White Coat Warriors | Season 1 Episode 1

Dr. Lipman’s Blend of Medicine, Sports, & Tech

Join Dr. Chris Myers on White Coat Warriors as he interviews Dr. David Lipman, who brings a unique blend of podiatry, exercise physiology, and tech startup experience to the table. Explore how self-care is crucial in the demanding field of medicine and learn how insights from athletics can enhance professional life and patient care. Perfect for medical professionals and athletes alike, this episode offers valuable perspectives on balancing performance and practice.

Published on
July 24, 2024

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This podcast focuses on human performance and how it can affect medical providers

Dr. Chris Myers: The views expressed by myself and the guests of this podcast do not reflect the official policy or position of the US Air Force, Department of Defense, or the US government. Welcome to White Coat Warriors. I’m your host, Dr. Chris Myers. And on this podcast, we talk about human performance optimization and training paradigms for you, the young medical professionals, and how you can use it in your own professional practices to help yourselves and your clients. Hey, everyone, welcome to the White Coat Warriors podcast. Today with me I have Dr. David, Lipman, a, great friend of mine. We’ve been working together for a few years here, and we’re here to talk some shop on human performance and how it can affect you as medical providers, both for your patients and yourself. David, welcome to the show.

Dr. David Lipman: Thanks for having me, Chris. Really excited to be here and very, honored. So thank you, thank you.

Dr. Chris Myers: I mean, you’re the first one in the shoot here, so we’re going to have some fun.

You started coaching when you were 17 and now live in London

Dr. Chris Myers: So before we get into it, tell me a little bit, actually. Tell us about yourself.

Dr. David Lipman: Yeah, I guess, as most people can tell from my accent, I, spent a large portion of my life in Australia, but was born in South Africa, then moved to Amsterdam for my wife, and now live in London. And with those moves came some interesting stuff. But, I guess my undergraduate, I did a dual degree in podiatry and exercise physiology because in Australia, podiatry is an undergraduate qualification. and from there, when I finished that, sort of worked for a little while and ended up going into medicine. So I went into postgraduate medicine and worked as a doctor for a little while and then had met my wife while I was traveling as a doctor. And then moved to Amsterdam and went back into coaching. I’d sort of picked up coaching when I was 17. It was something I wanted to do straight away. Started coaching, as I said, straight out of school, and coached all the way along, basically even, while I was working as a podiatrist. Left it a little bit as a physician for a while, but then got back into coaching when I was in Amsterdam to meet people, got heavily involved in the rugby programs there, coached, at a sort of national level. I was the assistant coach for the under eighteen s and did some other coaching as well. And then moved to London and started working in a tech startup, which is how you and I met. And so then sort of now work in tech startups and still doing some coaching and a few other things, some podcasting, but, yeah, that’s kind of the meat of it in terms of athletically. Started out as a runner running track, then got bitten by the meathead bug when I was working as a strength conditioning coach. Started lifting heavy things, got a bit bigger, started doing some Olympic lifting for a while, which was really fun. And then went back to running and now run sort of marathons, ultramarathons.

Dr. Chris Myers: That sort of stuff.

Dr. David Lipman: It’s kind of the branches of my life, sort of social, professional sporting.

Dr. Chris Myers: Yeah, I just remember we were out together just a few weeks ago. You were putting in some major miles down there, in eastern Spain, clocking some miles down there. That was pretty interesting. Going fast, you guys. I’m telling you, this guy has got some speed to him. with all that being said, that’s an interesting, background. Definitely between medicine and coaching. When you were younger, you mentioned, so you’re at 17, what really interested in getting you into coaching, especially with team sports?

Dr. David Lipman: well, I actually sort of was an athlete when I was in high school. I had a really good coach. The same old story for most people. I had a good coach, right? And I had a good coach. He’s still a close friend of mine. I’m the godfather to his daughter. so he’s a close friend of mine. Had a huge impact in my life. He was a good coach and I thought this is what I want to do. I kind of always was more coach than performer in everything I did. I mean, even 1415 as a skateboarder, I was helping other people more than I was, getting better myself because I was no good. So that sort of teaching, coaching archetype was something I definitely did. And I actually did some teaching universities as well. It’s something I really enjoy and I see them as the same thing for the most part. And so it’s kind of always something I wanted to do. My exercise physiology was actually with the view to use that to help coaching because my podiatry was kind of what I wanted to do out of school, or thought would be my profession. And it turned out that I actually probably enjoyed the coaching more than the podiatry for a large portion of it and got a very good. I started coaching team sports rugby straight away as an in and then got offered to work in the gym at that school and had a really good mentor there who’d worked professionally as a strength and conditioning coach with high level organizations. And so he mentored me for the best part of five years plus. And so I got really good opportunities that I really didn’t. I don’t know if I was ready for them, but he was a very good mentor and taught me a lot. We’re talking sort of early two thousand s and I was playing with bands and chains and gps units and all the stuff that was super revolutionary at the time or very niche. So I got some good exposure early and just loved coaching and just loved helping, particularly teenagers get better at that stage. And then it just sort of progressed from there. You get an opportunity at this rugby club and then you’re sort of moving here and then all of a sudden there’s this individual athlete. So it was really cool.

You took time off to go to medical school and then became a strength coach

Dr. Chris Myers: Interesting. That’s good. And that actually brings up another question. So kind of thinking about that. So you said you took a little bit of time off to go to medical school, become a physician during those times. Right. It’s very difficult. It’s very strenuous. Ah, lack of sleep, stressful. Right. How did you take some of the lessons learned being a strength coach and apply that to yourself to help keep your sanity? and that’s definitely a high level of fitness because you’re going from being endurance athlete to a strength athlete. And now you’re coming back at an older age as an endurance athlete, so you’re able to maintain it, especially through those four or five years of medical school residency, because if you take those away, it’s really hard to come back, especially when you’re older. So can you talk to us a bit about that?

Dr. David Lipman: Yeah, I guess one of the reasons I really enjoy going back to medical school was I became a student again, so I had more time to train. so yes, medical school is a lot, but medical school is not full time work. And when I was working full time, I was also coaching. So we’re talking, okay, I’m working 40 hours a week plus coaching on top of that, and I’m trying to get training in around that. So we’re talking 04:00 a.m.. M, we’re talking evenings. So going to med school, yeah, it’s a lot, but it’s not 40 hours a week plus coaching. So it was a lot more time and actually trained a bit more there. and it was kind of as I was transitioning back into endurance sport, it was a little bit before that, just towards entering medical schools when I was transitioning back. So, how did I manage it? Look, the lessons I took were, you’ve got to look after yourself, and this is something med students and doctors do terribly like. You just need to look after yourself to be able to sustain that because I had colleagues, we’re all free to choose, and we’re not free from the consequences of our choice. But I certainly was living a very monk like lifestyle. And if you talk to people from medical school that I’m friends with, they were like, yeah, that guy. I was bringing my own food to classes. I was training all the time. I wasn’t drinking. I was like, in bed at 09:00 p.m. Latest up at 05:00 a.m. I was doing all that stuff and really trying to do that, and probably to an extreme level, probably a bit far, but nonetheless, that stuff really helped me, in contrast to some of my colleagues who were like, they’d be drinking a lot to try and blow off steam. So it was just like a different kind of different choices. And, I think it helped me. I don’t think I could have lived the way they lived, and they would probably say the same thing, which is fine. And as I said, everyone gets to choose. But in terms of how did I stay sane? I really struggled in that med school bubble because we all moved there, and it was a tiny little town, and so there was a lot of bubbling in terms of, you didn’t have a way to get out of that. It’s like your friends were all med students, so the conversation naturally drifts back to whatever’s happening. So it’s really hard to get out of that. And actually, I found, running and going to meet people by running, because I was interstate. I didn’t have any friends in the state, really. So meeting people through running was really helpful. And I remember distinctly met this guy, and it was just this really perfect contrast. We were running along, and he was somebody I ran with pretty much every weekend, like a really good dude. I still talk to him. I remember him being like, hey, man, so what are you studying at university? I was like, medicine. He’s like, cool, so what will you be when you’re done? And I’m like, doctor. And he’s like, doing what? And I was like, well, working in a hospital as a doctor, he’s like, okay, huh? And I don’t think he still understood what I was doing. So that was just perfect for me because I could talk to him about running. I talked to him about other stuff, his life, his family life in general, but he just didn’t care at all about medicine and didn’t have any insight. And that was super helpful to me, to have that real contrast for what’s important and what isn’t. He’s got two kids and a wife. You’re talking about really important things, and then on the days of the week, you’re talking to med students about like, oh, I got 90%, not 95% of this exam. I’m devastated. And you’re like, really? Are we? This is ridiculous. certainly, having that life outside of medicine was really helpful and just helped me turn up and be better on campus at medicine, I guess that’s good.

Dr. Chris Myers: So it sounds like you use that more, just also personal performance, but it was a great stress outlet for you as well. And that really probably helped you with the emotional side of it, the psychological side of it, and most likely even the cognitive side as well, because you’re able to clear your mind. And that really helped with the learning aspect of things, too.

Dr. David Lipman: 100%. Saturday and Sundays were big study days for me. I’m a morning person, so I tended to like to work study in the mornings, and I would do a ton on Saturday and Sundays, and it would be after I ran. And that would calm, the mind. It would be like, run on breakfast, calm the mind, and work for three, 4 hours. And I found that that was a more productive b.

Dr. David Lipman: My retention was a lot higher as a result of that, for sure.

You mentioned bringing in your own food to improve your performance

Dr. Chris Myers: Yeah, that’s great, because I love the fact that you said, the lesson you mentioned is taking care of yourself. You mentioned, okay, you’re running. So we’re talking about the physical aspect or the musculoskeletal side of it, but you also mentioned bringing in your own food. So you’re taking yourself the nutritional aspect, which, if we just look at just a couple of different domains of human performance, that is kind of the unknown domain a lot of people call it, or, the third unofficial domain when it comes to human performance. And so talk to us about that, where even contrast it, if you can, on the days that you were able to pack normally, versus the days that, oh, no, I got up late. I have to deal with it on the go. And how that affected your performance, your emotional status, little things like that.

Dr. David Lipman: I didn’t do a lot of the second one, I’ll be honest. I was pretty meticulous. Again, I made this point earlier, probably, the crossover between how much, work and stress that created m where that benefit starts to be detriment again, or you start to crest that benefit and start to become detrimental. I probably passed the true crest of that. It was into a detrimental stage, but nonetheless, not many days where I didn’t bring my own, so to speak, but a lot of like, there were multiple factors to it. The first factor was what I wanted to eat, and that wasn’t really available on campus from, a health standpoint. Ah. But also, like, type of food. The second thing was cost. I could get by financially, eating healthy, but also, it was actually cheaper than buying stuff on campus because I was bulk preparing salad. So I’d bulk prepare a salad. It was the same salad every week. I can tell you exactly what was in it right now. bulk prepare that, bring it, and then, you know, I eat that instead of whatever else that I could have eaten on campus or whatever. And again, you’re time poor on campus. You’re like rushing between classes, you got an hour to eat or whatever. I’d never worry about that stuff. It was like, all right, I’m just going to go to the lunch hall and eat this and be done and go back to work. So we were pretty fortunate with what was available locally and then the sort of situation we were in. I was a 15 minutes bike ride from college, like from campus. So I’d be throwing in my backpack, ride to college, ride home with it, and clean the container in the evening and be done. So, I was doing that, to be fair, I was baking my own bread, which was not super cheap and somewhat, extensive, but it was kind of also a way of meditation on the weekends, bake my own bread, do a few other things like that. So, I kind of found solace in that, I guess.

Dr. Chris Myers: Good. Okay. I’m glad to hear that.

You’re applying what you’ve learned as a medical coach to wearable data

Dr. Chris Myers: So, enough on the interrogation on your medical school years, of course, but it’s great to hear that you’re taking a lot of those elements that you learned as a coach. Right. Both the personal and team athletes, and they are applying it to yourself as well. Now, let’s fast forward a few years. it’s basically about the time you and I started. So, like you said, we met through tech startup, and one of those is utilizing, continuous glucose monitors. And at least the work that we’ve done, I found that you’ve been able to blend, actually all three areas. Right. Your medical background, your extensive coaching background, and applying it to this new realm of data, actionable data. Right. And so talk to some of the lessons learned that you have found with this technology, if you can.

Dr. David Lipman: Yeah, I think there’s like, a specific and general lessons. Like general lessons, I’d say is you kind of need a bunch of normative data to understand when you bring a new technology in, you need to understand what’s normal and you need to start from the point or the assumption that you are normal, you may not be, but that needs to be the starting assumption versus the opposite, which is this is abnormal. And continuous glucose monitors, as an example, the assumption that you have good glucose control should be, or your responses at normal should be the default starting position, unless you are clinically diagnosed with something. Right. Of course, that’s a bit different. But part of the challenge with that, or the industry is that all of our knowledge around glucose and continuous glucose monitor use is from people with diabetes, which is fine, but it’s a different realm. And it’s generally through the lens of blood as well, because that’s historically where we’ve been able to do it. So you’re now measuring, in a different place, for the most part, on a different audience, and you can’t then take that. You can use the learnings from the people with diabetes and from blood, but it’s not going to be the same. And so giving people normative values from that just doesn’t make any sense. You kind of have to wait for some big data to come out, and some of that’s now being published, which is cool, but that’s kind of one of the learnings I would take from that. I would say the other thing is, there’s a lot of education you need on this thing. And there’s a lot of people want tech to be simple, and they want it to be a score, and they want it to be, whatever, and that’s fine, but it’s a pretty coarse tool. You kind of need to take the time and understand what’s measured versus what’s calculated versus what’s inferred and all those things. And probably the best example is some of the wearables we have now that effectively measure heart rate. And they give you anything from sleep to stress, to heart rate variability, to respiratory. But actually, all they’re measuring is heart rate. Maybe some, accelerometer stuff, and maybe temperature. Those are the three things they’re measuring. So you can take those as we’re not going to say gospel, but as close to good as you’ll get. The rest is infirmed, and you have to treat it as such to understand that. And you need to understand how they’re, or at least have some insight into how algorithms work so that you can understand that. And another example you see all the time is a risk based heart rate on running watches doesn’t work. Well, no, it works perfectly. It’s just that it’s measuring changes in light, and it’s cadence locking on you. So the movement of it on your arm is causing the problem. The technology is great. You can use it on fingers, you can use it higher up. That works fine. And again, now we’re learning. Perhaps not if you have differently colored skin, be it tattoo or otherwise, and, perhaps not if. I mean, the classic example in medical school is carbon monoxide poisoning, right, where it looks like oxygen sats are 100% when they’re not. But the tech is fundamentally good. But if you use, a hammer to try and dig a hole, you’re going to say it’s bad. Yeah. Because if we’re not doing the right thing in the right spot, so don’t blame the tool, blame how it’s used. So it’s probably the big things I take from learning. And then that education component is so big. I mean, that was fundamentally my job at the company, was, like, just educating people on this. Now, that could be individual athletes on their own glucose and optimizing it. It could be working with people like you who are working with their own athletes, or it could just be educating the end user of, like, what’s normal, what’s not. How do I use this? What do I do with it? that’s good.

One of the common comments about wearable technology is accuracy

Dr. Chris Myers: You’re talking about the normative data and the differences on the type of metrics, or actually where it’s measured versus beniol versus interstitial, which is really interesting. One of the common, comments I see within this field when talking with other military, leaders or physicians and stuff is the accuracy. Right. So there’s a big difference between clinical and performance. Right. typically with clinical, you want your deviations to be very small, very small. Because if you’re looking to change one protein or one biochemical. Yeah. That’s why we have clinical testing. But the variance tends to be, you have a wider acceptance. The variance, with performance biowearables. So what are your thoughts on that? And how would you talk that to, emerging medical professionals?

Dr. David Lipman: Yeah, I’d say we’re starting to understand this, and I think if you’re an emerging medical professional, the best thing you could do is get good with wearables because it’s coming for you and it’s coming for us, and we need to be ready for it. And I think you’re alluding to accuracy. And we’ll ignore the discussion of, like, you’re actually measuring something different between blood and need to switch off. Those things are not the same. And if you think they’re the same, yeah, we need to talk a bit more. But regardless of that, let’s set that aside. You can understand the acceptable error in your tools and even, using that example. So we use a finger stick versus, glucose, monitor, continuous glucose monitor, which measures interstitial fluid. They both have an accepted error as part of. It’s the same amount. But if they. I think it’s 5% to 10%, that’s accepted by the FDA. If they vary in opposite directions, they are both acceptably accurate. And, you’re then talking about a delta of somewhere like 10% between them in opposite directions, when actually the measurements are same. So you need to understand that. And I think there’s a lot of system, sort of system. One, thinking, like, thick slicing, rules of thumb, and not a lot of system. Two, understanding first principles, thinking, understanding why this could be different. So we’ll set that aside and talk more toward.

It’s hard to reconcile clinical and scientific significance in podiatry

Well, we’ll talk more towards effectively what you’re talking about, which is lab versus field. Right. And in the podiatry world, this is why I actually didn’t do a PhD or do anything like that was. It was really hard to reconcile clinical and scientific significance in podiatry, because in podiatry, it’s all about your foot. And I’m talking about, from a sporting aspect here, where we’re talking about orthosees and trying to modify forces. My prescription for your orthosis has to be for you. So, inherently, it’s very clinically valid, because that’s exactly what I want to use for you. But then, scientifically, it’s cooked, because I’m giving everybody a different prescription. So how do I prove anything? Right? So, anything you found, from a scientific point of view, statistically, was really hard to apply clinically and vice versa. And that’s an extreme example. But thinking about it, say, from a, medical field, let’s take blood pressure. Now, I sit down in front of you, and I’m real nervous. I get white coat syndrome. Now I’ve got hypertension, and we’re happy to call it white coat hypertension. We say, okay, it’s probably that, well, actually, is it? And now we’ve got a continuous blood pressure monitor. That is, it’s got a CE mark. It’s available in the EU. I think it’s called akita or something like that. And I’ve heard good things about its accuracy, so I wouldn’t say it’s not perfect and it’s not ever going to be perfect. But the question is, is it useful? Now, there is an answer for you. If I can show you that over, multiple days, I get specifically high blood pressure in these parts, or it’s significantly higher, then there’s a real discussion to have. In contrast to, hey, I’ve had normal blood pressure, in the office, or I’ve had high blood pressure in the office, or anything like that. So I think there’s a huge difference between isolated snapshots and continuous data. I think there’s a huge difference between when we’re measuring these things and how we’re measuring it and how useful it is. So, to look at even just glycemic profiles in the wild versus not. Right. Like, trying to understand the real world application of things, we published a paper looking at rebound hypoglycemia, for instance. And one of the criticisms was, all, you know, is that somebody ate and that they exercised afterwards. You have no idea what they ate. And my answer was, exactly, that’s much more useful than eating. I’m inducing 45 grams of carbohydrates as a sugar solution. It’s like, who does that in the real world? Now, it’s helpful to understand the mechanisms and the mechanics of it and understand where to go looking, but it’s not either or. It’s both. And we need both of these things, because telling you what happened in the lab is great, but if you can’t apply that in your real world, then how useful is it? And conversely, telling you what happens in the real world is great. Now let’s go work out why so that we can understand physiology better. It’s both ends.

One of the biggest discussions within HP is how do you operationalize

Dr. Chris Myers: Yeah, it’s interesting you mentioned that, because that’s, one of the biggest discussions we’re having here within the HP world, here in the military, is, how do you operationalize? And that’s the big word right now, how do you operationalize what you find in the lab and applying it to actual tactics in the field. Right. How can our soldiers and our airmen or our weapon systems actually be able to do that? And I think that’s a key point to really kind of hit on as well with our medical professionals is the same lessons apply, not even just for the patients. We’ll talk that in a minute. But even just for themselves, one way to really kind of help with their performance is, okay, we know, and kind of going back to what you were saying, that you packed your food all the time, so you knew what was going on, but for the majority, they don’t. And so they could be operating at a hypoglycemic level and not know that, okay, we need to eat, or when to eat to get back to a normal level to help improve, learning the cognitive side of things.

How would you instruct medical students on how to use wearables for performance

And this is kind of leading into the big question here, is if you had a magic ball and all the money in the world, how would you instruct senior medical students, young residents, on how to use this type of technology for themselves, whether along with just by itself or integrated with another wearable, like a Garmin watch or an aura ring, whatever.

Dr. David Lipman: Yeah, I think I’d go back to first principles and think what’s important for them. So, importance for them is performance. And performance could be physical, it could be mental, it could be emotional, it could be all of those things, right? So let’s assume that it’s all of those things, and you’ve got a full system about the human weapons system, right? And you can use that same approach for doctors. It applies right now. Of course, it’s a differently stressful environment, and the physical aspects are probably a little bit less, and maybe the fine motor aspects are a bit more, but otherwise, it’s fundamentally the same. But let’s say you need to perform like that, and you do. And so then it’s, how can I use these tools to give me feedback on that? You would use an aura ring to give you feedback on sleep. And again, you would be looking for, assuming you’re normal, looking for changes, looking for big changes, not small changes, and acknowledging that your body’s probably smart enough to work out if you need more or less rem or more or less deep sleep. So trying to optimize for those things probably doesn’t make a lot of sense. Let your body optimize for sleep, and then what the stages are, your body will work out in terms of a continuous glucose monitor and how they may use it. I’d say things like, take a period of time and observe your CGM data in context of perhaps aura data, or just, like, a subject of sleep. Like, rough idea of how many hours you slept and how good that was, out of ten. And you use that and look at energy levels, because that’s probably the big thing, is energy levels to some degree. Emotional aspects as well. Are you erratic and emotional because you’re hypoglycemic, or is it because you are tired? these things can be the same. So I would say those things and focus as well. Again, it’s very hard to disentangle sleep and aspects of glycemia, and they are linked. Right. If you have a bad night’s sleep, you will be hyperglycemic, you will have more variable glucose. It’ll be harder to be stable. So I would look at those two in context and try to understand a disconnection of them, but then also reconnection of them is like, which is driving which. And how do they work together, not just separately? So I would try to understand them separately, but also look at them together and understand how they work together and look at aspects of that. And I would say both of them, and all wearables, to a degree, are, feedback. So. And this is probably where CGM is most powerful. And why I think it is powerful is that, for the most part, if you make dietary choices that, let’s call them, suboptimal, whatever that is for you, I’m not going to prescribe to a paradigm here. Like, you make suboptimal choices, and all of a sudden, two years later, you work that out, because all of a sudden, you put on some weight, or your body composition is not what you wanted it to be, or you’re not performing or whatever. It’s a long, very loose feedback loop. And anybody who knows coaching, who understands teaching, any of that stuff, the tighter the feedback loop, the better. And the thing with CGM is it’s a very tight feedback loop. Nobody thinks you should be mainlining cookies after dinner. That’s not part of any healthy diet. And the number of people I spoke to who said, oh, when I put a CGM on, I stopped doing that. And it’s not because I didn’t know, it’s because they saw. There’s a huge difference between intellectually knowing and then really seeing it and going like, oh, that shouldn’t be doing that. I don’t think that’s good. I’m going to stop, actionable data. Yeah. And tightening that feedback loop is so big. And it’s the same with. For me, I started using sleep wearables and started to track how my sleep was affected by alcohol. And I found out that, hey, if you have three glasses of wine, it torches your sleep. And at no point did I think three glasses of wine was actually going to help it. But it was very clear that there was a real big line between two and three me. And at that point, I was like, okay, well, it doesn’t make any sense for me to have a third glass of wine, and ultimately, now I don’t drink anymore. But the point was, I didn’t think it was healthy. I knew it wasn’t healthy. I was a doctor. nobody had more information than me. But the knowledge action gap and crossing that is very difficult for some. And seeing the data sometimes helps. That is like, oh, actually, I can’t lie to myself that I feel okay. It’s pretty clear that, yeah, I might feel okay, but I have not slept well here.

Dr. Chris Myers: Yeah.

One of the conversations you and of I have had is about glycemic levels before sleep

Dr. Chris Myers: One of the conversations you and of I have had in the past too, is that linkage of glycemic levels before sleep. And some of the data is suggesting is if you eat too close to going to bed, your sleep is not going to be optimal. We’re definitely suboptimal. And like what you’re saying, you’re going to have those glycemic spikes and you’re not going to feel rested. But almost upwards to 2 hours before it seems to be like 90 minutes to 120 minutes seems to be kind of that golden area. Where’s the last time you should eat before going to bed? Do you still agree with that principle? if so, what have you seen that kind of further solidifies it or disproves it?

Dr. David Lipman: It’s a bit of a difficult one to disentangle for me. Like there’s this. You should be eating as far away from dinner as possible. And I tend to agree with that. If you’ve got the ability to eat only when it’s sunlight, like crack on and do that, I think it’s probably the healthiest thing. But how reasonable is that for people when you start to think about caloric needs? Right? So I’m not in heavy marathon training at the moment. My food intake is probably 30% of what it is in major marathon training. And so when you’re struggling to eat enough, you put it in where you can put it in, or else you’ll wake up. Right? So talking about glycemia and, sleep quality, the surefire way to wake up is have low glucose. And if you still have the opinion that you can’t have low glucose, as somebody who doesn’t have diabetes, I’ve got some data to show you. And a bunch of marathoners will attest to this. They wake up like, oh, I woke up in the middle of the night and I was hungry. It’s like, well, what do you think woke you up? So m. I think there’s that aspect which is just the first, most important thing is like, you meet your caloric and macronutrient needs. That’s like the primary. Like, if we’re looking at a hierarchy of needs, that’s the primary one. Then you try and shift food away from dinner for the most part. If you can sustain that. And then it’s about, okay, I’m actually going lower tonight. What do I do? That’s an interesting question to solve. And looking at some, I’m of the opinion that not all data has to be double blind. Rcts. If you have nothing else, you look at professional opinion, you look at things, and you also look at who has skin in the game, who’s got skin in the game and needs to have good sleep quality and needs to be optimally fueled overnight. Bodybuilders, what do they do? Protein shake at night. So when I was talking to athletes in the very early phases, and we had an elite crossfit athlete, and she was like, yeah, I’m like struggling to keep my glucose up overnight, waking up, what do I do? And I said, it seems like carbohydrates are going to help, but let’s try protein. And she just went to WPI shake late at night, just before she went to bed, and it fixed everything for her. Now, that’s not going to work for everybody, and I’m not suggesting it does, but what I’m suggesting is not all answers for glucose are carbohydrate. Sometimes it’s just about, total caloric needs. And all those things, because they’re linked, protein can become glucose as well. The krebs cycle exists, so all those things are important. And I’d say you kind of got to experiment a little bit with it. And the only way to experiment and get good feedback is you need objective data, not just subjective data. So you kind of need these things to understand it and understand what’s happening, because not every wake up in the middle of the night is going to be from glucose. At no point when I was working for the company or not, did I believe that glucose was the only answer. in fact, I thought it was. I’m not sure you can optimize glucose to optimize sleep, but I think suboptimal glucose will torch sleep. So it’s probably a detractor rather than, something that adds to it. But the other thing I’d say is the one observation that we had from diabetes that held true, or seemed to hold true in people without diabetes was like, stability begets stability and instability begets instability. And the people with diabetes will tell you this when they get on the roller coaster. it’s really hard to get off because now you got insulin in the system, now you’re eating to try and catch up, and you’re trying to play the seesaw game, the teeter totter game for the Americans listening. And that seems to happen a little bit with people without diabetes as well. Now, the swings are not as bad, they’re not as big, but it seems to happen. So if you want to be stable, try to be stable. So trying to limit glucose perturbations later in the evening probably makes sense to me for a sleep quality standpoint, but I got no data to suggest that other than bit of opinion, some observational stuff, and we go from there.

Dr. Chris Myers: your opinion is just as important. I mean, there’s very few in the field that has seen so much of this data. Right? So you have a lot of that field experience, and I love the fact that you’re sharing that with us. So thank you. With that.

Chris Myers: You need to arm yourself with understanding this tech

This kind of spurs, kind of a lingering question that I’ve had, and we’ve kind of talked this one a little bit, but let’s poke the horse a little bit more. So, we’ve talked about, yeah, you got to look at your long term baseline data, but it’s not pathological, right? And we have this emergence, you said, of all, get used to it. Your biowell rules are here. How would you talk to a young resident about someone who, like me, is wearing so many different biowareables? I track everything, and I see changes, but they’re not pathological. And I come with you with this data and explain to me what’s going on here. And how would you address that?

Dr. David Lipman: Well, I’d say this case is coming, and if a resident is not believing me, just go ask any of the cardiologists, you know, about what’s happening with the Apple Watch algorithm and the AfIB stuff. So Afib is the best example. Cardiology is a, great field because there’s really hard outcomes. You pretty much die or don’t die with cardiological problems. Now, of course, there’s some nuance there, but what I’m saying is, unlike many aspects of medicine, we don’t have to use surrogate markers. Death, is a hard endpoint that you want to avoid. So we’ve got some really good data in atrial fibrillation. In fact, if you experience atrial fibrillation that is symptomatic, and I catch it on an EKG in the hospital, I know exactly what to do with you. I can give you a piece of paper, and you can pretty much do it yourself. If you can prescribe the medications, it’s not difficult because there is so much good data on it. I have no idea what to do with you. If you have asymptomatic atrial fibrillation in the wild, we have no idea. And that’s what’s coming for us. We got a group of people who are going to turn up and say, my HIV is in the gutter and my temperature is up, I’m worried I’m getting sick. So now what I would say is you need to, as a young doctor resident, you need to arm yourself with understanding this tech. So these metrics is one point. You need to know what HIV is, and then you need to understand the tech that’s measuring it so that you can talk to strengths and weaknesses and what might be spurious. So if you come to me and say, hey, Dave, my overnight HIV is down and my temperature was up, I’m really worried about it, my answer to you would be, what did you do late at night last night? Because I know that the biggest impact on overnight HIV is the behaviors in the evening. So, yes, it’s a clean environment overnight and it’s a good one. And it could be that you’re getting sick, but it could also be that you drank alcohol or had a late meal or something like this that will impact your hiv, it will lower it and it will raise your temperature. So you need to kind of understand what you’re measuring, to understand what could be a source of noise, not necessarily error, but noise and those sort of things. And you need to understand beyond that top surface level of what this metric means. That’s the first thing I’d say. The second thing I’d say is you need to understand normal variation in this. So, for instance, HIV has a real big seasonal component to it. So even understanding that, like, oh, my, HIV has been down trading over time, you’re like, yeah, it’s winter, of course, who’s worried? So you need to understand all these metrics in a level of depth and understand how they work together. Again, strengths and weaknesses of the different tech and all of that, because as I said, it’s coming. And at the moment, my fear is that people are dismissing the Chris Myers that’s coming to see them and says, hey, I’m worried about this. You’re being dismissed at the moment, and that’s not a good way to have it. As somebody who know in podiatry at the time, barefoot running took now, yeah, I can tell you now that the best way to win people over is to acknowledge their viewpoint, understand it, talk to them about the strengths and weaknesses and challenges of it, and go from there. I’ll never forget having a lady come in and going like, I love running barefoot. It feels so good, but every time I do it, I’ve got crippling shin pain. I read this book called born to run, and I want to throw my orthotics and shoes in the bin. And I was like, cool. I love the book as well. I understand exactly why you’re doing it. Let’s talk about how to manage this load appropriately, how to run some barefoot and how to not run some barefoot. And when you need to use this and you have a textured, nuanced conversation, she walked out of there, and she’s like, oh, this makes tons of sense. And then three months later, she comes back. She’s like, actually, I just don’t really enjoy the pain much. So I just gone back to running with my shoes and my m orthotics. Is that okay? Well, it’s okay. You’re in charge. But, the easiest thing for me to do would be like, don’t run barefoot. That’s stupid. Wear your orthotics in your shoes. She then gets disengaged, and leaps goes like, this guy doesn’t know what I’m talking about. So you got to meet people where they’re at, and you got to ask them questions like, why do you think that? What’s going on? What do you think is going on? There’s a classic statement from one of the fathers of medicine whose name eludes me at the moment. I’ll have to look it up, but, he said it’s much more important to know what type of person the disease has than what type of disease the person has.

Dr. Chris Myers: Interesting.

Dr. David Lipman: So, you got to know who’s sitting in front of you and interrogate, talk to them and listen to them and all those things. The easiest way to make somebody feel good about the consult is to listen to them, and is the hardest thing to do, is to sit with your mouth absolutely shut, especially for me. You’ve all heard me on this podcast. It’s very difficult to sit and shut your mouth and just listen. But I’ll tell you, your results will be significantly better for not doing anything different aside from just listening, people feeling listened to is really important, and there is a therapeutic effect to listening. So I would listen. And when I say interrogate, I mean ask questions. Don’t actually interrogate. Especially for military people. Don’t actually interrogate. Just, ask exploratory questions around. So, what’s been going on? How long has been going on? What do you think? Do you have any symptoms are you concerned? What do you think this could be? And what you’ll find is usually, particularly if someone’s overly anxious about something, there’s a reason. It’s like, hey, I’m worried that I’m having a heart attack because my father had one. Okay, well, that’s actually interesting. You’re of an age now where you’re a male, and these things like, have you had your cholesterol check? Should we check these other things? And it might be, a good way into some really important health screening.

Dr. Chris Myers: Yes, it’s very good points. Really good advice. I even learned a few things out of that, too. That’s really good.

Some of the principles from sports have relevance in the medical world

So before we kind of wrap things up here, we’ve talked a lot of different things, but it’s really interesting how, and I really think you’ve connected the dots of, what we do in the performance world, even in the tactical world, too, has a lot of relevance in the medical world. And I’m not talking with patient care, we’re talking with the actual providers. And within, kind of that context, do you have any last minute advice for our audience?

Dr. David Lipman: Yeah, I think there’s lessons to be learned. You don’t have to treat yourself like an athlete, but you can certainly take some of the principles across it. I guarantee you people before big days, in the athletic world, are not skipping sleep. They’re not having a bunch of booze. They care about these things, and they’re important because they see the impact of it. And it can be hard to understand that. But I think if you are really objectively and subjectively measuring your outcomes, you will start to notice the effect of these things. So I’d be treating it the same when exams are on. I was super meticulous about this because I needed to perform just like on the sporting field or on whatever realm you compete in. That’s important, right? You wouldn’t want to use a different thing just because it’s your job. We tend to sort of diminish it a little bit. But if I told you that your bus driver, or your pilot, or your insert other important job, had not slept, drank a bunch of booze, and ate like garbage the night before, how happy are you to get on the bus or the plane? You’d be very hesitant to do that. Similarly, if I said your politicians had done that, they’re about to sign a bill, how happy are you for them to do that? Answer is going to be no. So why are we happy to sign drug orders or make decisions medically or operate on people when we’re not doing that appropriately. Now, there are some very difficult situations to navigate in medicine, call overnights all that stuff. I’m not pretending that doesn’t exist. I did those shifts. And we can talk about what I did to try and optimize in that context, but it’s not an easy situation. But you have to do the best you can and do the best for yourself and your patients. And again, I don’t live in a, fantasy world where everybody can live like a monk. I live in the real world. And some of the stuff, and I’ve already alluded to this as myself, can be too extreme. And there might be a benefit to being a little bit less extreme. I’m not advocating, like, only eating vegetables and, sleeping 10 hours a night on whatever mattress and doing the things that may not be doable for you. You may have children, you may have call all that stuff, but you need to take it more seriously than like, I’ll make it do. I’ll eat some takeout and get the sleep I can get and be done right. That’s not going to cut it. It’s not going to cut it from a hospital system either. The doctors are eventually going to say, like, actually, I don’t like this. I know that shift work is a huge risk for cancer as it is. I don’t need to be eating this garbage. I need to have a good option overnight. I need to have a place that I can sleep properly overnight. I need these things. And that’s where we’re headed.

Dr. Chris Myers: Yes. That’s good.

You did stuff to optimize your overnight calls, those 36 hours shifts

Just in kind of anticipating our audience, you mentioned in there, you did stuff to optimize your overnight calls, those 36 hours shifts. Talk to us a little bit before we close out on there. On some of the lessons that you learned, some of the things that you did.

Dr. David Lipman: Yeah. So I treated it like, time zone shifts. I’ll be fair. I trained in Australia where it was a lot more kind than a lot of the american stuff. I did do some time in America, but not as much. So I’m talking more about, like, er shifts where it’s overnight. I would do like a block of, say, four overnights and then come back on a days. And I would treat it just. I would be super circadian disciplined. So I would be melatonin to help me sleep in a dark room, cool room, all that. I would completely phase shift it. I would wake up. I, would go to bed as early as I could the night prior to, my shift, I would sleep in the afternoon, try and bank some sleep. I would get up, have coffee, breakfast food, go to work. I would eat a super low carb dinner overnight. Sorry. I would breakfast food, then I would train, then I would go to night shift, eat a super low carb meal overnight, generally something that was like, ground venison and vegetables, like a sort of chili type of meal. I would avoid all the garbage I have on the wards because there’s any number of things there. I would have a coffee overnight. I would finish in the morning. I’d go home and have the equivalent of dinner, whatever that is, go to sleep, and sleep properly through the day in a dark room, cold room, all that. And so I would treat it just the same thing. I was, like, not trying to live it in any other way. I was having coffee at night. I phase shifted completely, and then the other way back as well. And I was using melatonin to help me sleep, help me phase shift it.

Dr. Chris Myers: And.

Dr. David Lipman: And I would do that and come in and out of night shifts pretty well and then embrace it, because night shifts in the hospital pretty great in some ways. It’s horrible, but also, there’s not the same sort of rig morale through the day. It’s a lot less like, pomp and ceremony. It’s a lot more like, we just need to get this done. So you got to play the course you’re on like it’s the course or you got to play the hand you got dealt like it’s a hand you wanted. Like, if you got night shift, make the best of it, enjoy it. Band together sort of overnight in hospitals, a weird place, but it can be really fun. So I used to try and approach it that way as well and really sort of do that, but appreciate, that I had a pretty good experience with nights, in all the hospitals I worked in. I was really lucky. Had some great people that work nights with me in some great organizations and departments. So appreciate that. I know that I also was in a position where it wasn’t as stressful compared to some of the people I know that worked overnights who were, like, run off their feet. And in that context, I tried to help them just like, hey, can I get your coffee or can I do something for you? What can I do to help you? Because it’s pretty brutal. And I think in medicine, there’s a lot of self preservation at the cost of others, and it can be pretty ugly place in that respect. There’s a lot of, like, oh, that’s not my job. But I think if we can be a bit kinder to each other, probably improves everything.

Dr. Chris Myers: Sounds good. You know what? We’re just going to leave it there. That’s some really good advice right there. So, David, thank you so much for your time. It’s been a pleasure catching up and imparting some wisdom from all your years of just your experiences, both in human m forms, team coaching, and in medicine. So thanks for your time. We appreciate it. Hope you have you on again sometime in the near future.

Dr. David Lipman: Thanks very much for having me. Loved it. And, yeah, always happy to come back and yeah, thanks.

Dr. Chris Myers: Sounds good. See everyone next time. Have a great day.