialists yourself, correct?
Dr. Scheinberg
That's right. At Hopkins it's a very, it's you know, in general, it's a pretty conservative and historical institution. So within the Hopkins walls, I wouldn't say I've interacted with a lot of different types of practitioners you know in the kind of complimentary.
Dr. Wong
It's one of the first medical schools right?
Dr. Scheinberg
Yes exactly! So it has a very rich and long tradition right but very steeped in the western medical world. So I come into contact, what keeps me excited about being at Hopkins is there are amazing people who really you know their strongest desire is to do good in the world and help people and help patients. We do that by different innovations and research but you know in general they think within kind of our structured rhetoric of how we're taught in medical school to think.
Dr. Wong
So I think it's amazing that you've pioneered integrative medicine and perioperative care in a holistic way at Hopkins. So let's talk about, let's kind of take a deep dive into perioperative care here. First of all, what is perioperative care? What are some of the important considerations prior to surgery and things like that? Let's kind of start with some definitions for our listeners.
Dr. Scheinberg
Sure, yeah. It's you know the perioperative period is, it's a defined period that includes before the surgery period, the during the surgery period, and the aftermath after the surgical period. An anesthesiologist nowadays, we used to be thought of as just the person that's going to be in the operating room taking care of you while you're asleep and then waking you up and getting you through the recovery room process. Now, we're really taking ownership of that entire perioperative period. So we're physicians that not only specialize in caring for patients in the operating room but we can really evaluate them before surgery and make sure whatever conditions, issues, medical comorbidities are happening before surgery that we optimize that and that we make sure they're fully evaluated so that we can take the best and safest care of them during the surgical period. And then we also have specialists that take care of patients after surgery whether that be in the ICU. So intensivists that specialize in ICU care and beyond. There are physicians now that specialize in pain from the anesthesia perspective and so we take care of people after for the long term as they recover and you know help people wean off of opioids for example a very important part of recovering now that we're in a day and age that there's a lot of awareness of opioids and the potential dangers they have.
Dr. Wong
Yeah, and so what are some important considerations prior to surgery? What kind of self-care is important, do you think prior to surgery? I would say first?
Dr. Scheinberg
It's a great question. I think this is an area that is now being looked at in a more structured way more than ever. Previously we just thought more about getting people through surgery and then helping them recover but now we're expanding that view to what can we do ahead of time to optimize people so that their outcomes are even better? And so it's a great question. And I think it's one of the right questions to be asking especially if you have the luxury of time before surgery. There are some surgeries where it's just, it's emergent, it's immediate and you only have maybe hours two days before surgery. Someone comes in with a new heart attack and they, it's determined they need heart bypass surgery. You don't have the luxury of preparing for three or four months versus if you're having something like an elective joint replacement if you're having a knee or a hip replacement you may have the luxury of, “Let's get prepared and do what we need to do to optimize ourselves before we go into surgery”. Because we know clearly being healthier before surgery improves your outcomes it improves your ability to smoothly get through the recovery process, avoid complications get out of the hospital sooner, suffer less side effects of anesthesia surgery and recovery process. So some of those components are basic components that we would talk to anyone about, about a healthy lifestyle right. Nutrition is always a huge foundation of what we talk about in the health and wellness world in integrative medicine and functional medicine. You're not talking about a proper foundation of health if you're not talking about nutrition. Same thing for preparing for surgery. Some of the slight differences are we know that blood glucose control, so blood sugar control before surgery has a major impact on surgery outcome things like wound healing things like risk of heart events after surgery. So paying attention to whole foods and low glycemic index type foods is super important in the days and weeks before surgery. The range in the spectrum of all of the rainbow colors of fruits and vegetables because that's where all of those phytonutrients and really important chemicals that help give your body building blocks before surgery come from. The other thing that's a little that may be a little different before surgery is what's called a catabolic state. Meaning your body is in the process of breaking down its components rather than building up its components. So when you sort of take your body and put it in that catabolic state in order to recover and heal, your body needs to have provided the building blocks for all your cells to start building up the tissue that got damaged during surgery. So we think of that and one of those components is protein. So perhaps there is a little elevated need for protein in the weeks before surgery.
Dr. Wong
Just to get a drill down on that if you don't mind Rosie. What, how many grams of protein would you say people would be recommended per body weight if they're trying to build that up?
Dr. Scheinberg
Yeah. So in general, what's recommended before surgery is about 0.8 grams per kilogram of body weight okay in the weeks before surgery.
Dr. Wong
Okay. Like cup three-four weeks that kind of time frame.
Dr. Scheinberg
Yeah.
Dr. Wong
Got it. And then for the blood sugar, I'm wondering, do you ever recommend people go on continuous glucose monitors either pre-operatively or perioperatively to just understand where the glucose level is? Have people done that there?
Dr. Scheinberg
That's interesting we haven't gotten to that level to see if that kind of eye toward really minutely controlling it makes a difference. But we do know that glycemic control, in general, is beneficial. So, I can't say I've recommended anyone buy a continuous glucose monitor to monitor themselves through the perioperative period but certainly putting into place the lifestyle behaviors that impact glycemic control that's where I put the focus on.
Dr. Wong
Yeah, the whole foods diet rainbow you know healthy protein.
Dr. Scheinberg
That's right avoiding simple sugars.
Dr. Wong
Avoiding simple sugars, right. And just for all the listeners out there. I think most people may know this but alcohol is also a simple sugar. So we wouldn't want to really drink.
Dr. Scheinberg
As well as putting a load on your liver right. Your liver is part of what's going to metabolize all of the drugs that you're given perioperatively so you want to give alcohol and caffeine a break. Remember caffeine too, vasoconstricts blood vessels and you need good blood flow to all your body parts to help facilitate healing as well.
Dr. Wong
Got it.
Dr. Scheinberg
So alcohol and coffee for a couple of weeks before.
Dr. Wong
A couple of weeks before just totally eliminate ideally. Got it.
Dr. Scheinberg
That's ideal.
Dr. Wong
And I believe there's been research throughout the last few decades on smoking cessation right. Even if people are smokers and they want to quit even I think quitting before surgery you know versus someone that you know was a non-smoker throughout their whole life. I think there's still some benefit even if they have smoked a long time to quitting before surgery, correct?
Dr. Scheinberg
Yeah. That's right. Now, what people don't know and what, I, we know this from the literature. I would never discourage anyone from quitting smoking because I think and we know that wound healing and blood flow you know, that's improved by quitting smoking even in the short term is beneficial. However, I will mention this just for our more sophisticated listeners. It takes about six to eight weeks for the lungs to sort of start clearing up some of the all the carbon deposits that have been in there and the cilia, the little hairs that line all of the airways start to come to life when you quit smoking they get sort of paralyzed when someone's smoking. So when they start to come to life they start kind of moving up all of this junk that's been sort of lining the lungs
Dr. Wong
Detox.
Dr. Scheinberg
people start coughing up more, sorry?
Dr. Wong
Detox.
Dr. Scheinberg
Detox. Yeah. So, as they start coming, so we know that if people have quit within that six to eight week period, slight increased chance of pulmonary complications just because their lungs are doing what they're supposed to do and they're detoxing they're bringing up that junk but it's not the ideal time to be mobilizing and detoxing right before surgery.
Dr. Wong
So if they know they're having some surgery or want to plan. Let's say a total knee or something like that but it could wait a couple of months maybe try to quit smoking and get that junk out.
Dr. Scheinberg
That's right.
Dr. Wong
At least for you know
Dr. Scheinberg
At least for eight weeks would be, that's right that would be sort of beneficial in the global picture absolutely.
Dr. Wong
What about other hormones like cortisol or thyroid or sex hormones? Is there any association between, say like levels of cortisol levels of thyroid hormone, like TSH, things like that as a pituitary hormone that is you know measuring thyroid indirectly and then sex hormones in terms of that you know about in terms of research in terms of affecting surgical outcomes?
Dr. Scheinberg
Great question. An interesting question. You know, we tend to think of hormonal regulation especially you know. I don't know, I haven't seen a lot of research on like modulating sex hormones, especially around surgery we definitely have different surgical populations that have high low you know levels all the time especially when we take care of pregnant women around surgery or people on steroid replacements. But we don't have a lot of outcomes data I would say, from modulating. That because it's not a common thing you're going to modulate just to get a better outcome. TSH and thyroid can have especially in the more extreme really high or really low can have more perioperative implications than slightly higher slightly low. The cortisol is interesting because that's that gets into the whole question of the whole stress response right. Because cortisol is part of that stress response and what we clearly know and this is where we talk about you know the pre-operative interventions of like guided imagery and things to help lower that stress response and the anxiety before surgery. But what we know about the stress response in the body is that there is a natural biphasic response so there's two parts to this inflammatory response with surgery. There's a big surge right after the surgical insult. So when a surgeon comes at you with a knife and they do damage to your tissue and then that response calms down and then you know as things heal as the tissue starts to heal. Part of that is you know in the integrative world we tend to think sort of more anti-inflammatory is better. However, in surgery, you still need that inflammatory surge to kick off the healing process. So we don't want to squelch it all together so we want to sort of the natural rise of cortisol and you know all of the norepinephrines and epinephrines and cytokines and things because that begins. And that's part of the healing process. The problem comes when you have a very prolonged and exaggerated stress response that has been shown to impair and delay healing and being implicated in a lot of postoperative complications. So when I think about kind of cortisol and the stress response it's like let the body have its natural response afterward don't completely squelch it and then sometime in the recovery process that's where you do want to reinstitute all of these anti-inflammatory interventions so that reaction can come to its natural conclusion.
Dr. Wong
Great! Thank you so much, Rosie. So, a lot of questions just generated from that based on your amazing answers here. One of the things is that you know that the surgeon's coming at the patient with the knife or you know obviously, there's a lot of vulnerability there. The patient's unconscious, they're in general anesthesia often or at least LMA but the idea is that you know that person's really leaving their body to the surgeon right and to the anesthesiologist. But, what role do trust and the relationship between the patient and the practitioner have to do with outcomes you know, wound healing decreased complications? Does that play a role in how can that be fostered you know in terms of strengthening that relationship?
Dr. Scheinberg
So important. And the longer I've been practicing medicine this is such a particularly vulnerable time for patients when they're coming in to have surgery most of us in modern life, in our modern world. We have control over our daily activities and what happens to us and we like that we like control. And so when you come in to have surgery you really have to shed all of that control and people are just doing things to you without your making those decisions and it's very anxiety-provoking and vulnerable and that's again why you, it's imperative that you feel trust in the pro in the practitioners and providers taking care of you. Because you, your life literally is in other people's hands and it's their responsibility to get you safely through that and that generates a lot of anxiety you know. The stereotype of anesthesiologists is that we got into this business because we have no people skills, so.
Dr. Wong
I think knowing you that could not be farther from the truth, but uh.
Dr. Scheinberg
I mean, it may be true in some instances but I actually think the opposite is that we have a shorter amount of time to really get to know our patients and build that trusting relationship in a small amount of time. Because even though our relationship with the patient is short, we have it's a very intense and like I said a very vulnerable time for patients. So I always take time to acknowledge perhaps the anxiety and the uncertainty that patients may be feeling in, especially in the pre-operative area and I make sure that they know that all emotions are welcome because patients have a lot of emotions. And then in the pre-operative area because it's that moment right before this whole big black box that's going to be happening to them starts and so people have different feelings and different ways that uncertainty comes out and that's okay.
Dr. Wong
Yes.
Dr. Scheinberg
We can be present for all of that.
Dr. Wong
And I feel you know as integrative medicine practitioners we both believe obviously in the connection between mind body spirit and how the body is really even for something as vulnerable and invasive as surgery. The body's trying to heal itself postoperatively right but even preoperatively, I feel like what's happening is the body's probably anticipating you know that person's energetic body's anticipating there's something going to be happening and you know preparing that person building that trust up, that relationship with the practitioners, with the system, with the hospital, etc. That can be really healing and pay dividends in the short and long term you know post-op as well.
Dr. Scheinberg
It really can, having that lines of communication open with the surgical team you know we know that even just education which means having a conversation about what to expect, what it's likely to be like, how you can prepare best for it, you know. Even just if we think about it on its most basic level that improves outcomes because patients are more mentally prepared when we broaden that to the mind-body connection that you mentioned. I think mentally preparing for surgery is one of the biggest things that patients can do for themselves to help smooth out and help their own outcomes.
Dr. Wong
Great. What specific recommendations do you have to mentally prepare for surgery and I do want to touch on, like music and guided imagery too you know that would be helpful to talk about because I know we've talked about that before. But what kind of mental strategies or kind of tips or tools or techniques have you found to be really helpful for patients in terms of preparing for surgery.
Dr. Scheinberg
Yeah. I think some type of guided imagery since we're not all pre-trained in how to do this you know. I think the people who sort of have that mind-body connection which is really the autonomic nervous system that controls the stress response and the relaxation response that's what we're talking about. You know like, Tibetan monks and Buddhist monks who may spend a good portion of their day really turning inward and learning how to very finely control that autonomic nervous system so for us who are not maybe as practiced in that, having guided imagery. I think is a really good way to prepare and there are several on the market out there now that have been developed that are pre-operative sort of guided imagery preparation.
Dr. Wong
Which ones do you recommend for listeners? if they
Dr. Scheinberg
Yeah. So some that I really like, I use a lot Peggy Huddleston's prepare for surgery heal faster. Martin Rossman has another one that is preparing for surgery, okay and the third one by Belleruth Naparstek also has a preparation. So those three are very good I think in helping people. I think doing something is way better than not doing anything.
Dr. Wong
Yes and also it does give people back a little bit of that locus of control like they're doing something even though they're about to go under anesthesia and you know be a bit at the mercy of the surgery in general. But that's great. And what about music? I know you had mentioned before about listening to favorite music and kind of calming down the nervous system, balancing that ANS like you said. What are your thoughts about listening to music? I guess in the preparative period both pre and post as well.
Dr. Scheinberg
Yeah. There's actually a lot of data on you know studies looking at when people listen to different types of music and I want to be clear because there are now emerging two types of music. One is called music medicine and that's kind of what we think about when we think about you passively giving someone music to listen to music, either they like or they resonate with there's you know some data to that whole the Mozart effect where certain beats like 60 beats a minute which is closer to the heartbeat may help calm that autonomic nervous system so listening to something like that versus so that's one category passive listening music medicine. The other category is what's called now music therapy. So there this is an interactive session with a therapist where then you more actively think about music and maybe create it or listen to something that in very particular ways. So when we think about perioperative, the most what's been studied most because it's most implementable is music medicine. And most studies have found a favorable outcome in using medicine to help calm anxiety even to help pain scores and side effects after surgery. I think people would agree right, most people feel good when they listen to music they enjoy or soothing music and so I think it makes sense and it's something that most of us can have on hand nowadays right some earphones or you know earbuds and a cell phone.
Dr. Wong
Yeah. So it's time for a humorous and potentially semi-controversial question but, do you recommend that the patient choose the music medicine or even the or the anesthesiologist versus the surgeon? I'm curious about that you know.
Dr. Scheinberg
In the operating room?
Dr. Wong
Yeah! in the OR, right. Like, what if it actually you know influences right three, four-hour surgery, six-hour surgery, maybe the patient should be part of that and just not sure if that would
Dr. Scheinberg
Well you know I think that's an easy answer when we think about the patient. Because there's an easy way to isolate the patient from the rest of the operating room because I think if they're just listening to the general talk in the room plus music I think that's less ideal perhaps for their subconscious that may be listening to kind of the garbage conversations we may be having. They don't need to hear what we're talking about in the operating room. But if you can isolate them and with earbuds headphones something like that to listen to something more ideal continuation of the guided imagery that they had been practicing ahead of time or some type of music in the operating room I think that would be far superior.
Dr. Wong
Is that happening at Hopkins now? I didn't realize that yeah.
Dr. Scheinberg
It's not. But it is, I think would be very beneficial. I used to have patients just bring their own devices with their music into the operating room and because of an unfortunate event where someone was trying to audio record on their device in the operating room we now have you know, policies designed you know against that kind of violation of privacy so until we can use more mp3 players or things that are not recordable I think that would be a more ideal solution.
Dr. Wong
Maybe something owned by the hospital that could just be kind of utilized.
Dr. Scheinberg
I think so, I think that would be you know the hospital liability would find that superior.
Dr. Wong
Yeah, that makes sense.
Dr. Scheinberg
The benefit of music is undeniable.
Dr. Wong
Absolutely, yeah. And it, you know, we know that we're really we're, we kind of think about biology in terms of you know we are a collection of cells and organs and we have different you know everything kind of communicates together but then on one level in an energetic level, we're also vibrational frequencies right and so the music is speaking to that and if we can have that aligned with our own cellular frequencies through the music that we play, I can say that would you know likely be you know to heal for the patient periodically.
Dr. Scheinberg
Although there haven't been randomized double-blind controlled trials on that I agree. We know there's this phenomenon of entrainment where you can sort of you know, your energetics can align with other energetic so why don't we bring the best most positive energetics that we can to help our body facilitate its own natural healing process that's what this is all about.
Dr. Wong
That's awesome and then I know you're a medical acupuncturist as well, correct?
Dr. Scheinberg
That's right.
Dr. Wong
And curious if you
Dr. Scheinberg
Trying to follow in your footsteps Andy, you know.
Dr. Wong
Well, I should give a shout-out to my sister Michelle who introduced me to medical acupuncture as well but yeah we're and actually even for functional medicine, Dr. Jeffrey who's I believe now in Florida. She introduced me to functional so it's all about kind of communicating you know networking and really understanding you know from our friends and family this is often who got leads away. So definitely you as well, you know I've certainly looked up to you and what you've done here in the academic setting. But I would say one other question I have about sort of the perioperative environment and setting and integrative modalities is for acupuncture. What is the role of acupuncture and perioperative care you know reducing the paradox of pain, decreasing complications, and increasing I guess the effectiveness of recovery?
Dr. Scheinberg
I think acupuncture is one of those most exciting and forward-thinking things that we can do for a perioperative patient because the data is so favorable with reducing the need for post-operative opioids. So lowering pain scores, and preventing side effects like nausea and vomiting after surgery which is the most common side effect after general anesthesia by far. It can, it's shown it can help with some of the common post-op complications like faster time to bowel and bladder function. So ileus is huge morbidity afterward urinary retention where just people can't get that urinary stream going again a huge issue and it's also beneficial in pre-operative anxiety too. One of my favorite stories is right after I was just credentialed in medical acupuncture, I had a patient reach out to me a young woman who was traveling to Hopkins with a shunt in her brain. So to help drain some excess fluid in her brain a VP shunt that she had and she would get periodic revisions of this, she said no matter what drugs and whatever we did to help her after surgery she had nausea and vomiting for three days straight every time she had surgery and she said it was so miserable, was there anything I could do to help? And I was brand new and I said you know what let's try. So I did some in the pre-operative area just for about, 20 minutes before surgery while she was you know waiting for her surgery to happen I did some acupuncture ahead of time, and no nausea and vomiting in the recovery room. She was so thrilled and we repeated that she had she's come back since and had another one and she goes, “oh please I hope you're there, can you do it again?” and I did and no nausea and vomiting. So it's really exciting to have just a tool that you can use in real-time simple that can add so much value for a patient.
Dr. Wong
I love, I love doing acupuncture at the moment. Not that I do it every day but as a primary care physician you know at the moment if I need to do it for something like IT band or back pain or even like that nausea, anxiety picture using four gates or something like that you know it can be really helpful. So that's great you're using it in the hospital it's amazing.
Dr. Scheinberg
Yeah. And I want to advocate you know, so one of the biggest barriers to implementing this because then you might ask well if the data is so good and it's so useful why aren't we just adding it to our hospitals, especially in the day and age of the opioid crisis the biggest limitation is that there's no way again this all comes back down to reimbursement for acupuncturists, licensed acupunctures to be reimbursed in a hospital setting. So there's no way for someone to hire an acupuncturist just to be in the pre-operative area and the post-operative area of doing these amazing you know treatments for patients. So that becomes a limiting barrier and so you know perhaps it's incumbent upon physicians to get the training themselves so they can add it in their practice.
Dr. Wong
Yeah. Is there a movement do you know if there's a movement towards that? Is anyone kind of advocating for licensed acupunctures to go into hospital settings to be treating or is that, or is there resistance there as well?
Dr. Scheinberg
Yeah. So I think you know there's a desire out there. I haven't seen an organized push because this is you know all in the bigger spectrum of reimbursement and how we're reimbursed and for what we're reimbursed. So as hospitals move toward more bundled payments, I think this is more and more challenging to advocate for individual services, even so, it's a challenging environment to advocate for this type of individual service. But I think in the long run you know proving its cost-benefit and it's you know in less drugs, less stay in the recovery room will ultimately be it's successful.
Dr. Wong
So, probably increasing clinical outcomes, reducing cost, and maybe starting with physicians and medical practitioners. But then you know potentially licensed acupuncturists downline, I think would be great to have them in the hospital too. If they're interested in that. And do you have any recommended supplements pre or post-surgery? Because I know a lot of people ask about that. Are there any supplements we need to stop before surgery? You know we talk about that too.
Dr. Scheinberg
Yeah. It's a really big area and it's a, there's a lot of questions about that because standard if you ask sort of any standard you know pre-operative clinic surgeon they're going to say you stop everything a couple of weeks before surgery right. Now there are some things I think we need to think about in terms of I'll start with what shouldn't we be on at first. So some things that I think about, I think about these in kind of three categories that could interact with the anesthetic part of this that make me a little concerned. One of these is botanicals, herbs, supplements that impact coagulation. Blood-thinning things so and we have a lot of those right because what makes them platelets and things less sticky is good for the heart so we have a lot of things that we take because it's got good cardiovascular benefit but in a surgical situation it could be that it might make you bleed more and we worry about that. So things like you know vitamin E, high-dose fish oils, you know all we call these the G ones. So there's garlic, ginger, ginkgo, green tea you know. Those kinds of things have those good heart healthy properties but they also tend to make you bleed.
Dr. Wong
And curcumin, curcumin too yeah.
Dr. Scheinberg
Curcumin too yeah. I don't particularly worry about them individually but what I do worry about is when you start adding them up plus maybe someone's on aspirin or we have a lot of people on different types of blood-thinning medicines not only kind of the classic coumadin warfarin but we have a lot of direct thrombin inhibitors and you know so more and more of the population is on those. So when you start adding those up then maybe we have a true increased risk.
Dr. Wong
Seven days before stopping them would you say or how many days?
Dr. Scheinberg
You know kind of the most you know, the most conservative is two weeks. I think seven to ten days is probably you know the minimum amount you should stop these just to make sure the half you have enough half-life is out of your system.
Dr. Wong
Sorry, go-ahead.
Dr. Scheinberg
Oh yeah. I was going to say the next category. I worry about is kind of the ones that stimulate that stress response the sympathomimetics. Because surgery itself is a stress test on your body so we don't want to add drugs that are stimulating that symptom you know, sympathetic system.
Dr. Wong
Like, kind of revving up the system yeah.
Dr. Scheinberg
Yeah. So Panax ginseng may be something that people don't think about, licorice not the glycerinated kind like DGL but you know just traditional licorice and ephedra which is ma huang. So those are a few that I just keep in the back of my mind as things that I think probably don't need to be on someone's plate as additional stress on the system.
Dr. Wong
Got it.
Dr. Scheinberg
And then lastly the sedative ones. I think that's an interesting category because I actually think we should be using them to our advantage. But you know when you have a practitioner who's not aware of those and what they are and how they might interact with what the sedatives they're going to give them you can get too much of an effect. So Valerian and Kava kava and Saint john's wort and passion flower. Those things have sedatives which are great. I think they're relaxing effects and they can help people with some of that anxiety especially beforehand. But at this point, since I don't think we have enough awareness of you know botanicals. What they are and what they do, we have to be very cautious about people being
Dr. Wong
And then, there are also the cytochrome p450 drug interactions too and some of them probably do have an effect on anesthesia and cardiac drugs I would imagine.
Dr. Scheinberg
They do you know, I think there are only so many enzyme pathways in the body and so there's going to be a lot of overlap in what uses, what enzyme pathways the cytochrome p450 system being among the most well-utilized pathways that we have. So I think there are a lot of concerns that if we truly drill down are probably more theoretical than actual patient harm but in being conservative we do want to think about those.
Dr. Wong
And because something major like surgery that makes sense, that makes sense. I wanted to ask you about post surgeries. So like when is it, when do you feel like it's safe in your opinion for people to restart some of these supplements? Whether they're more blood-thinning botanicals vitamins or sympathomimetics or sedatives you know. I know it probably depends on each case and how they're doing too but, curious.
Dr. Scheinberg
Yeah. So you know things like probiotics. I think should be started pretty quickly once you're starting to take it.
Dr. Wong
Pretty immediately like most people get antibiotics right a lot of people get antibiotics
Dr. Scheinberg
That's correct almost every surgery comes with at least a dose or 24 hours of antibiotics so yeah so we know there's huge alterations in the gut and the microbiome that happened because of that yeah.
Dr. Wong
How how long do you think people should take probiotics and again this is probably an individualized approach but you know post having any sort of antibiotics whether it's oral and IV antibiotic
Dr. Scheinberg
Yeah, that's a hard question and again we don't have a great randomized controlled trial to know when does the microbiome sort of repopulates and gets back to normal. I think of the prebiotic as a placeholder. It's a stop-gap toward you know toward quickly repopulating your gut with some beneficial bacteria while you get your nutrition back on board which is really your baseline of keeping your microbiome healthy and diverse and happy. So I think at least a month to six weeks maybe after surgery although that is you know I'm just sort of extrapolating based on that.
Dr. Wong
I agree with that. I do think there’s certain harder antibiotics like the fluoroquinolones that you may need even longer you know based on some of the data that might be out there for as much as six months. So it's really really, it's a lot that can you know as one does going to do that who knows. But these antibiotics are pretty strong you know. So it is possible and this gives me another excuse to give a shout-out to a Baltimore-based Sauerkraut company called HEX ferments that is really great. So they, they're a good you know, Sauerkraut would be something to help with as a prebiotic to help get it out.
Dr. Scheinberg
Absolutely! I love it! I have it in my fridge and yeah.
Dr. Wong
Do you have the HEX ferments as well, or?
Dr. Scheinberg
I haven't tried that one I think, you know.
Dr. Wong
Apparently, it's an, it's either in Towson or Baltimore. We got h-e-x ferment.
Dr. Scheinberg
I'm gonna look for that. I love sauerkraut.
Dr. Wong
Yes and they have a turmeric one too although I think food-based you know you could, people could have like turmeric and they could eat fish and those type of things before surgery right it's not like it's if it's not a supplement if you're eating like a food or something.
Dr. Scheinberg
Absolutely. And when I talked about garlic and get you can absolutely have those spices in food and in food form don't hesitate to do that before surgery
Dr. Wong
And that would help anti-inflammatory benefit to have those in a way which might help too.
Dr. Scheinberg
Absolutely!
Dr. Wong
Great! Well, thank you so much, Dr. Scheinberg, Rosie, for being on the podcast. We have a few fun closing questions here which I believe, I think you said. But I may be mistaken that are you an early morning person or not but either way, do you have a morning routine and if so would you mind sharing that with us?
Dr. Scheinberg
Oh gosh. Well by necessity I'm an early morning person because of my job. So, we start the cardiac, so cardiac surgery which is my subspecialty starts 45 minutes other than sooner than regular surgery so we're in the operating room at 6:45 every morning.
Dr. Wong
Those are long surgeries, yeah.
Dr. Scheinberg
Yeah, they tend to be you know at least five to seven hours surgery and so to get a couple in throughout the day yeah we don't want to be here forever. So we try and get an early start to those so I'm up at about 4:30. I don't have a very exciting morning routine. I've since, I've started doing intermittent fasting, I don't even make breakfast in the morning but yeah. Morning for me is just about basics. What I do when I first get to work is, I do my heart rate variability for five minutes. I do my heart math. The first thing I do when I get to work before I change into my scrubs for the day is I'll sit down, and I'll open my app and put my little ear clip-on and do five minutes of breathing. So at least i start the day by activating my parasympathetic system and lowering my stress response before the day might happen to raise my stress risk.
Dr. Wong
That's a great idea, yeah, especially before surgery. Are you doing coffee with intermittent fasting or is it more just like water and things?
Dr. Scheinberg
Yeah. So it's funny, I was actually never a coffee drinker but I was always a breakfast person. So when I started doing intermittent fasting which is tough right because we don't have exact data on you know what we should do. There's some data that maybe we should do it before surgery the prolonged you know fasting-mimicking diet maybe you should do that in the month before surgery and help your autophagy right before surgery.
Dr. Wong
Like a five day, like a five days of the prolonged like one.
Dr. Scheinberg
Like a five-day prolong that's right like, like a month before surgery. There are some suggestions that could be beneficial in helping prepare the body.
Dr. Wong
I guess that makes sense you're cleaning out the system a bit preparing cleaning the house a bit before surgery.
Dr. Scheinberg
Exactly!
Dr. Wong
Cool!
Dr. Scheinberg
Exactly you know, just like vitamin D like make sure your vitamin D levels are optimized before surgery, you know little things like that.
Dr. Wong
What do you like the D levels to be? Because I know that would be a question?
Dr. Scheinberg
I know. So I just, I don't like them to be bottom of normal you know. When I think about kind of the functional medicine view a lot of talks is kind of 50 to 80 in that range so I, at least like them in the mid normal range at a very minimum.
Dr. Wong
Yeah, 40, 50 something like that.
Dr. Scheinberg
That's right we know that's where optimized immune function happens.
Dr. Wong
Right, right. I mean there is this some evidence from basic science at least that vitamin D decreases interleukin-6 so in that way, I suppose a mid-level would be nice because then you're not having too much but then you're not you're probably not totally blocking it either. So it's theoretical at this point we don't really know but I guess we could say that you know safely that, or is there is research on low vitamin D like frankly, like you know vitamin D less than 20 let's say is that associated with worse outcomes is there is?
Dr. Scheinberg
Yeah, there is worse post-operative infections and in general yeah.
Dr. Wong
Okay, so that would certainly be something and then what book or podcast are you enjoying the most right now?
Dr. Scheinberg
Oh well, this heralds back to my, I think a child like nature. What I got back into and I'm re-listening to I tend to do audio books because I can then multitask that makes me happy you know when I'm doing my saturday morning cleaning routine or laundry. I get to listen along. I re-engage with the Harry Potter books.
Dr. Wong
Oh nice, yeah. Which book are you on now? There's like seven right? I think.
Dr. Scheinberg
I, yeah. There's seven. I, actually am on book seven.
Dr. Wong
Book seven, all right the climax. That's great.
Dr. Scheinberg
I know, the climax. I love it.
Dr. Wong
Yeah, yeah. Well, they're books that are amazing to keep on reading them over and over you know.
Dr. Scheinberg
Yeah. There are so many good things out there though, so it's hard to, you know. It's hard to choose.
Dr. Wong
Yeah. There's a book that I just got from the library. This is random but if you ever watch that movie called “A man called Ove” then there's this author named Fredrick Backman who I think is from Sweden. It's really good. He wrote a book called “Anxious people”, so it actually is and it's an interesting book. So if you're interested in more books like that and you know we'll talk about that more.
Dr. Scheinberg
Oh lovely, yeah definitely!
Dr. Wong
And then what do you do every day to cultivate joy? So maybe like after you get out of the OR, you know, and those types of things.
Dr. Scheinberg
That is such a good question. What do I do every day to cultivate joy? You know, I can say this is acute so this is more right now when I come home I love, different times of the year, different things are blooming in my garden nice. So when I just get home and I get to see kind of like the mums right now right it's fall and the mums are starting to bloom and I had just planted a couple of plants of them. So every day I come home and I'll just stand there and it's you know, it almost becomes a family event like I'm standing there and my husband comes over, “what are you looking at?”, “I'm looking at the mums and stuff”. We all stand and enjoy because it's just such a beautiful pop of color you know when the summer had kind of made everything just green. So now, I've got this pop the color again and I just enjoy some of the fruits of the hard work of all the plantings I've done around my house. So just coming home and seeing that actually makes me internally smile.
Dr. Wong
Absolutely! Nature brings us joy for sure we're part of that. So thank you so much again Rosie, Dr. Scheinberg for coming on today. And how can listeners learn more about you and and potentially work with you? I guess, are you doing like more integrative concepts now. Are you doing only for like pre-operatively or kind of what's going on?
Dr. Scheinberg
Yeah no. So, I am open to integrative medicine consults. I do them most of them in the context of cancer patients. So I'm working with the metastatic breast cancer clinic at Johns Hopkins but I am open to having sort of you know, a diverse population. I've worked with people in chronic pain, I've worked with some patients before and after surgery some people who've had traumatic events around anesthetic experiences particularly.
Dr. Wong
Okay, so how do people get in contact with you then to work with you?
Dr. Scheinberg
The email address is “healatopkins” (h-e-a-l-a-t) “Hopkins” (h-o-p-k-i-n-s@j-h-m-i.e-d-u) johnshopkinsmedicalinstitute.edu. Yeah.
Dr. Wong
So, “healathopkins@jhmi.edu”
Dr. Scheinberg
You got it.
Dr. Wong
Got it. And is that going to the main box or is that going to you, or?
Dr. Scheinberg
Both. It goes, but it's something that I regularly check as well.
Dr. Wong
Okay.
Dr. Scheinberg
The other thing that I offer for it is, you know mostly for our Hopkins patients is, I do offer for free Peggy Huddleston's pre-operative workshop. So I do Peggy Huddleston's you know, prepare for surgery workshop which I think can be really helpful for people. So if anybody happens to be having surgery at Hopkins you can google that mind body and my name and it'll come up the the link. But you can also email the email address to find out more information.
Dr. Wong
How long is the workshop, is it like?
Dr. Scheinberg
One hour. And I do it remotely by phone. I think her program works best if you at least have a week to ten days before surgery to do the preparation work.
Dr. Wong
Great! Thank you so much for sharing that and I know we have likely, our listeners. I'm sure you know since Hopkins there's a lot of different hospitals now part of Hopkins so you know and I guess in general it's great that you know we've talked about this today because people are having surgeries even during the pandemic you know there have been a lot of you know need for both elective and emergent surgery. So thank you so much for the work you are doing in the integrative space here academic space with perioperative medicine. Thank you so much Dr. Scheinberg for being on again.
Dr. Scheinberg
My pleasure, Andy! Thank you for hosting this amazing podcast. So, yeah. All of your listeners have an opportunity to hear some of your amazing pearls of wisdom that you garnered from all of your training so yes thank you for all the work you're doing for your patience.
Dr. Wong
Thank you so much Rosie. All right, good to see you and talk soon. Take care.
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