Written by Christopher Kelly
July 19, 2016
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Christopher: Hello and welcome to the Nourish Balance Thrive podcast. My name is Christopher Kelly and today, I'm joined by Rory Heath. Hi, Rory!
Rory: Hi! How's it going?
Christopher: Great! Thank you. Thank you for coming on. I'm excited to have you. Rory is a fourth year medical student at King's College London and he's a writer. He has his own blog and he also writes for the Strength & Conditioning Research website, which I will link to in the show notes for this podcast.
Rory, can you tell us about your interest in medicine and how you got started with medical school?
Rory: Okay. I studied in the UK. Our application process is when we're 17 or 18 and then we apply to medical school. When I applied, I was still really quite young.
Christopher: You look young now in your picture. How old are you?
Rory: I'm 22.
Christopher: Twenty-two. You look really young. That's a good thing. You'll appreciate that later.
Rory: I was thinking a while ago I haven't gotten around to changing it yet. Yeah, so I was 17 when I applied to medical school and I applied because of my background in sports and my general interest in the human body, how it works and how it goes wrong. My interest in medicine has changed over the years throughout medical school. We can talk about that later.
In terms of my sporting background, I used to play a lot of rugby. And so, I've been quite closely tuned to how my body works when I'm training in the gym or on the pitch, and then I also have had all the injuries as well. I've come to contact with the NHS and the health services and then the whole rehabilitation process and trying to get myself better on a physical level.
I also experimented with different types of diets and macronutrient ratios and things like that to try and get every little ounce of performance I could at home so I could perform better on the pitch. That's why I applied to medical school so I could learn about those areas a little bit more and then translate that into a career and helping other people and getting more involved into that.
Christopher: What qualifications did you need to get into medical school?
Rory: So because you are applying when you're in [0:01:54] [Indiscernible], it's just A-levels. I did Biology, Chemistry, and English. In general, you need three A's to get to med school.
Christopher: Oh wow! That's quite an achievement. I'm sure that some people listening to this won't be familiar with the purchase system of academia. A-levels are what you finish when you're 18 years old, is that right?
Rory: Yeah.
Christopher: And so, you only do three or maybe four subjects, I believe. Some people are doing five now. Am I right in thinking that?
Rory: Yeah. My brother completely eclipsed me. He just applied to Computer Science. I think that's like yourself.
Christopher: Yeah, that's right. I have an undergraduate degree in Computer Science.
Rory: Yeah, so he's just applied to do that. Now, he has five A levels. He does Maths, Further Maths, Physics, and then two others that I'm not sure about.
Christopher: Tell me about King's College then. For people listening, you probably won't know that King's College in London, it's on Strand. It's a pretty amazing part of London. Is that why you chose King's College?
Rory: Yeah, it is. I chose it because it's one of the famous medical schools. It's got a really, really long history behind it. I chose it because of its location, too, so it's got multiple campuses throughout London. It's got one at London Bridge, which is Guy's Hospital, St. Thomas, which is just by Westminster. It also has Denmark Hill, which is in South London.
I chose it because it's part of the South Thames deanery, so you are able to not only have the London hospitals, but be sent to peripheral hospitals and down on the coast and explore [0:03:24] [Indiscernible] to explore areas of southern England. So I thought it'll be a good place to go because it offers a wide variety of patients to see and many different demographics as well. That reflects the diseases that you come across.
For example in South London, we have a large African population, so the diseases in South London are more like sickle cell. We've got a lot of malaria, too, which is not usual for United Kingdom, but then if you're sent down to Chichester by the coast, then you get different diseases and different demographics.
Christopher: Wow! That's so interesting. Where do you live at the moment? Are you living in London?
Rory: My student accommodation is in Peckham, so in South London, which is good fun. It's got a really, really big student community, so I'm still able to get into Central London really easily. Currently, I've moved back to my parental home at North London just because I'm in a [0:04:21] [Indiscernible] written exams, and so I'm trying to get a little home [0:04:23] [Indiscernible] as I can.
Christopher: Oh no. I'm sorry if I'm keeping you from revising that [0:04:27] [Indiscernible].
Rory: This is a really good break.
Christopher: Tell me about -- let's start to the degree then. So you're in your fourth year. Can you give me a general overview of what the years were like, year one, year two, year three? When was it you first started seeing patients?
Rory: Typically in the old days, you'd have the first two years being pure clinical sciences, so you're learning your physiology, biochemistry, and anatomy, and then you wouldn't see your patients until years three, four, and five. That's changing in many medical schools. King's is still quite typical in that you have your two clinical years, but they're embracing patients a little bit earlier.
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So throughout one and two, you'd go to a GP practice and be allocated to them and then you see a few patients. However, that was very rare and you wouldn't really be able to have a doctor-patient relationship in any form. You get your true exposure to patients when you go to three, four, and five, and so that's when your learning is very much based in the hospital setting, and then it's benefitted also by lectures throughout the week.
I'm in my fourth year. I've now had two years of seeing patients and that's been through different rotations. Last year was largely general medicine, so looking at the abdomen, the chest, and the brain's semiology. This year, it's been more based on the different specialties. I've just come off my reproductive and sexual health rotation. I've also done pediatrics. I've done orthopedics and rheumatology as well, so I've had a really good, broad sense of medicine over the last two years.
The fifth year is kind of the consolidation year before finals, so it's based in three different rotations. One's in the community, in the GP practice, so you're seeing very common medical problems and you're able to -- it's a different field to hospital medicine and the majority of people who go to medical school will end up being GPs, so it's in the central part of our learning.
The other two blocks are based in surgery and in medicine and in the hospital, so that's just recapping everything we've learned over the first two years of clinics, years three and four, and preparing for our final exams, written exams and a final practical exam called an OSCE.
Christopher: Tell me about some of the problems that you see in the hospital setting especially in London. I'm really curious to know about what you see in London.
Rory: I think every hospital has its problem of chronic disease, and so wherever you are, you'll always have the same bread and butter cases for each specialty. So if you're a respiratory doctor, then you have lots of COPD in the chronic setting. If you're a heart doctor, a cardiologist, then you have lots of heart failure.
It's very much dominated by chronic disease within the hospital. It's quite amazing really. You'll be in a ward and there won't be many acute cases. Many of the patients who are there will have exacerbations of a longstanding chronic condition and that just needs looking after until they can be sent home.
The exciting stuff happens in A&E, so that's when you have trauma. That's where orthopedics are based. You have anaphylactoid reactions, heart attacks, strokes, things like that. It's a bit more dynamic and fast-paced and a bit more scary. Some of the most medically interesting cases you'll find in the ward though, so things that are based in the immune system like rheumatoid arthritis, scleroderma, different kinds of autoimmune diseases that you see.
Christopher: Okay, and you see those in the ward. How much thought goes into what's causing those types of problems and what are your thoughts on what's causing those problems?
Rory: In the UK, we're very much within the conventional approach to medicine where we look at the pathophysiology of that and then try and use a drug to treat it. Our thinking in the hospital doesn't really go much further than that. It's nowhere near the approach that functional medicine takes towards treating, treating a disease where you're trying to look for a root cause and then treating the root cause and then looking to see if the symptom is resolved.
It's also treating a patient when they've come in sick, so rather than taking a preventative approach within the community, the mainstay of our treatment is prescribing pharmacological treatments, medications and drugs, and then there's the rehabilitation side that goes on within the community that we don't get to see in the hospital.
Christopher: And how successful was it in your eyes?
Rory: I think it's successful that it completes what it sets out to do, which is bring patients back to their baseline and then manage the symptoms and stops the exacerbations. I don't think it's successful in completely removing the disease because once you have a chronic disease such as COPD, you're never expected to return to normal, but ideally you would have had an action put in place earlier, 20 years earlier that would stop getting COPD in the first place.
Christopher: Okay. Better explain what COPD is.
Rory: Okay. COPD is Chronic Obstructive Pulmonary Disease. It's a condition where you basically lose the function of your lungs to transfer gasses, so you need oxygen when you breathe in and that's essential for life, and you need to excrete carbon dioxide out of your lungs as well.
When you damage your lungs through things like smoking, you damage it all. You scar the barrier that the gasses usually go over and then you find it very difficult to exchange these gasses, which means that you are hypoxic, so you haven't got enough oxygen within your blood and you may retain carbon dioxide as well, so you end up being quite a sick patient.
You gradually lose the function of your lungs to transfer oxygen and carbon dioxide and you need more therapies to keep your airways open and you may need full-time oxygen therapy to make sure your body is getting enough. You're also more susceptible to infections and traumatic problems in the lungs. Infections are a large cause of people being admitted to hospital with COPD.
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Christopher: So what's going on there? Are people smoking? Are they inhaling traffic fumes? What's going on? What's causing that, do you think?
Rory: Oh man, it's going to be multifactorial definitely. There's so much research that's been done to smoking, so I think that's the number one cause. Traffic fumes, that's ubiquitous in every city. I haven't looked at the data, but I'm sure -- well, I expect that rates of COPD will be higher in people who are constantly exposed to these fumes. It's just gradual lung damage that you get as you age and as you come across different pollutants.
Christopher: Tell me about your interest in sports medicine. What does sports medicine look like for rugby players? Is it just the type of acute injury that they pick up on the field or is there something that sports medicine can help with rugby players in their diet or body composition or strength? Tell me about sports medicine.
Rory: Sports medicine is huge. You can attack it from different angles. The training pathway to sports medicine, you'd need to go through a surgical pathway, so you do your basic surgical training and then you qualify in sports medicine so you'd be able to look at different sports injuries. If someone's come in with an ACL, you could address that injury in a sports medicine fashion.
You can do it through hospital medicine. I know a rheumatologist who's also interested in sports medicine. Rheumatology is kind of a joint's immune system and connected tissue and things like that. He can look at sports medicine injuries through his lens and he can do sports medicine as well through a GP setting, family medicine in the American term, and then you're looking at common illnesses, common problems that humans go through, and then also having a sports medicine layer upon that.
It depends on which level of rugby you're talking about. If you're talking about professional club, then the doctor will be working as part of a multidisciplinary routine, so there'll be a physiotherapist involved. There'll be personal trainers and strength conditioning coaches and probably nutritionists, too. So the doctor is like a jack of all trades, I suppose, and they're able to treat the medical problems that some of the other members of the team wouldn't be able to treat, and then bring everybody else together, so all the different aspects of the healthcare team within the sports setup are going to be influenced by the doctor's actions or wishes, I think.
A lot of it would be managing I think a GP role, so looking at the general player health, but you can go more down the performance aspect, so you're looking at how the players are training and trying to monitor load, how they're performing on the pitch, how they're recovering, and then trying to predict an injury risk upon that, so that's going beyond medicine. It's going more into strength and conditioning and physiotherapy.
Christopher: Where is this happening? What level in rugby are we talking about? Is this at the elite level or is this happening --
Rory: This would definitely be an elite level because to get a team like that, you're going to have to have some considerable funding to have all of them going on at the same time and to have a facility as well. At a club level -- so that's kind of a weekend club -- we have lay people playing rugby. You wouldn't have any of that. You'd have a physiotherapist in the first day. A sports medicine doctor doesn't have a setting there.
For medical students, it's a good place to get experience. I'm getting a placement next year just doing a regular gig at a rugby club. I'm getting to know some of the common injuries and problems that go on at rugby club, so yeah, the high tech stuff is definitely exclusive to early level rugby and sport.
Rugby is catching up with football because football is huge in the UK and it has so much more money, so there are massive conferences and every club is going to have a doctor and then a good team around them.
Christopher: Tell me what you're seeing at the conferences. What's hot at the conferences at the moment? Are they using heart rate variability to track the players' progresses? What are the technologies that you see are hot at the moment at the conferences?
Rory: The majority of the conferences are based on medical and surgical issues, so we see lots of ACL and then ACL injury and how to repair them in the best way, tendonitis, so the chronic obese injuries. They don't really address any dietary principles you could use to prevent that injury in the first place. I'm not sure if there's the evidence base for that yet, but you're right, there are quite a lot of -- so you have the exhibitors at the conference that you go [0:14:45] [Indiscernible] and those are really interesting things.
People definitely use cold, not quite cold thermogenesis, but they're using cold packs and different cold garments that they can use to shut down inflammation or increase blood flow within an injury, and they're using heart rate variability as well.
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It's kind of taking off. I think the clubs find it difficult to -- so what I've heard from talking to the exhibitors is that clubs find it difficult to implement HRV on a large scale because they have so many members within the squad and then there's compliance. They have compliance issues. People have their different schedules and things like that.
In the past, they've just used resting heart rate, so you wake up and you have resting heart rate rather than HRV, but it's probably going to move towards HRV in the future, but it could do as we get to grips with technology and improve an understanding within the clubs so more people can access it.
Christopher: And then tell me about the diet piece then. This obviously really intrigues me for multiple reasons, but you just touched on that you might be able to prevent some of the injuries with dietary interventions. Did I hear that right and what are your thoughts?
Rory: That's just my personal interest really. We always talk about diet and inflammation and things like that. On a very superficial level, you need to make sure that you have enough protein, carbohydrate, fat and calories to make sure that you're recovering after each training session.
And then from that, you can look at your macronutrients as a whole. I know that in Australia, some of the cricket team doctor over there is experimenting with high fat low carb in some of the players. There's one really prominent, Australian rugby player. His name eludes me, but he's changed over to high fat low carb diet and he says that he's recovering better and he feels better. His performance in the pitch has improved, which is something that you wouldn't necessarily expect or conventional wisdom wouldn't expect that to happen.
We're always told that if you play elite sport that you need the carbohydrate to have your glycolytic bursts to be able to run fast, but perhaps not so much. Perhaps it's not as important as we previously thought.
I've mentioned earlier tendons. Tendonitis or tendonosis is kind of like a chronic, inflammatory condition of the tendon where you have gradual buildup of damage and then either a catastrophic event where it ruptures or just needling pain that goes on for a long time. They're really difficult to treat and there are many different approaches and no one really knows how to do it best. That's a really common area of dispute when you go to a conference, is how to treat it best. Is it surgical? Is it medical? Are you using steroids? Are you using PRP?
Christopher: What's PRP?
Rory: PRP is protein-rich plasma. Do you know what it is?
Christopher: I've heard of it. I don't really know what it is and how it's used.
Rory: I'm certainly not an expert in this, but what I understand is that you take blood from the patient, you centrifuge it and you extract the plasma from the blood sample. It's supposed to contain different cytokines and growth factors that you inject into the area, the sore, and that might stimulate some sort of healing process.
We're not sure if it's the PRP itself or the fact that you're sticking a needle into an area and causing local inflammation. It's massively disputed and it depends on where you look. I know that one of the editors of the British Journal Sports Medicine is strongly for having an open mind when looking at PRP and has done some really entertaining speeches or talks and conferences in the past completely debunking all the evidence that goes on with PRP.
And then you have other people who are tied to other organizations that are very much for PRP as a treatment and they can bring out their organization's evidence-base for it, so it depends on who you believe. It depends whether you are going to invest your time into the research or not.
Christopher: Let's talk about the role of inflammation and the diet then. You've talked a little bit about macronutrients. Do you think there are other things that rugby players, for example, or football players or any other type of athlete could be eating that's causing inflammation that could be contributing to the injuries that you see on the page?
Rory: Yeah. I haven't done any of my own research. These are my ideas of what I've learned and what I've read from other people, but we think that many people have sensitivities and intolerances to foods that are common in our diet, for example, gluten, so if someone's eating a lot of gluten. Carbohydrate is very common within performance sport, and if you have carbohydrates, it's likely to be coming from bread and pasta just because they're common and they're cheap and they're tasty.
Christopher: I certainly used to eat a lot of bread and pasta in my days when I lived in London.
Rory: Yeah, exactly, especially if you're living on a budget as well. If you go to a supermarket and you're looking for a cheap source of nutrition that's readily available, carbohydrate is definitely at the top of the list in terms of calories per currency.
And so, if you have an elite athlete who has a large caloric demand and you have a club who's trying to feed them, they're going to be downing lots and lots of potentially inflammatory food like gluten or wheat and things like that.
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If they're sensitive to it, that could be feeding a low level intolerance or low level inflammation which then could contribute to degeneration within a tendon, similar for post-workout, high carb drinks and sugar. Sugar's been linked to multiple different diseases on an inflammatory basis, so if it contributes to diabetes and if it contributes to your heart disease because of inflammation, then why couldn't we see a link where it contributes to inflammation within a tendon?
The way I look at it is that they're all chronic diseases. They all show degeneration over time and diet is one of those things that you carry with you from day one to the day you kick it, so if diet is one of those factors that sits with you for a long time, why couldn't it be something that contributes to the chronic disease?
Christopher: I'm really interested to know how much you learned about diet at medical school. I've heard numerous doctors on numerous podcasts say that they had an hour of training on nutrition or maybe even less, maybe even none.
Rory: Yeah. I wouldn't even say it's an hour of training. In medical school, you have the first two years of pre-clinical sciences over which nutrition will be an hour or two, but then people didn't go to medical school to learn about nutrition first [0:21:21] [Indiscernible] or fix for someone's chronic disease. They want to know about all the --
Christopher: Juicy stuff, sexy stuff.
Rory: Yeah, exactly, the cool drugs and all the biotechnology and all the prosthesis and prosthetics and stuff like that. They're not going to want to know about fats, carbs, sugars, and proteins. The King's did put on a lecture for us, but whether the full cohort of the year turned up, I doubt it.
The information they gave us as well, so it would be what makes a protein, what makes carbohydrate, how are they metabolized. We're very much focusing on glycolysis as our main source of energy, so breaking down carbohydrates into sugars and then sugars making ATP.
Christopher: Sometimes, especially in the older discussions of biochemistry that I've seen, the glycolysis is almost synonymous with energy production. They don't ever consider that you could make energy out of anything other than glucose, which is not true.
Rory: Yeah, it's true. Yeah, you're absolutely right. That's where medical school still is, so we still recommend carb loading and eating lots of carbohydrates as our main source of energy and that's the only fuel we have. That's the fuel that our brain runs off.
Ketones are associated with starvation and scary conditions like diabetic ketoacidosis where you're in a really bad state and that can kill you, so it's tainted with a bad rep from that condition. And then we look at fat as a demonized nutrient that we should all be avoiding. The thing is they don't tell us any of the evidence based behind it. They just tell it to us on the lecture slides and we're expected to believe it.
Christopher: I would've done as well. To be fair, the only reason I know that this might be wrong is because I've tried it and it didn't work for me, and then I've done my own homework afterwards and figured a few things out. But if I had been told this at medical school at your age, there's absolutely no way I would've questioned it.
The same thing happened to me at the university when I did Computer Science. I never even thought for a moment that what I might be taught was wrong. It doesn't even cross my mind, and it wasn't. Everything they taught was obviously correct because that doesn't happen in Computer Science, but this -- what's the word I'm looking for -- cognitive dissonance maybe is the right phrase.
How do we even know that the problem exists? Is it just your exposure to the internet? You could just do your own -- but why would you do that? If you've already got so much work to do from the university, why would you spend your time reading [0:23:46] [Indiscernible] course about nutrition on the internet? I just don't know why you're doing that.
Rory: Yeah, that's true. First, what I find scary is that if the nutrition is wrong, then [0:23:57] [Indiscernible] is wrong. I'm not trying to promote any conspiracy theories here, but it's terrifying to think that something so broad as nutrition could be taught wrong, taught badly, and then everything we're doing is based upon that learning.
In terms of my background, my initial interest in nutrition came from rugby and trying to get the best of my body on the pitch, so we're given nutrition lectures when I was part of an academy. They'll tell us have your protein afterwards and watch your fat and eat more carbs and carb load and drink responsibly Gatorade.
But then I have an auntie as well who's very much into nutrition and into functional medicine as well. She's just moved over to Sydney, so she's practicing out there and she was a huge influence when I was a kid. I think my 16th birthday present was Nourishing Traditions.
Christopher: Oh wow! Yeah, of course, Weston A. Price.
Rory: Yeah, so we've got that. And then subsequently I've got Fermented Vegetables and Nourishing Broth and all the Lustig books, you had Ken's book as well. Nutrition, yeah, I've been biased towards it since the early days.
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Christopher: So the knowledge, the Nourishing Traditions, it predates medical school. This is the thing I wonder about. How do you not tear your hair out then every time you go and get taught some of this stuff, the carb loading, energy is glucose, all of that kind of stuff? Do you not just want to go bananas in the lecture hall?
Rory: It's difficult. There was that occasion at first you want to get the rest of the lecture for the first time. I sat with a group of friends and we happen to all be very similarly minded. No wonder we were friends, but we were just thinking about insulin and thinking about carbohydrates and yeah, as you said, tearing our hair out. That was going on the entire year of being taught this. It's rubbish.
From then on, my medical school -- King's is one of the largest or maybe is the largest medical school in Europe. So in my year, in year one, there were 450 people who were studying and then just realized it's a huge problem and then just me tearing my hair out is a bit of a futile thing to do. It's not going to solve anything.
When I'm in a small-based, group-based discussion, then I just try to ask questions about what the speaker understands about it and then propose or see what they think about a ketotic diet or a low carb diet and how the body, how the physiology would adapt and how that could provide any disadvantages or advantages just to see an idea or an alternative. But even then if you do that, people breeze over it. They're not really worried. I don't think they see nutrition as important as I see it or as people in this sphere see it.
Christopher: I was wondering whether you've maybe sent some studies to some of the lecturers, but it's not even really like you're being taught that much nutrition, so there's not really anyone to send studies to, I suppose.
Rory: Yeah. So we went to our nutrition expert/bionutrionist. We were taught by GP, who've been pulled in to teach it, so it didn't seem like it was the right place to fight an argument.
Christopher: And then what about the other things that I know -- you've talked about most of the problems that you see in the hospital ward are chronic in nature and one could only assume that if you were to talk to those people that you are seeing on the ward and in acute situation right now 20 years ago then you maybe could've done a lot more good. We've talked about how nutrition is either not taught or perhaps is taught badly.
What about the other things that I figured out are really important like stress management or sleep? How much time do you spend learning about those things?
Rory: Let's start with sleep. Sleep is more focused upon by the medical school because it has a scientific basis -- well, a longer scientific basis than stress management and mindfulness, so we'll learn about the different wavelengths or the frequencies of the brain during sleep and then the difference of REM and non-REM sleep, and then how that affects us and how we can treat conditions like narcolepsy or other sleeping conditions and how sleep has evolved and memory formation as well, so it's all very much based in science.
We're not taught about how that relates to a patient. We're told that if you're sleep-deprived long enough, you would die, but not that chronic sleep deprivation over a number of years will increase your risk of cancers or metabolic disease, not anything like that. That's still to come, I think, within medicine.
Christopher: To mean within your career in medicine or within the career in general, the curriculum?
Rory: Both. Sleep is definitely getting bigger. You've had a podcast with Dr. Parsley, haven't you?
Christopher: Yes.
Rory: Yeah, so I listen to that. That was really fascinating. That's [0:28:41] [Indiscernible] to me how important he was, but I think within the normal population, people don't see sleep as essential especially with the medical student population. People don't see it as essential because they are very Type A personalities, just do, do, do and sleep is for the weak or sleep is for the dead.
Christopher: So you still see that then within your fellow students at King's that there's that attitude, that people are not really valuing sleep in the way that they should.
Rory: Absolutely. I think sleep is seen as a luxury and perhaps it's a waste of time depending on who's looking at it. Luxury is in the Sunday morning line because throughout the week, Monday to Saturday, you've been slogging and studying or partying, whatever, or that sleep is just a time where you close your eyes because in between, you're eating and studying or doing other things or in lectures and doing other fun things because you want to be alive and awake.
Christopher: And do you think that translates to how the doctors interact with patients? I'm just wondering what it would be like for a doctor, how sympathetic they would be towards a patient that was perhaps suffering some problems that were due to sleep deprivation when the doctors themselves are sleep-deprived. Am I touching on something here or is that irrelevant?
Rory: It depends on the context. We're just discovering the link between sleep and cancers and sleep and metabolic diseases, and so it's not going to be on the top of the doctor's list of things to address.
[0:30:08]
They're going to be addressing the acute problem while the patients come in and how they can treat it and they'll be very much overwhelmed by the medical model. "You've got cancer. Let's send you in for a scan. Let's see how far it's progressed. Let's see what our treatment options are, whether I'll give you surgery or chemo or radiotherapy."
They're not going to be like, "How much sleep have you been having recently?" It's just not on top of the list. It's just not what they ask. If it's in a psychiatric setting, perhaps they'll ask for sleep a bit more because that is more based on someone's past. So if someone has a psychiatric condition, then the psychiatrist would be more attuned to looking and digging up what's going on in the person's previous life. So sleep is not going to be on the tip of people's tongues when they take the history.
Christopher: And then what about the mindfulness? It's kind of interesting to me because I think there's a great deal of scientific evidence to support mindfulness practices or guided meditation. There's a whole bunch of different things that work and the risk of that intervention or recommending that intervention is basically zero. There's no chance of you really hurting someone by recommending that they do some guided meditation. Does that ever come up in medical school?
Rory: I really like the idea of meditation and mindfulness. It is just taking off now. In the last year, I've met a few different doctors who've opened up and said they like meditating, which is interesting because meditation is one of those things that's associated with spirituality and woo-woo-ness if I say it like that in terms of -- in crude terms, it doesn't fit with the medical model of you've got something wrong with you and let's fix it. I'm not sure how to describe it more fully without sounding offensive.
Mindfulness is a very private practice. People will sit on their own or with other people and then they just think about -- or they try not to think or they just address their thoughts or their worries. It's very personal. [0:32:07] [Indiscernible] to British society, I suppose, and it doesn't fit well with the medical model, as I said previously. And so, it's not something that we talk about.
However, it's changing because I've met other doctors who've been doing it recently and they said they've got much benefit if you're stressed. I know the benefit personally. I know for family members, you do it, too. And so, it seems really important to me. I'm happy that it's increasing in medical schools. At King's, you've got one really good lead clinician of -- I think she's in the fifth year. She's one of the fifth year teachers, so medical students who are coming to the end of their exams and end of medical school, they're really stressed.
She's very pro-mindfulness and mindfulness-based activities to deal with stress and to make yourself feel better. So there's now a mindfulness society so people get together and meditate and it's led by this woman. There's a mindfulness SSC. An SSC is a student selected component and it's an actual curricular compulsory activity that you have to do. It can be based on a lab, so you're doing research in a lab. You could be doing a library project where you're researching an area. That's interesting.
For example, I did an essay on hyperbaric oxygen therapy and traumatic brain injury because it was interesting, but if you [0:33:24] [Indiscernible] first, then you can partake in this SSC that's learning about how to address stress, all the different techniques of mindfulness with the intention of benefitting medical students themselves and benefitting patients as well.
Unfortunately, it's just come in now and I don't have any more SSCs, so I can't do it, but I know people who are learning how to do it in the future who are younger than I am.
Christopher: Interesting, so that sounds a bit more promising then than the need of sleep or diet components.
Rory: Yeah, definitely. It's a definitely good niche in medicine because people are so stressed.
Christopher: Right. I can see that. What about movements? I know this is a particular area of interest for you, the strength and conditioning. I just sometimes wonder about some of the old people that you see on the street and how it might come to an end for them. I particular worry about the injury of breaking a hip in your 60s, 70s, 80s, however old you get to be, and the role that strength training might play in preventing that type of injury.
Again, of course, you've got to get to the person. It may not be any use to say to a 70-somethnig-year-old, "Oh, you need to start doing deadlifting." So tell me about what you've learned about strength and conditioning and where you learned it and how we can help people with it. It's such a broad question. I apologize for the broadness of the question.
Rory: Strength conditioning is an interest that I have from my background. It's what I like to do. I like training in -- I'm a really good [0:34:49] [Indiscernible] and we just built a gym at home for my dad and for my mom.
Christopher: There you go! That's exactly what I'm talking about. That's what I need to do for my mom, is build her something that she can use.
[0:35:01]
Rory: Yeah, definitely. I know that strength conditioning is really important because it's my background and I know how it correlates to function. The blog post I read on strength conditioning research was really interesting because it's -- well, for me it was because something like a broken hip is so common when people get older.
It's almost accepted as a normal process of aging that you become weaker and you lose your energy and you lose your ability to move around and be independent, and then you just fall over and then you break your hip and you're taken to the hospital.
Christopher: And then what are your chances of surviving that injury once you're in the hospital with a broken hip at age 70?
Rory: Mortality rates are high. Morbidity is high as well because you end up having a little old person who hasn't got much muscle mass stuck in a hospital bed waiting for their hip to heal, and when you're lying down on the bed waiting for your hip to heal, your muscles fade away as well. You're not using them at all.
It's just an accident waiting to happen, so you've got a person who's already weak then they break their hip. You put them in the bed and they get even weaker and then you tell them to get up and walk around again. They'll fall again and then it's kind of a slippery slope downwards.
And then you've got also the implications of surgical and medical, so the process of going through surgery is very traumatic. You may lose blood and it's very stressful for the body, so that could be a factor that really harms people. And then when you're in a hospital environment, you always run the risk of having an infection and other problems, so it's just not a nice area to be in.
Christopher: So I'm just wondering how much of this is taught at medical school. You said that most of the doctors will become general practitioners and I think we both agree that strength training could be a really powerful prescription, slightly more risky than the mindfulness practice. You could put your back out or something doing a deadlift, but it's still a lot of gain for the wrist, so I'm just wondering how likely it is that those GPs that are going through King's are going to learn strength and conditioning as something they could prescribe.
Rory: Yeah, you're right. We've got one lecturer. He's pretty cool. I think he's a sports and exercise medicine doctor and he is based at UCL, one of our [0:37:17] [Indiscernible] universities, but he comes to King's and gives us lectures each year.
To explain this, King's is a spiral curriculum, so something that you learn in first year will be built upon in the second year and then subsequently will be built upon on the third year. So on the first year, we were given a lecture on the benefit of exercise and then next one would be like how to implement exercise and then the last one would be exercise prescription, things like that. So we do have exposure to exercise, but the flow on that approach is that you have around a year in between each dose, and so each dose is nothing. It ends up being very, very little and a takeaway message isn't necessarily had.
So for the generations going through the medical school or medical schools around the country, I don't think they are going to necessarily learn the importance of exercise and strength training as a preventative treatment. I'm not sure about the GP setting and whether they have more training because once you decide it's become a GP, you're pretty much a [0:38:15] [Indiscernible] population and then they can teach you more thoroughly.
I do know that there's an exercise prescription initiative, so some of the gyms in South London that I've been to, you can see their exercise prescription forms that a GP could fill in for a patient.
Christopher: Oh really?
Rory: And then they go to the gym at home, so that's the start of something, I guess, but I don't know the statistics when it comes to compliance whether GPs are prescribing it in the first place, whether they know who to prescribe it to, how much funding is behind it, and whether the patient they prescribe it to will act upon it and go to the gym, and then subsequently whether they'll have any benefit from it, so I think it exists. I think it's something that should increase.
Christopher: Is that promising as it is? That's more promising than the diet piece to me.
Rory: Yeah. I'm not sure why that is.
Christopher: Yeah. There are all kinds of historical and political reasons probably. Tell me about your future goals. What's your plan? Are you going to become a general practitioner? Are you going to become a sports medicine specialist? Are you going to do a PhD? What's next for you?
Rory: That's a huge question.
Christopher: I know. I like my huge, broad questions.
Rory: You know what, I'm not really sure. I'm always for goal setting, but there are just so many things going on right now, I'm not quite sure where I see myself in the future. I don’t know if people on your side of the ocean understand what's going on in the NHS, but the NHS is going through many, many changes currently.
Christopher: Oh yeah, tell us about this. For people who are listening -- a lot of people won't know what the NHS is. The NHS is the National Health Service in the UK. So in the UK, you pay tax and they use it to spend on healthcare so that you actually get something for your tax dollars, whereas that's something that doesn't happen in the US. You have to pay $1000 a month for health insurance here, so there's a big difference between the US and the UK. Tell me about the changes that are happening in the NHS.
[0:40:05]
Rory: The NHS is great and it's one of the most brilliant British institutions. That whole idea that you can get free healthcare no matter who you are and no matter what cost is really fantastic.
Christopher: When I break my wrist or I break my ankle on my mountain bike, if they would let me board an airplane and get back to the UK to get it treated, that would actually be a cheaper -- no, it wouldn't be better, but it'll be a cheaper treatment option for me. Even with health insurance, you still get handed out with this huge bill for the treatment. Sorry to interrupt you. Tell me about the changes that are happening.
Rory: The NHS, because it's such a large organization, it has a huge bill and it's getting worse as the population increases and chronic disease increases and we have an elderly population that's increasing because of the baby boom back in the '60s, so many people are coming in with diseases that have been there for a long time and needing treatment. And so, the cost of the NHS is arising very rapidly.
In an attempt, I think, to reduce the cost of the NHS, the government is trying to decrease pay for the people working at the NHS and then increase hours, so they're trying to make it work better for them longer for less money. The government proposed that the NHS only actually works for five days a week and on the weekend it doesn't exist, which is not necessarily true. If you go into A&E on the weekend, then you'll have treatment and there will be doctors. It's not nonexistent. It's not really a [0:41:35] [Indiscernible], so that's one of the issues that we have.
The NHS already is a seven-day service and the requirements that this contract is suggesting that doctors do is going to work them very hard, and then reducing the amounts of pay they have will make life difficult and will change many people's plans for their life in terms of having a family, where they can live, and all the things they want to do within their life.
So yeah, it's just unsettled people quite a lot. That's on a very superficial basis. You probably need to look into it more to get a full explanation. And then there are all these conspiracy theories about why the government is doing it and that's basically going down the root of privatization. Because the NHS is so expensive, perhaps it's a cheaper option to let external companies take a role and control sections of healthcare, a bit more like the American system.
Christopher: There's a fundamental difference actually as well as the fact that the carrier is provided directly by the government or paid for and that there's a budget. In theory, there is a budget that goes into healthcare whereas in the US, there isn't. It's like an industry. It doesn't really have a cap, so it doesn't matter that the cost could keep spiraling out of control. Maybe eventually the whole country will go bankrupt, but it wouldn't be immediately apparent that you're over your budget.
Rory: I think the main objection that doctors have with the contract is that they're going to be working a lot more and they're going to be very, very, very tired. They're already tired. And if you make a workforce that's already working hard work harder, you're going to increase the rates of errors, and increasing rates of errors means more patient harm and more patient death, and then you end up having an inefficient or immoral health service where it's not helping people as it should.
Christopher: So what's your plan then, to avoid the NHS completely and come do some functional medicine training in the US?
Rory: No. I'm going to stay in the NHS. My plan is to stay in the NHS for the first two years at least because I've done my years in medical school, you graduate as a doctor, but then you need to practice within a hospital setting to get you a GMC license. GMC is the General Medical Council and that means that you're a proper, official practicing doctor and then you can practice what you like within the UK, so I'd like to get that because it increases my options if I return to the UK. If I happen to travel abroad, then it means I can jump back into the NHS and work again.
I'd like to do some further education at some point. Tommy Wood is particularly inspiring with his PhD in neonatal brain metabolism, so I think it'd be really, really good to be able to take some time out and do some research and learn more about an area that's interesting to me so it allows me to differentiate myself and differentiate my career.
It's also nice to be able to take time out to follow other projects, too. I'm definitely interested in functional medicine. I'm definitely interested in diet and injury, for example. If I had the opportunity to do a study in tendon injuries and the high fat low carb diet, then I'd --
Christopher: That would be interesting. I like that.
Rory: Yeah, so I'd really like to do some research down that --
Christopher: Yeah. A little bird told me that Prof. Kieran Clarke at Oxford University said that you could do a PhD under her. Is that something that interests you?
Rory: Yeah. I'm looking for something to do. I was a bit bored and I was just looking at all the opportunities that they have on the website, and then I came across this really cool program. It's [0:44:54] [Indiscernible] or a PhD in ketosis and performance. It was just really, really interesting because I'm interested in diet and performance. I know that some of the cyclists are using exogenous ketones and ketone esters to give them a boost. That's something that I'd like to explore more.
[0:45:11]
Christopher: I just interviewed Prof. Kieran Clarke for the Keto Summit.
Rory: Oh, nice!
Christopher: Yeah, so she showed me some very interesting data during our talk. She shared a screen and showed some data in elite British rowers. They were two-time series, some rowers that did some rowing and some rowers that remain sedentary, and then she showed what happened with the plasma beta-hydroxybutyrate based on the ketone ester supplement that she'd given to the rowers.
I'm not going to spoil it. You're going to have to find the link for the Keto Summit in the show notes for this podcast and sign up to see the whole interview. It's not very long. It's only about 40 minutes long, the whole interview. I think she's doing some really, really interesting work with the exogenous ketones, so yeah, that'd be fun. I was hoping you could explain to me how ketones affect the Delta G of ATP and maybe give that to our listeners.
Rory: I've got no idea. You should've asked Kieran Clarke.
Christopher: Yeah, right, I should've asked Kieran Clarke, but I was too afraid to because I knew that I wouldn't really understand the answer and that I wouldn't be able to follow up with a meaningful question. I'm just kidding with you.
But yeah, I think it's a really exciting area. For people listening to this, you should check out our link in the show notes. There have been two podcasts interviews with Dominic D'Agostino. One was on The Quantified Body Podcast and then there was another on a podcast at STEM-Talk Dominic D'Agostino, both of which were fantastic.
The applications for these exogenous ketones I think are really exciting. I'll be interviewing Dominic for the Keto Summit very soon, so yeah, I think that's a really, really interesting area of research and I certainly would be drawn to that if I was you.
Rory: Yeah. I haven't quite cracked my own ketotic diet.
Christopher: Oh really? You've been experimenting with it then. It's interesting enough for you to experiment with it.
Rory: Yeah, definitely, because it's always sold as the diet that helps you concentrate and eliminates highs and lows [0:47:12] [Indiscernible] and things like that.
Christopher: So that's your application. I always think it's important to have an application. You just don't do ketosis for no reason. There has to be an application, so that's the application for you. I guess you're sleep-deprived. You need to concentrate harder. You need to get through these exams. How has it been? Has it helped you at all?
Rory: Well, I'm already quite biased towards high fat low carb, and intermittent fasting as well. I find that my concentration is definitely highest when I'm fasting. I find it difficult to get into ketosis because -- I don't know. I just never really got into it. That's the thing.
When I exercise, I'm having this taste in my breath, which I assume is some low level ketone production. I haven't got a ketone meter to really take my --
Christopher: Oh yes, you've got to measure blood ketones to know what's going on.
Rory: Yeah, exactly, so that's the next thing in my purchase list with my student loan.
Christopher: Oh no! I feel terrible. You can't be spending your student loan on five-dollar beta-hydroxybutyrate strips. That's awful.
Rory: It's quite expensive, yeah. I've bought a blood glucose monitor just for fun and that's good just to see how I could track it throughout the day and when I have a meal, when I wake up my and cortisol spiked in the morning, whether it's high or low or things like that. A ketone meter is definitely what I'd like to get next.
I haven't really been able to get into full ketosis. I'm not sure why. I can eat low carb, I can eat no carb, but I usually feel really crappy before I feel any benefit, and then compounded with training as well, so going to the gym or running. I'm always tempted by a sweet potato.
Christopher: I don't think there's anything wrong with that especially when you're doing -- so you've mentioned CrossFit Football and I know you're a strength race kind of guy. I don't think there's anything wrong with being scared over sweet potatoes especially if you don't really have an application.
For me, it's just been so wonderful as an endurance athlete on a mountain bike. It's worth it. I can use the discipline to avoid the delicious sweet potato and that pays dividends for me. I'm not sure that's a very good general recommendation for anybody listening to the podcast.
Rory: I'd also like to do more research before I fully embrace it. I saw Dr. Tamsin Lewis' podcast on the HPA axis and that's affected by carbohydrate availability and caloric availability, so I'd like to make sure that I'm going to be intact, hormonally intact if I attempt something more severe.
Christopher: It's difficult for me to summarize this, but yeah, that's basically being -- the whole purpose of the Keto Summit is to get all of these people, 33 of these experts and try and figure out what are the benefits, what are the applications, what are the pitfalls, how are people going wrong with this thing. Maybe I can create a resource that can avoid these problems for people in the future just by getting the information together in one place.
[0:50:04]
Rory: Absolutely. I'd like a meter, but I'd also like a more sophisticated testing, too, so I can track real time. I know that you do the DUTCH testing.
Christopher: Yeah. We're doing all kinds of testing, so that's the thing. For people that we work with in our practice, we're not just doing blood beta-hydroxybutyrate. We're also looking at 75 marker blood chemistries and then another 75 markers on the urinary organic acids and then more urinary metabolites in the hormone test, the DUTCH, and then we're also doing stool test.
It's not like we're not seeing how the impact of low carbohydrate is affecting the rest of the biochemistry and the physiology. We absolutely do, so it may turn out to be important to have that extra information and maybe I'll know more about that once I finish the Keto Summit.
Rory: Yeah. That's something I'd like to get to groups with before I take it any further. I'm quite happy with my current approach. I feel good and I can concentrate and I can still exercise, which is good.
Christopher: Well, this has been great, Rory. I will link to your blog. I think you're a really great writer actually. I'm quite impressed by your writing. Actually, the thing I'm most impressed with is the fact that you find the time and energy to maintain a blog while going through medical school. I think it's quite extraordinary. I will of course link to your blog.
You've also been doing some writing for strengthandconditioningresearch.com. In particular, I read your article on strength and conditioning and bone density, which I thought was really interesting, so I'll link to that in the show notes so that people can read that article.
Rory: Awesome!
Christopher: Is there anything else that people should know about you?
Rory: If you're in the UK or anywhere I suppose in the world and you want to learn more about resources that you could have if you're a general practitioner regarding exercise and diet, you should check out the moveeattreat.org website. It's got a whole lot of resources that a few doctors have curated as a general approach to try and reduce chronic diseases in the community.
It's trying to make it accessible mainly for healthcare professionals, so doctors and GPs, people who work in hospitals and then the community who are seeing patients on a regular basis. It's also worded well enough so that lay people can read it as well. It covers diet, exercise, and mindfulness as well. It's really, really good.
Christopher: Interesting, move, eat, treat, I will link to that in the show notes. And then also for people, if you've got any questions about the type of testing that we do at Nourish Balance Thrive, you can actually come to the front page of my website and there's a button there. You can book a free consultation.
I'm off to the BC Bike Race in Canada, so it'd be quite hard to get a hold of me for the month of July, but you will be able to get a hold of my colleague, Amelia Luker. She has all the same functional medicine training that I do. You can talk to her about your problems and how the testing might be able to solve them.
Also, we do diet and lifestyle coaching obviously, so that's the main way which we see improvement on the lab results. We've been getting fantastic results, so come to the front page, nourishbalancethrive.com, book a free consultation.
Rory, thanks very much for your time. I really appreciate it and I wish you the best of luck at medical school. I think you're doing an amazing thing and I wish you all the best.
Rory: Thanks very much.
[0:53:12] End of Audio
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