Since You Put It That Way
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Since You Put It That Way
Prehabilitation with Scott Russo, MD
In this episode, Dr. Louder talks to Scott Russo, MD, about the process of "prehabilitation"--getting patients ready for the experience of surgery or a life-changing diagnosis.
Dr. Scott Russo specializes in the surgical and non-surgical treatment of spinal disorders and orthopaedic fracture care. He is accomplished in all areas of cervical, thoracic and lumbar spinal surgeries, including trauma, tumors, degenerative conditions, scoliosis and herniated discs. His subspecialty of interest is in the non-surgical and surgical care of pediatric and adult scoliosis and kyphosis. Dr. Russo is also part of the clinical faculty at Grand Valley State University, Michigan State University College of Human Medicine and the coordinator for the spine in the Grand Rapids Orthopaedic Residency Program. In addition, Scott is the founding member of Recover Health.
Patients are referred to Recover Health from their surgeon, primary care physician, or other medical professionals, to optimize the outcome of their surgery. Recover Health medical professionals create a comprehensive care plan for patients that will strengthen the body and mind through physical optimization, nutritional optimization, and behavior wellness optimization.
For more help with Prehabilitation, download our Prehabilitation FAQ.
Intro for "Since you put it that way" podcast.
Outro for "Since you put it that way" podcast
Hi, welcome to today's episode of Since You Put It That Way. I'm going to be in conversation today with Dr. Scott Russo. He is an orthopedic specialist in West Michigan. He specializes in the surgical and non-surgical treatment of spinal disorders and orthopedic fracture care. Dr. Russo is accomplished in all areas of cervical, thoracic, and lumbar spinal surgeries, including trauma, tumors, degenerative conditions, scoliosis, and herniated discs. His subspecialty of interest is in the non-surgical and surgical care of pediatric and adult scoliosis and kyphosis. Dr. Russo is also part of the clinical faculty at Grand Valley State University, Michigan State College of Human Medicine, and the coordinator for the spine section in the Grand Rapids Orthopedic Residency Program. Today's topic is going to be on the prehabilitation process, meaning getting a patient ready for surgery. And, in addition to the podcast, it would be good to download the transcript from today, as well as an FAQ page that I put together (it's actually a few pages) that goes over some good ideas and information that you as a patient can use for yourself or your loved ones as you prepare for your surgeries or even if there's a life-changing diagnosis that occurs. So, without any further ado, here's our conversation. Since there's two of us physicians, I guess it's a paradox. So, enjoy today's show. So Dr. Russo, go ahead and explain to us, go ahead and introduce yourself to us. What should we know about you? What's important?
Scott Russo, MD:Mary, thank you so much for the opportunity to share my story and my interest and passion with your listeners. And so I'm just a young man from the east side of the state grew up in St. Clair Shores right outside Detroit, went away to Michigan State for undergraduate, and from there after getting a degree in chemistry, I went to Wayne State University School of Medicine. I was blessed to have graduated from Wayne State and obtained a residency in orthopedic surgery in Grand Rapids at the Grand Rapids Orthopedic Residency Program so long ago, and from there, from there, I went and did a fellowship in spine surgery, and then came back to Grand Rapids. So came back to Grand Rapids and joined two fine orthopedic surgeons and was there for a couple of years before I went out to form the Spine Center West Michigan, which Spine Center West Michigan was a multidisciplinary program that had both medical component and rehabilitation component. And that kind of started my relationship with physical therapy, rehab, and health and wellness and that was kind of the introduction. From there we went and formed Orthopedic and Spine Specialists and then ultimately ended up at Orthopedic Associates of grant of Michigan now, and that's, I've been there for 17 years. And I am a member of the American Academy of Orthopedic Surgeons, North American Spine Society, Scoliosis Research Society, which is one of the preeminent research societies in all of spine surgery. I also am part of Michigan Orthopedic Society. I am a Resident Educator, former coordinator for the Spine Program for the Orthopedic Residency Department. I'm also an Associate Professor of Surgery for both the Michigan State University School of Osteopathic Medicine and School of Human Medicine, and I sit on the Alumni Board for the Wayne State University School of Medicine. So, a lot of different things. I'm very committed to teaching and education. But more importantly, I'm committed to my patients and patient care. And so this conversation we're going to have today is based on a lecture that I just gave to the Michigan Osteopathic Association this past weekend, as you know, you attended that. Preparing Your Patient for Surgery and Beyond. So that was that's where, that's where I am right now today.
Mary Louder:Yes, well, welcome. We're so glad you're here. You know, we shared patients many years ago when I practiced in Michigan, right out of residency, and it's been really good to reconnect. And so I'm really appreciating that, you know, after we've both been, you know, working, I think I've been a physician 30 years, so just, you know, right on your heels there. So, a lot of good experience. There's a story you have, though, about kind of what really kind of put you in this direction where you had an opportunity to experience you know, maybe a healing crisis and opportunity for enlightenment, for growth. Can you share that before we get into some of the details of prehabilitation?
Scott Russo, MD:I would welcome that. Yeah, so in 2008, my life was ambushed overnight, and I wasn't ready for that. And so I went from fully functioning, high energy surgeon to patient, and I was admitted to the hospital with high fevers, in sepsis, with a staph infection in my blood and an abscess in my spine, and a heart valve that had vegetations on it from the bacteria. And I was pretty sick and really, really scared. And after eight days and almost dying, I was able to leave the hospital. And I left the hospital and I had three things: a PICC line in my arm, which is a long term IV, I had a bag of antibiotics, and a couple of follow up visits with the Infectious Disease and Cardiologists, those specialists. But nobody told me how to recover from such a debilitating illness. 20 pounds of weight loss. So I went home, and I didn't realize it till I reflected on it, that I was depressed. I didn't know what to do. And I somehow just figured it out. I started to walk to the end of the driveway and back, and I just progressed up the street until I could build my strength up. I started eating healthy. And, but I think the mental piece was what really left me here as I was going from, you know, 60 to zero overnight. And how would I--how would I provide for my family now?
Mary Louder:Right, so high-functioning, near-death experience, you know, tremendous amount of infection and recovery for the body to recover. But I think the mental and emotional part is really a key. Because I think one of the things in medicine that we perhaps don't do well enough is how to prepare patients for what they actually may experience.
Scott Russo, MD:That's your statement. It is it is a true statement. The mind either works for you or works against you. While it's the patient's choice to embrace it, it's the health care system's responsibility to encourage it.
Mary Louder:Yes.
Scott Russo, MD:That's where the healthcare system really has taken a backseat.
Mary Louder:Yeah. And you said you were scared.
Scott Russo, MD:Oh, frightened. That I was gonna have my chest sawed open, and my heart valve removed. I can't tell you anything that's more frightening than that.
Mary Louder:Yeah. And, you know the inside scoop, meaning, you know what goes on in the hospital. You know what goes on in the surgical suite. You know what goes on on the medical floor and the ICU. I mean, you know, you're intimately acquainted with all that, and yet, you were scared.
Scott Russo, MD:That is correct.
Mary Louder:So I think we can't leave that statement untouched. Because if you're scared, and you know what to expect, think of our patients and what they don't know what to expect.
Scott Russo, MD:That's a true statement. And I had to go and go a little deeper. I had to figure it out.
Mary Louder:Yeah. Yeah. And I think that this is really something that, you know, my side of the table here in our discussion is primary care, getting all the patients ready to--for surgery, and meeting all the criteria. But by and large, the patients have always come back to me and said, hey, the specialist said this, that and the other. I don't know who to believe, what to trust, because I trust you, I've had that relationship. So really, one of the things we're talking about here is how developed is that doctor-patient relationship within a systematic approach to patient care?
Scott Russo, MD:That is true. I mean, the the relationship between the primary care physician and their patient is sacred.
Mary Louder:Yes.
Scott Russo, MD:The surgeon kind of comes into that as a side piece. And that's where the system is not communicating. You know, the surgeon says to the primary care, doctor, hey, clear, my clear my patient for surgery. And the primary care does that. But they're not really talking about what are the real needs of the patient? And how do we get that patient ready to do battle in the operating room? And then the recovery afterwards?
Mary Louder:Yeah. I had a well-known acquaintance recently who had a significant medical procedure, and the outcome was going to change a considerable amount of physiology within their body. And that was in the cardiovascular system. And the patient just had no awareness of it. And I just sat there and I went through, I don't know if you'd call it the mental gymnastics or you know, I'm Joe's heart or whatever, but I just went through all the things like the heart would be experiencing and feeling, and what the blood vessels will be doing, just in response to how the the volume change, because, you know, cardiology is, you know, fluid dynamics. And so just the basics of those mechanics changing of how that can only imagine how that could feel inside of a person's chest. So same thing, getting a valve replacement, cracking of the chest, moving of the bones, being wired back together, I mean, that's just a tremendous amount of surgery. And yet we do it all the time.
Scott Russo, MD:All the time. We do it all the time. The patients don't have it all the time, but we do it all the time. And it's their first time, and they're hoping it's their only time. And the question is, how do we prepare them for that experience? So more this concept of anti-fragility, right? We're--when I work on, I work on resilience, mental resilience, physical resilience, nutritional resilience. But how do we take patients and have them come out of an operation stronger for it? And that's something that's never been talked about in healthcare.
Mary Louder:That's correct. That's correct. And you use the term interestingly, that I've always considered, but I've
never heard a surgeon say it:that a surgery is traumatic. And I was like, Yes, it is. And I think I honestly believe you're the first physician and first surgeon I've ever heard use those terms.
Scott Russo, MD:And I appreciate that, because I truly believe it, and I understand it, and I feel it for my patients. I know what they're going to have. And I want to respect that. And that's why I give them the tools to deal with it. And then the choice is up to them if they take the tools and use them.
Mary Louder:Yeah. So your experience provided you not only compassion, but you know, really empathy. You could definitely identify and knowing you before, you know, many years ago, I never considered you not empathetic to be interest, you know, interestingly. And so it's, it's an interesting--it's interesting now to hear how much more that has actually permeated your practice, and how much influence that has in the decisions you make and the direction you're taking not only your patients, but you know, how you want to influence the medical system.
Scott Russo, MD:It's a true statement. I think there's such opportunity for change, such power in the relationships that physicians have with their patients, surgeons have with their patients, and surgeons and primary care physicians have with each other, that we're not tapping into this. Yeah, I understand medicine is a business, but the reality is, is this is the opportunity to improve the lives of our patients and their family members, and everybody else that we touch.
Mary Louder:Yes. So medicine's changed, though, because, and I would put it on the backs of the electronic health record, and I would put it on the backs of large systems that are, you know, very numbers oriented, very driven by procedures, very driven by referrals, and down--what we would call downstream revenue. But I think the electronic health record is a big disrupter that we have a lot of net, I would say, I would call it negative consequences from or unfortunate consequences. Because we don't have the ability to bump into one another as physicians anymore, pick up the phone and call. You know, I came it's really hard for me as a physician, as a primary care physician to get the specialist on the phone. And we used to do consults all the time sharing patients, we would get a letter back, you would send a letter we'd, you know, have a specific question that we asked in the consultation, we'd look for that answer in return, and then the next steps. And the communication I felt, you know, when I first was in practice in the 90s was pretty good.
Scott Russo, MD:Oh, yeah, it was a blessing. You'd walk down the hallway and you'd see the, your family physician was making rounds. And nowadays they're hospital-based physicians, and they're good people. They're great people, and I'm very thankful for them. But it's not like it used to be where we would connect regularly. We see each other in medical records, and now everything's electronic. So there is truth to the fact that that has disrupted the relationships that we have, and the ability--but I always still welcome any primary care physician who has a question, has a concern, to reach out to me personally. Much rather talk to them.
Mary Louder:Yeah. I think the other thing that's been a bit of a challenge, too, is, we, I think we probably discharge people home who are more ill now than what we used to admit them to the ICU.
Scott Russo, MD:I think, yeah, I think that's true. Yeah, we're doing a lot more surgery outpatient on older and more mature patients. And yes, those, those are changes in the times.
Mary Louder:Yeah. And that has been, I think, difficult to catch up with. And I think that's, you know, I wonder if that's played into the idea of how prepared patients are is, you know, the communication with the patients, the, you know, that--the consistency between the specialists and the primary
Scott Russo, MD:Right, and I think that's the real care doc. opportunity for what I am proposing or trying to do is that prehab specialist, so to speak, who really kind of looks at the patient from a preparatory standpoint, and communicates with the primary care physician, these are my concerns regarding the risk factors, can you help address them? Can you optimize them from the medical standpoint? To the surgeon is, we need more communication with your patient. They're coming in with all these questions, I can help you if you'd like, you know, or, or let's get them back in the hands of your staff members and let's get those questions answered. Let's build the social team around them, right? The family. Do we engage in church or other things? So how are we doing this so the patients come in seamlessly, they flow into the system, they get their care surgically, and they go home, and they recovered quickly, with less likely complications, and maybe, hopefully, ideally, lower cost. Better for our healthcare system?
Mary Louder:Right, so one is--if we were to define prehabilitation, because it's kind of a new, I would say it's an old new concept or a new old concept, or, you know, how would you define that?
Scott Russo, MD:Yeah, so I think the way to look at prehabilitation is that it's pre-surgical optimization, right? It's the--it's the process of taking part before surgery, identifying where they're at at that point in their life functionally, in this case, will be, what are their medical risks? What's their nutritional status? What's their mental well-being? What's their physical status? And taking an elevating that through a series of processes to a level--a new level. So when we wound them, when we enter them with surgery, they recover quicker. Right? Because if you start at a frail state, and then we injure them, they may never get back to their baseline, and what a detriment that is. But if we build them up, and we give them new tools, a health and wellness toolkit, so to speak, then we injure them with surgery, because there's an appropriate injury that goes along with surgery, they recover quicker, faster, more successful, to be a happier patient, lower cost, better value for care.
Mary Louder:Yeah. And I think speaking to maybe the emotional and mental health part, maybe the fear would be diminished. Because they know that communications there, they would feel, I think two things come to mind: seen and heard. And oftentimes, you know, the advice for patients can be you got this, you can do this, you know, yep, it's a difficult process, but you got this mean, the body has the inherent capacity to heal.
Scott Russo, MD:No question about it.
Mary Louder:If we get the parts together so it can do that. And then get these, you know, get the emotional component. I think, so, if we, you talked about nutrition. So, what do you see from an--let's look at orthopedics and spine because those are, you know, often chronic conditions that bring a patient in, osteoarthritis. How do you see nutrition being able to impact that patient? If they were getting ready for a surgery to, in this process?
Scott Russo, MD:Well, let me tell you just kind of a funny way in which I approached nutrition with my, and health and wellness with my patients. Yeah, so I asked my patients if they've ever had a new car before, and most patient has, and I say, well, what's the cost of a new car? Let's just say$50,000. I said, it's pretty expensive, isn't it? Oh, yeah, that's a lot of money. I said, when when you get a new car, do you--do you put the worst gas in the car? Oh, no, I'm not going to go to the worst gas. I'm going to make sure that I give it the best fuel. And so when you--when your car needs a tune-up, it's at 3000 miles do you take it in for its tune-up? Rotate the tires? Absolutely. It's a lot of money, $50,000 I say well, what's the value of your body over the course of your lifetime? And they say I don't know. I say, let's say millions of dollars that you will earn for somebody else or for yourself, all the joy you will give to other people and to yourself. But why do we as a society treat our bodies like a second class citizen? And so the reality is, is that the food we put in our body is the fuel for our body, the exercise, the mental well-being is a tune-up for our body. We don't do that regularly. We don't celebrate ourselves. And we don't do this because we're not assuming responsibility as individuals for ourselves, and we have free will. That's the problem, or the goodness and the greatness of our life is we have free will to do what, what hopefully drives us, but at the same time, we miss out on how to care for our body. So nutrition is the fuel, that is the most important thing, and that fuels every cell in our body throughout our lifetime.
Mary Louder:So in the prehabilitation process, are you having folks meet with a nutritionist, or are you have staff members that share information? Or do you have handouts? How are you practically approaching that?
Scott Russo, MD:So we have a dietician on staff, and we make that, that patient, we don't make it, but that's part of the program. So it was one arm of the program, three parallel arms. One of the arm of the program, the patient meets with the dietician, the dietician does a nutritional assessment, right, screens them, assesses them, and puts in place ideally, we use the Mediterranean diet, it's probably the most well-known studied diet out there, and pretty darn healthy. And we'd probably lead it, lean it a little bit more towards the ketogenic ban. So keeping down the sugars, certainly no processed sugars. And we put that in place. And so that's the anti-inflammatory piece of the body. So the diet, the patients are working with that. If patients are overweight or obese, and they want to lose weight, or they need to lose weight before their knee replacement, or their spine surgery, then we have a meal system, that's a VLCD, very low calorie meal system ketogenic in origin, high protein, that jumpstarts that process, so we get them to win for a couple of weeks in a row where they get five to 10 pounds a week weight loss on a very low calorie. They work with the primary care physicians if they're on diabetic medications to adjust them appropriately. We engage them also in the physical conditioning piece. So now we're getting to right size their body, we're getting to condition their body physically. And we'll talk about that more now. The whole time they're doing their mental well-being, mindfulness exercises, positivity drills, and their different rituals that kind of optimize their mind for the process. So that's what we do. That's the nutrition piece.
Mary Louder:Yeah. So how, what--can you share with us a success story that you've had with that from--with a patient that you can think of?
Scott Russo, MD:Successfully with the whole process? Absolutely. Gentleman came in, he was having his hip replaced. Not super heavy, but probably BMI between 30 and 35. We got him going on the Mediterranean diet. A short week of the meal system, lost 10 pounds. He was working with me on his mindfulness, we helped him most importantly, identify his why for he's having surgery. So that he can he can play the sports, play golf comfortably. That was his why for having his hip replaced. Now we got him going on a Mediterranean diet, we optimized his weight, at least initially, gave him the tools to continue that on with fresh healthy food afterwards, he was working with the physical therapist strengthening his aerobic capacity. So we've got the nutrition piece, the physical conditioning piece, and then the behavioral wellness piece all rolled into one.
Mary Louder:What was his age, if I might ask?
Scott Russo, MD:He was seventy-two, if I recollect accurately. Pretty strong--what's that?
Mary Louder:Because he pretty active before he needed his hip? I mean-- Yeah. Yeah. So you mentioned with him the why. And
Scott Russo, MD:Very active. you had mentioned that in the lecture, understanding the why of the patient. So when a patient understands their why, when I understand their why I can guide them, when they understand the why they can guide themself. And it's about personal leadership. I mean, it really is, and personal responsibility. So when a patient knows their why everything else follows. If they know that to get a spine fusion, they're going to have to quit get off tobacco. And they know that they want to have a spine fusion so they can go out and play golf or pickleball or one of those things, or walk their daughter down the aisle, when they know that, then quitting tobacco becomes easy because they know the outcome will be much, much higher likelihood of having a great success. They'll eat healthy. They'll lose their weight. So that's the why is what drives all behavior. The purpose.
Mary Louder:It's interesting because we see you I see patients in a chronic fashion, you know years, you might have them in your primary care, and getting them to understand personal responsibility, getting them to understand that they have choices versus, Well, this is just what the doctor told me to do. I think, and I feel that that's kind of a generational thing, where the older generation, the front end of the baby boomers, who we, kind of go there, tend to be a little more paternalistic in their approach to medicine, sometimes just do what the physicians say. And the younger boomers, you know, Gen Z, Xers, those millennials, they like questioning a lot of things. And so the personal responsibility, then fits in there, but have you run into that where maybe patients didn't really want to pick up that sense of personal responsibility?
Scott Russo, MD:All the time. Unfortunately, it's a it's endemic in our society, that patients want to either say, you know, I'll try it. In, you know, I will say, if you say, you're gonna try something, you're--it gives you an out, right? You know, historically, you know, when when nations conquer other nations, they burn the boats, because there's no going back. Right? When they land on a shore, our patients, our patients don't want to burn the boats. They always want to say, you know, I try, see, I couldn't do it, but I tried. I'd say it's not acceptable. Acceptable is, I'll tell you what's best medically based on the literature for you, but it's up to you to embrace it. And for us to have a conversation and me to support you, as you go on this journey.
Mary Louder:Yeah. Yes, I think I think that that's really important because, you know, ethically, that's correct, you're making medical decisions, you're providing your guidance as a professional, as a physician, as a specialist. And then the patients can choose, that's their autonomy, but that's also their informed consent. And that is their, you know, right to do that
Scott Russo, MD:is true. But I also choose to take care of them in the operating room when they're asleep. And they could have a catastrophic event. And if they're not prepared, they could have a heart attack on the table, they could die on the table. Every time I operate on somebody, I assume the responsibility for their life. And I don't take that responsibility lightly. Because there's a family member waiting out there. And so it's important for patients to assume as much responsibility for their life as I do as a surgeon.
Mary Louder:Yes. I think that I think that's actually an excellent point. I think sometimes patients think and we sometimes as physicians think things are so routine, but each time that, you know, a patient goes under anaesthetic, they truly, their life is in your hands.
Scott Russo, MD:That is correct.
Mary Louder:Yes. That that was never lost on me, when I did my surgical training, I'll tell you what, that was always kind of up there. I had conversations with patients often before I you know, assisted and, and, you know, just touch base with them when they were under anaesthetic. And, for me, participating that way as a physician was very meaningful, because I knew you know, as as it is, in the operating room, you've got that screen where their head is up by the anesthesia. And then below that, where everything is draped and sterile and doesn't look like a patient, it looks like a procedure down there.
Scott Russo, MD:And that's, yeah, it's true. And that's where you have to be. Your head has to be on the procedure. You're not worried about that, because the anesthesiologist is fortunately taking care of that. Things are routine, until they're not routine anymore. And then it's a problem. So our goal with prehabilitation is to make sure that things will stay routine in the operating room, and that their recovery will be routine in the operating room. But even more important, Mary, is the concept of the potential changes that giving these patients all these skills in advance--should they embrace them? Will they carry them on after the surgery to live their best life? And that's--so you learn your way up front, you get these tools, and then downstream, the health care system benefits greatly by the patient's changing behaviors so that they're fueling their car the best thing their body, exercising regularly and having a positive mental attitude really celebrating their life, their--and their newfound successes from surgery.
Mary Louder:Yeah, I think that's an excellent point because a lot of patients have a perception that they want to get back to what they were doing but actually what you're promoting is going beyond where they were.
Scott Russo, MD:Going beyond.
Mary Louder:Yep, and optimizing. So using that surgical intervention as a chance to optimize their health and their life and impact that, you know, in, in many, many, on many levels.
Scott Russo, MD:In ways that they can not even imagine. And I understand that the family physician, the surgeons don't have the time to do that. But if a program like ours is able to introduce that mindset, and it's reinforced by the dietician, by the physical therapist, and the--and the prehab physician, that supports everything that the primary care doctor has been trying to do for a lifetime with the patient, and the surgeons trying to do in this short window of time with the patient.
Mary Louder:Yeah. What have you seen, and what has been your experience with reimbursement for a program such like this?
Scott Russo, MD:So we're early in our development. And so we're, you know, communicating with the insurance companies. I'm not entirely certain how this will play out with various insurance companies. So that that is yet to be determined. I think there's there's going to be great value in it appropriate and from long term savings. I think the literature shows that, and I is my hope that the insurance companies will see the value of this, embrace it, and allow us to move forward and start changing the lives of the patients that they insure.
Mary Louder:Yeah. Yeah, it's, it's an interesting time, and it's a different topic, but we, one of the things that is really important, and the area I'm going to go to in future podcasts has to do with who's controlling the purse strings, who's getting paid, who's actually paying for health care. And you know, we have a lot of people functionally uninsured in our nation, who, you know, could really benefit from things that are just typically not reimbursable. And just how that whole structure really needs to evolve, to be honest.
Scott Russo, MD:I think the idea of having skin in the game too, so you are investing a little bit of your own money in your own health. And our goal is to, as we roll out our program, our goal is to figure out what's the most appropriately cost effective manner to deliver this to the healthcare system, to patients and in general in that respect. So it's yet to be seen, but and maybe it's, maybe it's optimistic, but I'm, I'm an optimist. So I believe that there is, there's ways to do this.
Mary Louder:Yeah, I and I actually think that people who are positive disruptors, such as yourself and myself, you know, we've got to act on what we really truly believe and how we, you know, really, really want to care for patients. We have to.
Scott Russo, MD:Absolutely, yeah, gotta forge ahead.
Mary Louder:Okay, um, a couple more questions here, I've got for you, this is a great conversation. So in your mind when you're looking at prehabilitation, what's the keys that makes the patient at higher risk for surgery?
Scott Russo, MD:Well, certainly, when we look at risk factors we look in at, do they have cardiovascular disease? Do they have pulmonary disease? What's your level of physical conditioning? We're looking at their nutritional status, are they living with obesity? And you know, people that are overweight or obese, they know they are. So we're not here to criticize. We're here to support, be an accountability manager for them to support them in that journey. But we know that if we can get them down micro goals, small steps, help them start to lose weight, get them on a plant-based, appropriate Mediterranean diet. And with some fish, poultry, maybe a little bit of red meat depends on what they like, we can, we can start to tailor that down. If they're diabetic, and their hemoglobin A1C is out of control, then we want to optimize that. So that's where we communicate back with the primary care doctor and the patient saying, Look, you're--you gotta be accountable for this, we've got to stay really strict to your diet. If they're, they're running high blood glucose, we got to work on that, if they're a tobacco user, absolutely got to get off of that. I mean, it messes up their pain receptors and everything, and it really hurts their lungs, their blood vessels. If they're, if they're using alcohol in a significant manner, anywhere from three to five drinks a day, we know that we need to get them cut down on that significantly, because that's hurting their liver, their clotting studies, how they process their food, there's their lining of their stomach and their GI tract. So we know that we have to do that. So those are the factors and if there's living with depression or anxiety, we're not here to, to treat depression. We're not here to treat anxiety. We're here to give tools to, to help them deal with those emotional states when they're--when they're going into surgery. But if it's interfering, then we engage the appropriate consultants in that area too, working with primary care. And their primary care doctors usually know their patients so well that they already have that engaged. So we're just giving them tools to handle. So mindfulness training, positivity training, we teach them how to visualize coming into the hospital. So they see themselves coming into the hospital, they've already done it in their mind, before they ever get there on the day of surgery, and they see a successful outcome. We're already planning for that.
Mary Louder:Yes. I teach my patients that. I teach them to, you know, whatever their belief system is, to tap into that. So whether it's angels, or ancestors, or spirit animals, whatever they, you know, really where their beliefs come from, and what supports them, and look at every aspect all the way from who greets them at the hospital, when they register, getting ready for the surgery, going into the surgical suite, the surgeon, the team, everything all the way through recovery. And every step, really all the pieces falling into place.
Scott Russo, MD:Can you share how your patients have have dealt with this? And how what the benefits they found from this?
Mary Louder:Yeah, it--the biggest thing that they share is that first that they've been seen and heard by someone that they actually have a fear and apprehension about going,
Scott Russo, MD:How important is that?
Mary Louder:Huge, huge. And because there's a lot of things we can't fix or adjust, but to know that someone's with you. And it's very vulnerable, to open up your emotions and not have control over the outcome of what someone's going to do with them.
Scott Russo, MD:That's, that's very concerning, isn't it for patients.
Mary Louder:And so then you're giving over your control to go into a hospital, you're giving over your control to lose your consciousness, you're giving over your control, to lose control over your bodily functions, all the way down to breathing. It's an exquisitely vulnerable position to be in.
Scott Russo, MD:You're stripped naked, aren't you? In so many different ways? Yes.
Mary Louder:And it's, there isn't one thing they give you that's warm. Rarely.
Scott Russo, MD:Rarely.
Mary Louder:This, you know, and anything from, you know, also disinfecting yourself the night before, the day before, the day of surgery, all the things that you do now to go in to get ready for a surgery. So that by itself is overwhelming, but it's just, it can be dehumanizing if it's just done in a procedural way. Well, this is what you do. This is what you do. And so for patients to--for me to ask them how they feel about that, where do they feel they have questions? Where do they feel they just feel uncertain? And so, listening to them. And that takes, it could take 15-20 minutes. But it changes their approach and their comfort because I can encourage them to also ask questions. And then they feel that, because they've asked me questions, I say, well, you're asking me, I'm no different than the person who's going to be helping you. Just a different role. So feel just as comfortable. So that has changed a lot of outcomes, just helping to waylay the fears and the the uncertainty, because where there's uncertainty and lack of control anxiety just goes off the chart.
Scott Russo, MD:That is the truest statement anybody could say.
Mary Louder:Yeah, yeah. And then just really, really, you know, letting them know that, that by and large, everything is going to go really well. Because it typically does.
Scott Russo, MD:Yes, that is correct.
Mary Louder:And so, and then just really paying attention to what their feelings are. And as long as--I always encourage people, as long as they acknowledge and understand what their feelings are, typically, we can describe three feelings, you know, happy, sad and angry. But as we increase our language to understand and identify our feelings and emotions, that helps us connect with ourselves more and with each other. So you could be feeling anxious, you could be feeling unsettled. Those could be different words than scared or overwhelmed. So defining that and being a little more nuanced helps a patient understand by opening up their experience a little bit more.
Scott Russo, MD:I would agree totally. I think that having that conversation, and maybe having teaching patients how to have a conversation with their loved ones, and loved ones with the patient, because there's a lot of anxiety that goes back and forth at home that I think as caregivers we don't see as clinicians. Patients are like this, and, you know, it's really important for them to learn how to talk too.
Mary Louder:Yes, yeah, and I think I think that that's just really important. The, I think the mindset and the resiliency, because coming into alignment with how the body heals, I mean, the body knows how to heal, we cut ourself and we don't sit there and why can't, can't come out today because I got to sit around, watch my finger heal, we just have to get this skin together, maybe get it clean, and we go about our day, because the body inherently knows what to do. Right?
Scott Russo, MD:That is true.
Mary Louder:And so then, I think at a bigger level, the same thing, whether it's healing from an orthopedic surgery, a fracture, a spine surgery, the fusion the body picks up, and we put it in a position to know what to do, even after traumatizing it.
Scott Russo, MD:That's correct.
Mary Louder:So I think the key to the optimization, the nutrition, the mindset, and you know, all of the teamwork is something that is, is reminding the patient that the body has the body's got this, they can do it. You know, and it also takes energy to heal. You know, someone said well, I have to do all this resting, I don't you know, I'm going to be bored. I'm like, well, you're actually not really, I mean, you're resting, but you're actually healing. It takes a fair bit of energy to heal.
Scott Russo, MD:It does. And that's the purpose of physical conditioning, though. So what we don't want to do is take somebody who's already frail, put them through a big operation, and then they start to heal, but what they do is they start breaking down their muscle to heal. Right? And so what we want to do is fill the nutritional stores up for surgery, build up the muscle stores, so that they have all the necessary substrate and necessary ingredients, so to speak, to form a great healing experience after surgery.
Mary Louder:Yes. So, in your mind, what do you think is the ideal timeframe for the prehabilitation process to take place?
Scott Russo, MD:I think the literature supports, ideally, probably six to eight weeks before surgery.
Mary Louder:Okay.
Scott Russo, MD:And so the, it's not just surgery, though, these are patients who, let's say, a person comes in the hospital with a femur fracture, right, they weren't planning on having an injury, but they have a femur fracture, they go through surgery, just like I had my illness, right, and they're discharged home, this process can work for those patients after discharge. They're not sick enough to go to a rehab facility. But they're gonna go home, but they don't have a way forward, they don't have anybody guiding them down the path. We can be that that group, that team to guide them down the path, we can support primary care, support the surgeon that did their surgery, but also, more importantly, give the support to the patients to nutritionally get better, physically get better and mentally, really thrive going forward, really put some some support to the situation for them. Or if it's somebody who's just living with a chronic illness, right there, they're living with obesity, this same process can be used with patients with chronic illness. So there isn't, one piece is not more important than the other. All three pieces, integrated patient focused care, is what it's about.
Mary Louder:Yeah. So it's different than just a pill for every ill.
Scott Russo, MD:Oh, for sure. This is this is not, this is not about--medications have their place. They're just a tool in the toolbox. This is about identifying what the patient's needs are, what resources they have or don't have, how we can support primary care in helping their patient get back to their best life.
Mary Louder:Yeah. And different than a supplement for every symptom. Because we've got folks who, you know, I don't want medications, but I'll take a supplement.
Scott Russo, MD:Right? There's a place for supplements, no question about it. You know, and--but we always want to power the body with healthy fuel, fill in the gaps with the supplements, right? And then just use the other tools, get their mind in place, and then start training their body, getting them back into shape. And they may never have been in shape, right, they could have suffered an injury or illness or go into surgery and never really have been in shape in their life. Like you said, they expect the physicians to do it, but the reality is, they have to be the driver of the process.
Mary Louder:Right. So there's a lot here and unpacking this where I could see this really comes in needing a lot of reworking and change with our healthcare system.
Scott Russo, MD:Yeah, no question about it. We're, there are a lot of opportunities for our healthcare system here. And I think this is probably the most sustainable aspect of it, and it's probably the most challenging and difficult aspect of it is going past freewill and saying, Okay, you do have free will. But I'm going to ask you to redirect your freewill towards a different path towards life. Yeah. And lifestyle medicine applied to, to certain pre-surgical preparation and hopefully extending past the surgical experience. So leveraging the surgical experience to provide an excellent--a path towards future health.
Mary Louder:Yeah, I see that too, as the surgical experience being just another entree to be able to access the patient for change. Correct. And I think that that's really important because, you know, it's not just--we've often left the the prevention only to primary care. And it does wear a primary care physician out, I'll raise my hand as one in the room, when patients, you know, you're going around the same conversation time and time again. So it is good to see more of a team approach, it is good to see, you know, surgery being an optimal opportunity for lifestyle change.
Scott Russo, MD:I think it is such a unique, unique situation that it needs to be leveraged, it needs to be growing that whole mindset of that, and I think this, we're at a crossroads right now, with, with expenses going up, and illness going up and population going up that we have to make a decision. As individuals we're responsible to have control of our lives. And the healthcare system has to provide the tools to achieve that. That's how I look at it.
Mary Louder:Yes, I think that's great. I agree fully, I think, I think we could have hours more of conversation.
Scott Russo, MD:I would, I would welcome that.
Mary Louder:So I think it may be good to come back with some patient stories, some things more that's been looked at as we--as you go down this path furthermore. I'd like to, you know, revisit things down the road from now.
Scott Russo, MD:I would welcome that very much.
Mary Louder:So, today, I think really, I appreciate, Scott, your approach, I say, I appreciate you as a--as a physician, as a healer, as a community member. And, you know, not many surgeons pick up on this, and I appreciate that you're really leading, leading this and I'm really thankful as a primary care physician to connect this way because it's it's been in my heart and in my drive as a--as a primary care physician to care for the whole patient. And that's really what you're talking about.
Scott Russo, MD:I am. I think that I've always celebrated the my relationship with primary care practitioners in so many different ways. Physicians, advanced practice providers do such a lion's share of the care in the hospital, outside the hospital. So I'm very grateful for the opportunity to share my story and to share my--what is becoming a very deep passion, and hopefully a movement to change how healthcare is delivered. I know there are a lot of people out there that think along these lines and I just want to try to be the catalyst for this process. And catalyst for, and speak for patients, and in fact, hold patients accountable for you know, being responsible for their health, but helping them see what the future can hold that's so much different than their past. And their present.
Mary Louder:Yeah. Well, thank you for being a part of our podcast. The title of our podcast is Since You Put It That Way. So you since you've put it that way, we will continue the conversation down down the road and thank you again for being with us today.
Scott Russo, MD:Thank you for having me, Mary. I appreciate that so much.
