Tips for Keeping Your Brain Healthy from a Neurosurgeon | Real Talk

There's nothing about my upbringing, there's nothing about my IQ that I'm aware of. It was really work ethic. How do we teach young Americans that grit is a superpower? You don't need to be brilliant. You need to be extremely tenacious. Doesn't sound like a work-life balance. Yeah, work-life balance is usually not the life of a neurosurgeon. I operated this morning before I came here. Apparently there has to be something about the EI included in the CME. Medicine and politics should also be distinct. Are you worried that machines are going to replace you as a surgeon? Is there anything stronger in this cup before I answer the question? Jared, thank you so much for coming in. I'm humbled that you came in because I know that you have very important patients and hopefully you didn't have to put off a brain surgery or a spine surgery to come here. I think the brain is like out of space. There is so much to discover. I think that you're the quintessential example of how important it is that people have grit and merit. My vision is to understand the brain a little better, to understand technology a little better when it comes to medicine, and then to get some serious advice as I'm not getting any younger and I need more neuroplasticity so I can keep doing the job that I'm doing. Thanks for coming in. Thank you for having me. I look forward to just getting to know how your mind works a little better. Why don't you describe to me what your work looks like? Are you mostly doing brain surgery, spine surgery? Neurosurgery in private practice tends to be a blend of both, but just by sheer volume, it's mostly spine. In my practice, I still do a lot of brain, but it's still 60%, 70% spine. A lot of our research and some of the cutting-edge work we're looking into is spine-related, spine trials, FDA trials. So just by sheer volume, we're seeing more spine patients, but we do both. I'm fascinated with the brain. Can you describe to me just a little bit how the brain works? We hear about these things like pain is in the brain. What does that mean? A lot of the practice in spine surgery is pain-mediated. People are having what we call sciatica. They're burning pain in the legs. The nervous system is being impinged somehow, and that's around the spine. The brain's perception of the pain can be handled two ways. Either you mask it, and that's something called neuromodulation, where you trick the highway, where you literally turn on and off the signals using electrostimulation, high-frequency stimulation, so that the brain doesn't perceive the pain. But as we talked about earlier, it's potentially dangerous because you're not treating the problem. The pain is a way of your body to tell you there's a problem. So the other option is to go in and find the source of the problem, which is part of the job. That part of neurosurgery is being a detective, making medical diagnoses to figure out what the right solution is to the problem. You can go in and fix a structural problem, and that can also treat the pain. So there's many ways to go about it, and sometimes you want to go to the origin, or sometimes you want to cut off the highway. What about the case where somebody has cancer, for example, and it's just incredibly painful? It's not in the spine or in the brain. Is there something that you guys can do? Cancer-mediated pain has a long history of having it, because it can be anywhere in the body, and people can have just horrendous pain. So there are older procedures where we actually make little micromillimeter lesions, where you actually burn with very, very precise control lesions in the spinal cord, and you're targeting specific pathways from the pain receptor anywhere in the body. It could be an abdominal cancer, pelvic cancer, even just bony cancer, skeletal cancers, where you actually create a lesion that cuts off the circulation so the patient will no longer feel the pain, because it's not perceived, that signal never reaches the brain. The other thing would be something like a neuromodulation, where we stimulate the spinal cord to take the pathway away. That's looking at it from a, let's go with the safest place potentially to cut off that signaling, treat the person's pain, and let the cancer, whatever part of the body, be treated by that specialist. The brain also has the ability. We've been working for years in Parkinson's, for example, where we put electrodes into the brain, you can turn on certain frequencies, and it can stop a tremor. There are ways to actually use electro-stimulation directly in the brain to also modulate pain, addiction. Those are things that are very cutting edge and being done. But again, we avoid putting electrodes deep into the brain. If we can avoid it, if we can do a spinal cord lesion, which is not without risks, people can be paralyzed, it's still a little bit safer than putting an electrode deep in the brain. Sure. How long are your surgeries? They vary. I often will do an artificial disc replacement in the spine in 45 minutes to an hour, or I can do a brain surgery sometimes in 2 or 3 hours, or 6 or 8 hours, if it's a brain tumor, depending on where it's located and how hard it's to access safely. How do you do those long ones? How do you maintain the tenacity and the stamina? You know... It doesn't sound like a work-life balance. Yeah, work-life balance is usually not the life of a neurosurgeon. At least that's been the stigma for decades. It has gotten better. We can talk a little bit about work-hour reforms and policies designed to make it better. Not really for the surgeon, it was designed to make it safer for the patients, because after a certain amount of time, errors can happen, it doesn't matter how good you are at your job. But you say tenacity, it's grit, it's training. I always tell people I wasn't born with superpowers. You were not? Well, I try to tell my wife from time to time, but she never believes me. I really wasn't. I think work ethic maybe is a superpower. There's nothing about my upbringing, there's nothing about my IQ that I'm aware of, that made me succeed through neurosurgical training. It was really work ethic. It's grit, it's tenacity, it is training, it's like the military. Life is on the line. It's a life and death decision at all hours of the night, and it's not something that just comes to you easily. When you first start doing this training, it's miserable. It's tiring, it's exhausting, it's depressing. It's emotionally charged. The highs and the lows, people die, people live, people are paralyzed, people walk again. Huge contrasts. And the emotional part, I don't know if it ever gets easier. I hope it doesn't get easier. People always say, do you get cold? I don't think it gets easier, but you definitely learn how to manage it for the patient. Because I had a patient who we did a surgery on and woke up and wasn't moving her legs. And we did everything possible. I took her back to the operating room. I could not figure it out, and she actually ended up doing well. But at the moment, I didn't know that. Why did I have to be able to have that emotional grit to be able to compartmentalize, to be able to go through? Because I had another patient waiting for me. If I was distraught, if I was a wreck, how would I be my best self, my best neurosurgical self for the next patient that was waiting for an elective surgery? I owed it to the next patient to put on a little bit of blinders and focus on that patient. Now, that doesn't mean that after the fact, I was cold-hearted and didn't deal with the first patient. But we did everything possible for that first patient. At some point, I realized we did everything possible. We did everything right that we could. I owed it to the next patient to focus. And I don't know if you're born with that. I mean, I'm positive you're not. That's just something that has to be taught, and you have to be receptive to it. Live up to it. It's a challenge. It's a challenge every day. I'm an educator. I'm a mom of three. You're a dad. How do we teach young Americans that grit is a superpower? Because that was your superpower. You're obviously intelligent. I'm sure you did very well in school. Doing well in school and being intelligent is not what made you the top of the chain. It's not what made you the neurosurgeon that you are today. The great differentiator is for those who are willing to put in that extra work. But we're not really living in this culture that tells our kids, put in that extra work. It says, enjoy your life, which of course we have to enjoy our lives. But how do we realize that actually we can enjoy our lives and have passion and enjoy even the act of putting in the work? I don't know if I know the answer because I agree with you. I see my kids and this generation, they love being spoon-fed. They love the idea that daddy worked really hard. He's doing okay. I can go to the mall and ask for some money. I don't need to work hard. Honestly, it's upon each of us. As parents, as educators, we need to show that our success or our accomplishments weren't given to us. We earned them. You probably know this better than me. But as an educator, I think we truly lead by example. And I'm constantly telling my children, I'm constantly telling my patients, this is an effort. This is not just given to us on a silver platter. We have to work hard for successes and find satisfaction in those successes. And it's okay to take a step back and take a break. Balance is everything. And I'm also against the people that are just workaholics and neglect their families at home. So if you can take a step back and be on vacation with your family, be on vacation and be present. You're not staring at your phone or you're staring at your iPad. You're present, teaching by example. And every chance I get, I'm showing my kids what hard work means and what it can result in. I don't have a better answer than that because I've seen what's going on around us. And it scares me that everyone should suddenly just be privileged. And suddenly you should be given everything because it doesn't work like that. There are certainly people that are born with gifts, that are brilliant, that work in labs and work in aerospace or with Tesla. And they work in these industries and do amazing things, put people on the moon, right? There are some phenomenal people, right? But what's interesting about surgical subspecialties, it's funny we keep saying this word grit, but it does differentiate you from those other people because you sure have to have a certain level of intelligence. But you don't need to be brilliant. You need to be extremely tenacious. You need to be emotionally strong and available and you need to be resilient. Not afraid of hard work, not afraid of sleepless nights, not afraid of talking to a family about a dying loved one. The hard thing is how do you live that life and then go home and have some semblance of normalcy? How do you disconnect from being so with it and then go and be really there and really present and really emotional? You come across to me so calm, cool and collected. You come across very confident. Do you ever get nervous? Are you scared? I mean, I think of myself, people think that I go on stage and there's not a nerve in my body. They're like, you were probably born to give speeches. I'm like, little do you know how nervous I get sometimes. And when I was thinking that you're coming in today, I'm like, I bet you Jared just never gets nervous because they banged it out of him in neurosurgery school. Do you get nervous? Are you afraid? So I do get nervous. I do get afraid. I'm not impervious to human conditions. But you're right. They did bang it out of me a little bit. We were laughing before, but it's true. You go into neurosurgery, if you get into neurosurgery, you think of yourself or you were one of the best of the best in medical school. Right. It's part of the pathway. The first thing that happens to you when you go from being the creme de la creme, the best of the best in neurosurgery, they basically tell you you're worthless. You can't do anything. You may be a great medical school graduate, but you're not a neurosurgeon. I'm in a neurosurgery program. You can't do anything. That sounds like a huge HR violation. Are they still allowed to do that? In neurosurgery, you can do a lot. It really takes a toll on the ego, but for all the right reasons. They do build you up in a way to deal with the issues of the day-to-day of being a neurosurgeon that you really didn't know about in medical school. It's a humbling process. You asked me to go back to the beginning of your question. It's a scary process. Now, you go this interesting maturation through residency and subspecialty training and fellowship training where there's a lot of hand-holding. They break you down. They bring you up. They break you down. They bring you up. Then a little bit less and a little bit less and a little bit less. Before you know it, you're doing a surgery by yourself. The biggest change for me, and I remember telling people about this, when you're a chief resident, you're teaching the other residents, you really know you can do almost all the things you were trained to do. But at the end of the day, that attending, the senior surgeon is somewhere in the back. He's there. Maybe he's outside the room. But he or she is there if you need them. Then you graduate, and no one's there. You're all on your own. You asked me if I've ever been afraid. A hundred percent. Because if you're not afraid, and you don't respect what you're doing and dealing with, and the human being that's life is your responsibility, if you're not afraid, you're dangerous. And it is lonely. There are certainly relationships and interactions with the nurses and the anesthesiologists. But at the end of the day, the buck stops with you. You're the captain of the ship. It is ego-driven somewhat, but at the end of the day, it's also the fact that you have to be the one that makes that last-minute decision. And it's difficult. And I will say, though, having a partner or having someone that you trust in neurosurgery, it makes all the difference. Because, like I said, if you don't know when you're out of your element, you're dangerous. If you don't know when to be afraid, you're dangerous. Not knowing when to ask for help as a neurosurgeon is dangerous. And the first thing, even though my first few cases, when I was graduated, I really didn't have anyone around. And that's when I was first really, even though I'd done the case a million times in training, I had no one to back me up. I was scared. Thankfully, they were successful cases. And that helped, right? But being able to call my partner and ask for advice or ask a friend, it really does make a difference. Yeah. I relate to that. It's hard when you're at the top. It's hard that you have to really take the burden. And the burden of making the mistake is so much greater sometimes than the victory of taking things across the finish line. It's hard not to harp over the missing tile syndrome, as Dennis would say. You know, that one thing that I wish I would have done differently. Oh, completely. And it really requires a lot of mental strength to say, I can't beat myself up. I have to be allowed to just keep going. My partner and I call it the neurosurgery pits when we really harp on that one thing we just wish we could have done differently. And that's really important. Yeah. I think it's significant. I have specific animosity right now towards the American Medical Association. I know this gender blur that is created, especially around kids, where a doctor can't even ask whether it's a female or a male who has come into the office or there was no actual gender. And the stuff that happened, just additional surgeries where it's not needed and all kinds of—I mean, I don't even need to get into that list. I think you know why people are dissatisfied with the AMA. And I'm wondering, how is that impacting you? And how are these institutions, these organizations impacting America and America's ability to innovate and stay ahead when it comes to medicine? Do you have anything stronger in this cup before I answer this question? I don't know. Some doctors told me that wine is bad for you. We're going to get into that. We'll get to that. I've always said this. I think that medicine and politics should also be distinct. A doctor-patient relationship should have nothing to do with a political opinion, the AMA's mandate, any of that. And I really believe that that division is critical because that was what was special about the relationship and allowed objective decision making. Yeah. When you don't make objective decisions and somehow some subjectivity or some bias or some external factor is injected into that relationship or into that decision making, again, I think it's dangerous. Yeah. I think of you as the anti-surgery surgeon. A good friend of ours, Marty McCarty, wrote a book about how many surgeries are done in the United States that should never have been done. And there's obviously so much money coming from the operating rooms and operations. And so I know that you're kind of like an anti-surgery surgeon, but you also have a lot to say about fusion. So tell me a little bit about that. What can we learn? Yeah. So I do think that people over-operate. Remember, surgeons are incentivized to operate. And I always tell patients and friends and family, I try very hard not to operate on more than 10 or 15 percent of the patients that come through my door. It's just a rough number. I mean, it can be higher or lower depending on the day. But the idea is I want to be incentivized to do the right thing by people all the time. Pragmatically, no. You get paid to operate, right? So there are a lot more surgeries being done that probably are necessary. I truly believe that if you do right by people, it all comes back to you. The fusion concept is why the neurosurgeons and spine surgeons and the orthopedic surgeons who do spine got a bad rap. And my nickname has always been the anti-fusion doctor because a lot of my original research, now 15 years ago, has been on motion preservation. The concept of a fusion is you take a segment of the spine that's moving naturally, and you do whatever is needed to take the pressure off the nerves, the pressure off the bones, the patient feels better. But you lock the segment that you operated on in place. Let me ask you. You're not old enough. But if you needed a hip replacement, do you want a cement block in your hip or do you want one that actually works and moves? Same thing with the knee. So this concept of doing that to the spine doesn't make sense. Furthermore, there's a concept called adjacent segment disease. Now, not to get into the nitty-gritty of the medical terminology, but again, back to the car analogy. Let's say you took away the moving segment. You took away a shock absorber of your car. You're driving on it. Three shocks, four wheels. What happens to those other three shocks if you no longer have a shock absorber on the fourth? I fused it together like the spine with rods and screws. Those three shock absorbers are going to work overtime because they're compensating for the fact that that one was gone. So we know that if you fuse your spine together, even if you feel better at the moment, the levels above and the levels below will work overtime and wear and tear faster. So we always say the reason fusion got a bad rap is because it begets another fusion, begets another fusion, and another fusion. And I have seen disasters walk into the hospital or my clinic head to toe rods and screws, meaning they're like this. There's no quality of life if you can't move. So what do you do? Because there's also no quality of life if you're in so much pain and agony. Sure. So we look at alternative technologies. Israel's a great example. They just came out with this artificial facet replacement, which is just the part of the spine in the back. And that was FDA approved only a few months ago, but we've been doing trials for the last several years. And so whether it's the back of the spine or it's an artificial disc from the front, why don't I just give you a new shock absorber? New hip, new knee. So the technology has just been behind. But we now have, and this isn't new, we now have, and Europe's been doing it for 30 years, which is you go back to your innovation question. That's the scary part. Instead of putting in a fusion, a block of bone or a block of titanium, let's put in a moving disc, a bionic moving disc. So it functions like the shock absorber you once had. Why is that good? Treats the problem, but it's also been shown to reduce the stresses above and below. Remember adjacent segment disease? Now you have a normal shock absorber. So those stress on the levels in the rest of your spine goes down. So the same thing in the Israeli device, this new TOPS device where you take off the back of the spine where all the arthritis is pushing on the nerves. In the past, if you did that, the spine's unstable. You had to put rods and screws and lock it in place. Now you put in a moving joint. So the whole concept, for me, I always say motion is life. Motion preservation. If we can preserve motion in something like the spine, I always err on the side of motion and not fusion. I know you're working on something that's similar to Neuralink, Synchron. Synchron is, and this is a broader discussion about brain-computer interface. Freaks the hell out of me. Yeah, freaks the hell out of a lot of people. Using the concept of machine technology and computer chips with the body and the brain and the nervous system. Neuralink's the same thing. But Neuralink is an open procedure. Synchron is a technology where they use a little puncture in the groin and they feed like an angiography. If you're doing a blood vessel test, they puncture the groin and they feed this little mesh. We're talking very small, millimeters, up into the blood vessel on the very top of the brain called the superior sagittal sinus, a massive blood vessel. Not something you want to injure during surgery. A lot of bleeding. And they deploy it just through a little puncture in your groin into the vessel all the way up and they deploy it and it sits in the vessel. And what it does is it communicates with a piece of technology like a robotic apparatus so that people who are paralyzed or paraplegic can use the technology to move a mouse cursor, order food, use technology around them with some interface. But what's amazing about it is it's using a signal from your brain that says move the mouse and it connects via Bluetooth signal to a device that moves the mouse. That's revolutionary. And so I'm very excited to see kind of what happens with these FDA trials. Is it working in Australia already? There are people using it? There are several patients. We don't have huge numbers. They're not using it. It's not approved yet on grand scale. But the trials there were remarkably successful. And I'm lucky. I have a little inside information from my colleague in Australia who's a neurosurgeon. He's a phenomenal neurosurgeon who works at one of the public university hospitals that are doing this trial. So it's very exciting. But, you know, even I know for a fact that the Tesla team went to Synchron. It has enormous application. It's early. But the days of being paralyzed and not walking again are looking different. You know, when you mentioned BCI, then I said that freaks the hell out of me. You know, I think of it as even more screen time, but yet in your brain, or even more access to you and your, you know, I guess, autonomy and sovereignty when there is a chip in your brain. What are your thoughts on that? Are we a few years from a situation where we don't even text anymore? We just like text in our brain. Is that like something you're envisioning happening over the next few years? So I don't want to go all Terminator on you, right? We're not like we're not being taken over by robots. From a pure spine health perspective, if you can text from your brain, it's much better for your neck posture than looking at your phone. I don't know. You know, so I don't want to exercise your neck. I don't want anyone doing this. So if you're if you can text from your brain and look up, it's good posture. Not convinced by that. OK, but, you know, the idea that these devices and interfaces can somehow control us or take over is nowhere near plausible. Are we a few years away from texting from our brain? Maybe. That's different. The big scale of us being robots. Right. I mean, so Apple recently released their Vision Pro. You can have you and I could be FaceTiming with these goggles thousands of miles away and the viewers would think we're sitting in the same room. Right. So it's already coming. The implantable part is the kind of the scary part. Texting without a device, I think, is probably several years away. I think like robotic control and something more scary. No, we're not there. Are you worried that machines are going to replace you as a surgeon? So I already use robotics. I mean, that's a great question. We didn't, you know, that's something we've never talked about. We use robotics as assist devices. They are. They're an adjunct. Right. Robotics will help guide. It's called neuro navigation, but the concept is like GPS for the brain, GPS for the spine, where it helps us navigate the anatomy in real time when you can't always see as well as you'd like to. We're working in very small spaces under the microscope. There could be blood. There could be things going on. So we have GPS for the brain. It's robotic. We have robotic arms that come in and guide us, but we're the ones doing it through the arm. Right now, the Tesla car is good at avoiding a lot of accidents, but not all of them. That statistic is still unacceptable in neurosurgery. The decision has to end with us. Robots are assist devices, but they can't make critical decisions in the operating room. I don't see that happening anytime soon. Let's say you get older as a surgeon and develop a little bit of a tremor. If the robot can help your tremor and help you do the right maneuver better, that's okay, because that's an assist device. But they're not making the decision to do that maneuver. They're not making the decision not to do that maneuver. People always ask me, how do you know when to operate? The best surgeons actually know when not to. So we're not there. I'm not worried about robots taking over the operating room just yet. Okay, now to a question that I'm selfish about. How do I increase neuroplasticity? Are there really cool innovations out there, even on the technology side, where can we make humans smarter or help us preserve memory for longer or even increase our ability to comprehend and compute? It's a little late for us. For you and me? Yeah, for you and I. But unfortunately, because the neuroplasticity that you talk about is remarkable in children. We've seen extraordinary cases, and there's a lot of research on that. And what children can do is really quite incredible. It's not that we can't, it's just slower. Neuroplasticity, neuroregenerative healing of the brain as you get older is just much slower. There are things. We've known for a long time that education helps actually prevent dementia. If you're reading and you're more involved and you're having to use your brain, it's like a muscle in some ways, even though it's mostly fat. But it's really, the more you use it, the less you'll lose it. Like challenging education, like putting kids through learning, engaging. Yes, and so we know that that can help long-term mental health and neuronal health. Proper diet, whether that be, and I'm not a big supplement guy, right? I think you don't even need a multivitamin if you eat properly, but most of us don't eat properly. Proper diet, knowing what's in our foods, because a lot of the brain has something called the brain-blood barrier, a lot of it doesn't go through, right? We want to make sure that all the good things that you're getting in a diet are available to us to the best of our ability. And stress, we know for a fact that stress directly increases cortisol levels and a whole other slew of things on what we call the HPA axis. And, you know, the hippocampus, pituitary, adrenal gland axis. This HPA axis goes from the brain to the adrenals, and it's this whole cycle. And we know that stress directly mediates a whole lot of badness, and that's the technical term, okay? Because the more stressed we are, there are actual structural changes in the brain that can happen. The more we abuse drugs, all of them, it doesn't matter, even medically prescribed drugs, Tylenol can be toxic, right? Marijuana, all these things that we've talked about. Yeah, we're going to get into some of the specifics. But all of those things can cause micro and macro structural changes in the brain. The question is, are the micro and macro structural changes, what does that mean? It's a visual change that you see on an image, for example, on an MRI. Does that correlate with functional changes? And that answer is maybe. We know that if there's enough micro and macro structural changes, then yes, there are aberrations that go on and the brain stops functioning properly. But we've seen, the technology is so good that we can pick up on subtle changes in the brain that show no functional change. So we don't know. But there are certain habits and healthy eating and healthy lifestyle that will, and just using your brain in constant challenging exercises and ways that we know will help preserve a certain level of health. That said, that's environmental. There are still genetic predispositions that are very hard to fight. Sure. Some of us are more prone to certain things as we get older than others. Well, I want to ask a clarifying question when you talk about stress, because earlier when we started chatting, we talked about the importance of grit and hard work. And you had your fair share of stress and I've had my fair share of stress. And so what do we mean? Is stress necessarily like that bad for neuroplasticity, given that we are saying, well, you need grit. You need to work hard. Well, that's pretty damn stressful. Nothing about my training was healthy. Yeah. And how is your brain doing? I don't know. I hope it's OK. I mean, look, it's a little bit of a difficult question because you're asking about brain health and brain longevity, not necessarily my functioning. Now, I wouldn't be surprised if the highest functioning people that really had extremely stressful experiences or educational processes or rites of passages that made them who they are today. Yeah. Don't have health problems later. So it's a double edged sword. It's a little draconian, actually, because if you think about it, I truly believe what we said at the beginning. Right. It's a merit based system. When you really are stressed and you rise to the challenge and you put the work in, there are results. Earned happiness. Earned results and happiness. But there may be some health consequences later on for it. Unless living a fulfilling, happy life. Counteracts it. Counteracts, you know, whatever stress it is. I mean, at least that would be that would be my hypothesis, is that if you have this balance where you actually appreciate some level of stress, some level of anxiety, you learn how to work through it. You realize that those are those nuggets that actually build you and help you become a prosperous person, become a happy person. Then maybe you actually have a healthier brain because. Yeah. I'm not going to say it's never too late, but also remember that neuroplasticity we talked about. Yeah. Right. I would never say to anyone, if you're 45 or 50 years old and you want to change careers and it's stressful, you don't do it because you don't have the neuroplasticity. Right. But I do believe you have certain recovery ability and potential earlier on. When you're younger. You put the work in when you're younger. That totally makes sense. Is that true? Yeah. So it's interesting because language in particular is a very well understood and well studied area of the brain. So using functional MRIs, we can pinpoint language. Language areas is something as a neurosurgeon we're very aware of because we're operating on brain tumors in the area. We always map out language. We want to make sure that we're preserving those areas. And there's a lot of variability, but there are certain common factors in the brain where there is Broca or Wernicke. These are just terms, but there are certain areas within relative vicinity because of variability where we can map language. And what you can see in children or even, frankly, in adults who speak multiple languages, their language centers look different. Same location, but there's actually more folds, more gyri and sulci in the brain. There's more architecture going on in those language areas than someone who doesn't. We've seen that very early on. Wow. I mean, I've always found it's easy for me to learn new languages. I learned French and I learned a little bit of Arabic. I learned Hebrew and I learned Spanish very, very quickly. And I always wonder whether it's thanks to the fact that I had to move. I lived in the U.S. and I lived in Israel and I came back. So it's so interesting. We'll call my guy in Ventura and get you an MRI. I want to see what's going on in the brain. You don't want to look at what's in my brain. Okay. I want to play a little. It's a short game that I like to do when I'm trying to cover as much information as possible. And so this is very, very hard usually for smart people like you who have a lot to say about certain things. But I know that me and the people who are watching want to know about very specific substances or things that we come across in our daily lives. And how does that impact our brain? Is it good? Is it bad? Is it neutral? And generally, what do you have to say about them? So you ready? Sure. All right. Let's do this. Wine. I know you're a big wine lover. I've been reading every single decent doctor that I've spoken with has said to me that wine, including red wine, is not actually good for you. So I was in the wine business before medicine. So I do love the history, the complexity, the beauty of wine, the pairing with foods. Alcohol. Forget wine. Alcohol is a neurotoxin. It's toxic. We know this. I can very easily make the statement to you, everything in moderation is OK. I can fall back on that. Everything in moderation may be OK. It depends on a lot of things. We know that any amount of alcohol is a neurotoxin. We know that people talk about red wine. What's the difference between red wine and white wine? The big thing is people talk a lot about resveratrol. So that comes from the seeds and the skins, actually. Why do people talk about it? Because it has a lot of antioxidant properties. It was actually used in tumor research. So there's a lot of interesting things there. But remember, penicillin was found in nature as well. Resveratrol is another element. It's another substance that's found in nature that may have health benefits. It doesn't mean that drinking wine is the best way to get it, right? I do believe that the problem with wine and alcohol in general, when you compare it to other drugs, is it's been so normalized in society as the thing to do for dinner. It's cultural. It's very easy to abuse it, and the threshold for abuse is a lot lower than what people would think, in my mind, from a physiologic standpoint. It's easier to abuse it than people realize. I'm not saying you're an alcoholic, and that's a very clear cut, right? I'm saying at what point is it abusive in the sense that your physiology is actually, the toxins are bothering you. And I talked a little bit earlier about micro and macro structure in the brain. It is clear that alcohol can cause micro and macro structural changes in the brain. But all of the studies that have been reported on this, especially with wine, wine's always a big topic, it can show those structural changes, but they're cross-sectional observational studies. They're not randomized controlled trials. So we don't actually know how those changes affect function. And this is why I can fall back on the whole moderation thing. But we do know that there is a threshold where there is real harm. And if you think about it, if you can get to a threshold where there's real harm, there's a disease called Wernicke-Korsakoff syndrome, and it usually comes from a vitamin B1 deficiency. And that deficiency is directly related to alcohol intake and metabolism, and therefore you're deficient in the vitamin, and then as a result you get these changes in the brain. And it's devastating. Vision changes, balance issues, amnesia, right? It's devastating. And I always think to myself, if you can get to that point, clearly there's a problem, right? So the substance is not good for us. Alcohol is really not good for us. But the body is also an incredible filtration organism. And so the problem when I say moderation is okay is because we don't know where moderation is. Right. That's the issue. How do you draw the line? And I don't know. Right. What about coffee? Coffee is similar. Coffee is a neurostimulant. Caffeine is a neurostimulant. I have a friend, Dr. Mayer, who's at UCLA, who's an amazing gut, neuro-gut biologist, who says coffee, again, in moderation, is actually great. Good for you. That's what I've been hearing. Coffee is suddenly good for you. Again, take this with a grain of salt. There's a study that shows in rats, note the caveat, in rats, that more than the equivalent of six cups of coffee a day helps prevent Alzheimer's. Wow. That was in rats, and it's an interesting observation. The problem with all these things is that there are very few large enough well-constructed studies to make definitive conclusions. And a lot of this stuff doesn't happen overnight. It takes 10, 20, 30, 40 years of follow-up. So we're going to learn more. But yes, some of the early findings on resveratrol in wine, but you can also extract it, has great antioxidant effects. Caffeine in coffee, in the process, is very good for the neuro-gut interaction. But coffee can be hard on people's stomachs, too, right? So some of the recent research is exciting. Right. Cannabis. Trickier. Because cannabis and cannabinoid receptors, in particular, and how we utilize them for modulating pain in patients is actually a really important part of pain management. The recreational use of marijuana is different. You're never going to find a neurosurgeon that I believe to tell you that any sort of recreational marijuana use, especially in a young developing brain, is healthy. What does the marijuana do to a child's brain, or let's say a teenager's brain? Yeah, I mean, there's a lot of data out there that will show structural changes to development. So there's areas in the brain that, you know, the young brain is also, the plasticity is around healing. But there's also ongoing development, right? And that development has been shown to actually, in certain areas of the brain, the prefrontal cortex, some myelination problems. There are areas in the brain where actually there are developmental delays. In the hippocampus, around memory and cognition, there are developmental delays. So you talked about the structure that you see with language. So you see less of that. So is it fair to tell a teenager that if they smoke marijuana, they will probably become dumber? I don't make generalizations. But what I will tell a teenager is that if you use marijuana at a certain amount, and I'll tell them, I honestly don't know, that's a scary thing. We don't know the amount, right? Same thing with wine. At a certain amount, we'll see structural changes in your brain. Now, I don't know what that will mean for you, functionally, but structural changes in the brain can cause harm and can cause long-term, if not permanent, deficits down the road. So I will use the data to inform teenagers, patients, etc., because that's where I feel the most comfortable. I know what you're saying, but it's hard to say dumber when I don't know how to quantify that. Good luck getting a teenager to hear that entire whatever. You're right. At the end of the day, as parents, we want to know, is it really okay? Is it okay to take a puff every once in a while? Is it okay to let them go? Or should we warn them? I know this stuff is also laced with stuff, and it's not the same type of marijuana that it used to be. And then what do you call those little jewels? And that stuff and the chemicals that are in there. There is a general culture around this, which is a very accepting culture. And if you're saying, you know, marijuana, not a great idea. Oh, you're a dinosaur. Why would you say that's not okay? Everybody smokes it. It's a different conversation today, because one, you don't know what it's laced with. The quality is concerning. And all I tell patients is marijuana caught, and I'm going to try and simplify it, because you're right. You called me out on it, and you're correct. I don't want to be too neurosurgical, but marijuana causes structural changes in the brain. From what we understand, those structural changes aren't positive. And so I would simply say that's a big risk. It's not a calculated risk. It's a big unknown risk. And that's how I'd educate them. I just don't know. A very likely negative one. Do I think? Yeah. A structural change is not a good thing, unless it's more folds for your language center. And so it's a very likely negative risk to your brain. How that will affect you, we don't know. I'm also a pretty easygoing guy. I don't want to say that I'm very scary about the forbidden fruit theory, and you keep your children locked up in the room all day. They'll want all that. They'll want everything. So it's a very hard balance. For sure. But I also teach people, and this is important, I think, from an education standpoint, just because it's called a certain name, or it's called a drug, doesn't mean it isn't or it is. Everything you put in your body has elements of chemicals, has drugs. So the jewelry you're talking about is sure loaded with chemicals. People smoke cigarettes. The tobacco and the nicotine is bad, but it's half the other chemicals that are worse. You put a drug that was prescribed to you in your body, it's chemicals. And it's the same thing with marijuana, with any drugs. They're chemicals. And there's going to be a desired effect, but there very well may be undesired effects. What about vitamins? Do we pee our vitamins? Is it good for us? Can we do something prophylactically for the brain? Yeah, I mean, a lot of it is excreted. It's urinated out. I mean, it's not well absorbed. A lot of it's a big industry around vitamins. But I always say your body is your temple. If you eat right and take care of yourself, you shouldn't need much. Now that is a generalization. And you know I hate generalizations because everyone's a little bit different. And some people absorb all kinds of things well, and some people absorb them poorly. Some people are deficient in certain minerals and vitamins more than others for genetic reasons, for where they live in the world reasons, right, depending on just their diet and exposures. So there are certain vitamins. Remember, your brain is 60-60% fat. And so you need certain fat-soluble vitamins that can cross the blood-brain barrier to nourish the brain. One of the other important things that people don't realize, do you know the term mitochondria? Sure. Okay. So mitochondria are rated on a scale of where they're mostly located in the body. Heart's a big one. Organs are a big one. The brain is number one. And mitochondria I think of as like the cellular metabolism, right, the processing of the cell. Yeah, we all learn it in grade school. Right, cellular metabolism. It's in the cell, and it just processes, right? But the idea is that, remember, your brain is an active electrical unit with firing and connections. And the mitochondria are working harder than ever. And even if you think you're going to the gym and your muscles are working and that's mitochondria, no, the brain is really what's causing mitochondrial work. When the mitochondria processes cellular content, it creates waste, causes oxidative stress. So things that can help with oxidative stresses, some of those superfoods, even like berries, are phenomenal for your brain. And a lot of people talk about things like lion's mane and acetylcholine. Acetylcholine is a really important drug. I don't take anything other than this Axon supplement, but the reason for it is because it's designed for neurohealth. And the things that matter for the brain are fats. We talk about fats. So what's the best way to get fats into your brain? We all know this, right? Fish oils. But what's the problem with fish oils? Mercury content in fish. So you actually can get algae-based oils like any of the DHAs, for example, that are really, really healthy for the brain and brain membranes because the membranes are what helps us filter things in and filter things out in terms of cellular function. Acetylcholine is critical because the brain needs to produce acetylcholine and other neurotransmitters. So there are so many parts, even magnesium, vitamin B6, vitamin B12. I mean, I can go on and on about the things that are important. The question is, if you take them, where are you getting them from? Are they getting absorbed in the gut? Are they going to the brain? Are they going to the right cells? Are they going to the right process? Those vitamins and nutrients are required. They're called cofactors. You can't have neurotransmitters, which basically tell one axon to fire, like serotonin. All those things, acetylcholine, are neurotransmitters, the brain's communication chemical. Those things cannot be made without things like vitamin B6 and vitamin B12 as cofactors. So you need to get them into your body in the right amount. And the question is, in today's diet, today's busy lifestyle, do we and are we getting those? There is a big difference in bioavailability, how much actually is absorbed by the gut, and it depends also on your gut health. Which again, my friend in UCLA, Dr. Mayer, who's an amazing gut neurobiologist, talks about gut health. And we actually don't treat our guts well. We should be feeding the microbiome, the bacteria that live in our gut. Because if they're doing well, we're doing well. It's really interesting science. And if they're doing well and we're doing well, the brain's doing better. So it depends on your gut. It depends on your deficiencies. If you really are, like if you have something called pernicious anemia, you cannot absorb vitamin B12 because you're missing a certain factor, then you need injections. So yeah, you can't rely on any sort of absorption. If you're the average, you know, Joe Schmo, like you and I, and we just need a better lifestyle, healthy habits, then you need the right source. So vitamin B6 and vitamin B12, one of the most important things is methylation. And methylation is your body's way of adding a little bit of a chemical tag so that it's used properly. And a lot of people have trouble with methylation. So if you're going to get vitamin B6, B12, get the methylated version. And all the other things that we mentioned, if you're going to have omega-3s, right, the DHAs, I think that for safety, the algae-based omega-3 is critical for brain health. You don't need the mercury exposure that comes a lot from fish oils, unfortunately. And so, again, I take very little. But what I do take, you know, is often vegan-based, very pure sources with good bioavailability. So I just encourage everyone who's listening to, you know, do good research, do diligence, and think about things like methylation, bioavailability, the source of the ingredients, and the amounts. Because people thought, oh, vitamin C helps people with their immune system. People are taking toxic megadoses and getting these things at Costco, right, in these big jars. That's also not true. Too much. I know you're not vegan. You mentioned that you take vegan-based ones. I mean, I've seen you eat meat, a lot of meat, actually. I do love my steak, yes. So why do you want your vitamins to be vegan-based? Because you can choose your steak sometimes in a restaurant. You know where you're going to or you know where you're buying your meat from, right? But when you're getting certain supplements sourced, if you don't know where it's sourced from, you don't know what the fish was exposed to, the cow was exposed to. It's all about source. In the wine world, we call it province, right, where it came from, right? So we need to know the source. And the vegan sources are often usually safer and a little bit more naturally purified, if you will. So it doesn't have to be vegan. But if you don't know where it's coming from, it's generally safer. That's my choice because I just don't know, exactly. So this is basically what you take, this thing that you brought me. So what do you have in this thing that you take? Yeah, so it's a proprietary blend. It includes lion's mane, acetylcholine, magnesium 3A. It's got omega-3s. It's got methylated vitamin B6, B12. It's basically, I like this because it's a super vitamin for the brain, for your brain health. It's not a multivitamin. It's not a prenatal vitamin. It shouldn't replace that if you need that or are taking that. But it's really focused on all of the cofactors that the brain needs to function. And the idea is, and you have to be careful because these things are never tested in combination, right? But we have a lot of data on their own. And so a lot of thought went into kind of how do you put these things together so that the brain, the mitochondrial level, the brain functions more efficiently. We're giving it, not toxic doses, just a little bit more of the good stuff so it functions more efficiently. At what age do you think somebody should start taking these supplements? Is it, you know, do we give it to our kids or is it something where, you know, we hit our 40s and start worrying about our neuroplasticity? Yeah, so I mean brain health, brain substances, if you know the source, you feel like it's a good provider of nutrition. You know, teenagehood, late teenagehood I think is probably very safe. You just want to look at dosing. There are different dosing, different kind of supplements and medications that are better as we get older. There's different needs. But I think at an age of development of rapidly developing cells and a high demand environment, especially during high school and college, a lot of this is safe when you know the source in the right doses. I don't recommend that everyone just go on all the multivitamins that they can get in the store. I don't at all. I think that's dangerous. So please don't actually get me wrong. I don't want to ever recommend that someone go to the store and get this, this, this, this because they think the term supplement is so misleading. You're supplementing what, right? Really know what you're supplementing. Really know what you need and only get one or two or three things that you truly think is going to help and that you talk to someone to give you some advice that can actually help you. It's a slippery slope as well because I've seen people with stacks of vitamins and every day it's a production of 20, 30 pills. I think that's dangerous because at some point you don't know what you're taking. You don't know how it's all interacting with each other. Right. What about some of the supplements that are made in gummy form? Yeah, it's fine. It's just a delivery. It's just sugar, but it's fine. We're actually going to do it with Axone as well. When we created this, it was really for our patients around surgery so they could have better over neurologic system healing and health, reduce oxidative stress, increase your natural energy. After surgery, I want you to get up and walk and do things. That's why we created this. When we created it, we actually sourced it with extremely costly ingredients. Our margins are low because we wanted to do right by people. We put very expensive stuff in here. Because of it, we couldn't get into a gummy form. It's a structural thing, but there are ways when there's less in it. If it's something very isolated or very unique, it can be in a gummy form. Yeah, like an omega. Yeah, sure. Absolutely. I think of the brain as an area that doesn't do well with heat. What about things like the earpods, the headsets, 5G, going to sleep with the phone by your bed while it's charging? That entire world. Electromagnetic fields. We don't know is the real answer because this type of stuff takes decades of research. I will tell you that certain electromagnetic fields and direct heat to the brain is bad. Believe it or not, you can have a pretty high fever and it's actually good for you to fight off an infection. You shouldn't treat the fever too aggressively sometimes. Electromagnetic fields are there as a treatment for GBM. Glioblastoma multiforme is one of the most aggressive brain cancers that we deal with and unfortunately will strike men and women in middle age, 40, 50, 60, the most common time. And it's incurable. But one of the salvage therapies that is an FDA approved therapy is an electromagnetic field that can treat and actually inactivate brain tumor cells. So when people ask me about cell phone use and Bluetooth and AirPods, I mean, there may be an electromagnetic field and a frequency to wavelength that is harmful but there are certainly some that are actually good. So it's too early to know. I think we owe it upon ourselves and the next generation to do better research, to not poo-poo it, to not ignore it, to not discredit it. But I also don't like the idea of fear-mongering or conspiracy theories and all those things. I really think I'm a data guy. Good data in, good data out. If we do right by the next generation, by doing the right research, the problem is that we won't maybe know until the end of our life or their lifetime. And then the harm is already done for a lot of people. But that also is the risk of innovation. So it is a balance because there are going to be new things that come up all the time in medicine, in technology, in biotech sectors that are designed to do good or designed to help or be an assist device or augment your reality in a positive way. There's all these things and innovations that some of them may turn out to be harmful. Jared, what's your instinct? Obviously, we need to rely on data. You guys are entrepreneurs. You have a gut instinct. You're immersed in this. You're seeing brains. You've been doing this for a while. Would you say, I feel like there's probably an overreaction. It's not such a big deal. The brain is pretty resilient. Or would you say, this feels like something I would be a little careful about. Is it worth just charging the phones outside of the bedroom? Is it worth taking the computer screen out of our kids' bedrooms? Is it worth doing it? Or is it like, listen, it's just the chances of this happening, it's not really there. What's your instinct? So anecdotally, I have not seen in my career yet a higher incidence of brain tumors or cancers, especially in the region where I operate actually a lot. This is called a retrosigmoid approach. You go into the back of the brain. I go to the side here. I have not seen any direct correlation in my practice. And remember, that's anecdotal. It's my practice. I've not seen research or data to show a well-done study that increases a correlation between tumors adjacent to an area of high electromagnetic use. I haven't seen it. Whereas we've seen other studies where children's schools were near polluted nuclear reactors and there was all kinds of abnormal tumors and cancers and stuff. And it was much clearer. I haven't seen it. But I'm also still young in my career. I'd like to believe so. I don't feel that. And the gray is coming in more and more. But the problem I have with helping you with this answer is a lot of this stuff and the dosages and the exposures that we're talking about may take 50, 60, 80, 100 years to manifest. And so the question then becomes, do we care? I mean, maybe we care if the kids are being exposed when they're five or six, because it's a whole lifetime of exposure. It's hard. A lot of my patients are, even as they get older, are very savvy. And they're all on their devices. And they're all doing things. And I have not seen that increase. And I haven't seen data to support it. I do think this goes back to the marijuana question, the wine question. What is moderation? Where's our threshold? These exposures, we don't know. So in the setting of us not knowing, I'll try to answer your question more directly. I think it behooves us to be cautious, but not afraid. And not to the point where we don't try to embrace these technologies and stifle innovation. We should be cautious. If there are certain things we can do, we do it. Charge the phones a little bit away. Because we don't know that threshold yet. Right. But I would not say that we should overreact and that this is going to really be the next big nuclear waste site that causes cancers in everyone. I just don't see it yet. Sure. That's a fair answer. I think of your profession as, again, I mentioned this at the top, it's like outer space. Right? It's so small, but so big. And a lot of unknowns. Right? So that's why I think this subject is so fascinating to me. I want to thank you for coming on. It's really interesting. I learned a lot. Thank you for having me. I'm curious, last question. If you could have chosen a different profession, I think about this all the time. I don't know how many people out there lay there in bed sometimes and say, I love what I do. I wonder what else I would have done now that I've kind of like seen the world and I know my profession. If there was another dream job that you could choose, what would that be? You're going to laugh, but okay. Other than the sommelier wine gig, right? Other than that one, because you've done that already and you know how bad wine is. You'll laugh. I don't know if you even know this about me. I don't. Martial artist. Martial arts instructor. Really? So my passion growing up before wine was martial arts. And I always used to joke with my Jewish parents that I'm going to go with my sensei, we're going to go to Okinawa and train. And my Jewish mother got so angry at that comment once that she actually came to my karate school, unbeknownst to me, and lectured my sensei that no, he is a good boy and he's going to medical school. I have a true passion for martial arts. The history, the physicality, the mental component, the meditation, everything about martial arts is something that I've loved my whole life. Wow. I didn't know that about you. And you know what? It's so interesting because I happen to get along really well with people who are just even in the MMA world. And I keep saying, I think usually people who are MMA fans and people who actually practice are really grounded in reality because if you're not grounded in reality, it can hurt a lot. Absolutely. And I like people who are grounded in reality. If you're not, it's dangerous, right? Yeah. We have to take a dose of reality. You know, it's a real realistic kind of hobby and profession for some. So fascinating. It's cool. No one knows about it. I don't know how many people know about it. Now a lot of people know about you. Well, thanks for coming on. Thank you for having me. It was really fun. The pleasure.