The Medical Term You Need to Know: Understanding Salutogenesis with David Rakel, MD

[00:00:00] Dr. David Rakel: We have a whole healthcare system that does that, that says to your pathos, to your disease and suffering. And that's what we pay for. That's what we reward. So really what we're talking about here is shifting the intent to to your health instead of to your disease and suffering.

[00:00:17] Dr. Melinda Ring: This is Next Level Health.I'm your host, Dr. Melinda Ring, director of the Osher Center for Integrative Health at Northwestern University. On this show, we explore ways to take actionable steps towards optimizing our health with leaders in the integrative, functional, and lifestyle medicine fields who believe in science-backed and time-tested approaches to wellbeing. Let's take your health to the next level. Today we're diving into a fascinating approach to health that shifts our focus. From fighting disease to building wellbeing. My guest, Dr. David Rakel, is a true pioneer in integrative medicine and a passionate advocate for an emerging science called Salutogenesis. And if you've never heard that word before, don't worry, you are in for a mind-expanding conversation on how we can reimagine healthcare for the better. Dave has a long list of credentials. He's the founder and former director of the University of Wisconsin Integrative Medicine Program. Editor of Integrative Medicines, really the essential textbook of our fields, and he currently serves as the Esther Millard Endowed Professor and chair of the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health. But beyond that, he is someone who truly lives this work, and he has always pushed for just this major shift in how we think about health. So. Today we'll explore Saludo Genesis re reducing healthcare costs. What might, you know, what its role might be in cultivating resilience and shifting our medical model from reactive to proactive. So let's get started. Dave, welcome to Next Level Health.

[00:02:06] Dr. David Rakel: Thanks, Mel.

[00:02:07] Dr. Melinda Ring: I'd love to step back and talk about you. You've dedicated much of your career to integrative health at the University of Wisconsin. But I understand that your journey started far from academia back in rural Idaho, I think. Yeah. So could we rewind to the 1990s and Driggs, Idaho? Because I heard there was some defining moment for you that sparked your interest in the field.

[00:02:34] Dr. David Rakel: There was, yeah. 1994, if we wanna take a little trip back in time, you know, at that time  if there was one doctor that was needed to be trained to take care of a community and an isolated area, like a deserted island, I wanted to be that doctor. So I really went and got training and as many procedures as I could do so I could go out and serve a rural community. And I. When we were done with residency, I, my wife and I opened up the atlas and we saw this place called Driggs, Idaho, and it's at the base of the Teton Mountains, one of the most beautiful places in the world, and of course at a 12 bed hospital.And they were looking for a doctor 'cause there was one, one there. And, uh, he was, he was needing a partner. And the beauty of going and working in a rural area is everybody knows each other. That's the going joke in our town was you didn't need to use the blinker in your car 'cause everybody already knew where you were going. And when you're invited into a community like that and you hear people's stories, it gives you so much beautiful insight into what's at the root of a symptom and, and that. I could tell you some stories of what really encouraged me to look beyond my traditional Western medical training and realizing I needed to learn more.  I'll tell you a couple stories that really got me interested in wanting to learn more. One was my neighbor, actually, he had a severe stroke and uh, he. Such a severe stroke. His life expectancy was like a week, but that stroke attacked his phrenic nerve and he had these intractable hiccups to where he couldn't rest. He couldn't spend quality time with his loved ones 'cause he had these hiccups. So my western training, I gave him Haldol and Thorazine and all these really powerful drugs to try and get his hiccups to go away so he could die at peace with his family. And I tried everything. I supported the soft palate with a spoon. I did all the wives' tales to try and get his hiccups to go away, and then the family said, how about acupuncture? I kind of giggled and I said, Thorazine isn't working. I'm, I don't think acupuncture's gonna work. After one session, his hiccups went away from acupuncture, and he was able to die with his conscious presence without the sedation. With his loving family around him. And after I experienced that, I said, boy, I got so much more to learn. The other really big aha moment was the importance of listening to the context of people's lives, and I. One of my favorite quotes by Henry Mosley is the sorrow that has no vent in tears may make our organs weep. And when you really are part of a small community and you know people's stories, you start to realize how important that is and that Prozac at the time. What I thought was my most powerful medicine. Now I realize it's the process of caring and really understanding what people need to express and what we need to listen to and help them move through to a better outcome. So those were two aha moments that I had that said, boy, I. I need to learn more. And then at that time, Andrew Weil was writing books and I was reading 'em, and then he, I realized he had a fellowship. And so that led to applying to that fellowship. And then after five years, being a rural doctor, I went to the University of Arizona to start that fellowship.

[00:06:00] Dr. Melinda Ring: You know, both of us are in these academic institutions where, and the trend is like, you know, yeah, you have your primary, but you see all these different specialists for every different part of your body, right. And which I think is one of the things that both doctors and certainly patients are really frustrated with, like that nobody sees them as a whole anymore.

[00:06:24] Dr. David Rakel: Yeah. That's kind of the expectation of our culture is if I know more and more about less and less, I get more respect and that I. There's actually, I would, I'm biased, obviously, but having that breadth of context and knowing the biopsychosocial spiritual aspect of another human being I believe is also very important. That no dichotomy there. There's a yes and, but what is, what do we value? What do we value? We value that pathogenesis. We value the expert in the acute and catastrophic rescue. I think healthcare is needing this more super generalist, comprehensiveness lens, and I think with ai, all of the artificial intelligence. We're gonna need more humanism and people are gonna be asking for more humanism to really understand what's the authentic needs of a complex story.

[00:07:20] Dr. Melinda Ring: So I practice as a consult physician. You know, I'm the integrative medicine doc, and versus you have a dual model at the University of Wisconsin where there's both consult physicians and there's primary care that in incorporate integrative medicine into their care. And we have primary care like that too, at Northwestern who does that. But do you feel like that idea of an integrative specialist, integrative medicine specialist is almost counter into, you know, counter the, what we're trying to achieve in the field?

[00:07:57] Dr. David Rakel: You know, I'm gonna say I no. Okay. Because, you know, I mean the whole idea at the beginning of the whole labeling this field was to one day we get to a point where we don't need that label. We, that this just becomes good medicine. So. Um, when I came to be the chair of this department, I had to give something up. I no longer did consults, but I did wanna give up primary care because I think that broader training really helps us be a better primary care clinician. That first point of contact, really what we're wanting to do is bring the integrative functional medicine ideas to the forefront. So that's what we start with. So we need less things down the road and. Then we go more upstream into the precursors of where the disease starts, so we can really honor the tremendous wisdom of every human being to self-heal. And that's the art that we're talking about. So I love being a primary care doctor. My friends pay me money to be their friend. I mean, it's the best job in the world, and I get see them. I get to grow old with them, and it's just such a privilege to do this work.

[00:09:09] Dr. Melinda Ring: It is a privilege. So let's now turn back to that idea of Salutogenesis. Which is a term that I first learned about in one of your lectures years ago, and it immediately resonated with me. And I know you've called it one of your favorite words. So. Let's start with the basics. Like where did this term come from? What was the context in, or it arose like, and you know, sure. How is it applicable today?

[00:09:37] Dr. David Rakel: Yeah. Well, the first thing I like to do is I'm gonna toast you, Mel. So if I had a glass of water here, or a beverage of any type and I wanted to toast, Mel, what would I say? I would say salute, right? Salute to your health. Mel, I  wish you the most best health possible in your life? I wouldn't say pathos to Mel, right? Pathos means to your disease and suffering. I don't wanna wish that on to you, but we have a whole healthcare system that does that, that says to your pathos, to your disease and suffering. And that's what we pay for. That's what we reward. So really what we're talking about here is shifting the intent to, to your health. Instead of to your disease and suffering. And, uh, Aaron Antonovsky was, uh, the American Israeli, uh, researcher, social scientist who coined this term back in, uh, the 1950s. And he studied survivors, female survivors from Jewish concentration camps in World War two. And I'm gonna paraphrase, but he said, if life is this turbulent stream. Where there's rocks and rapids and, and dangers. What helps a human being swim well? What helps a human being swim well? And that was his research question. How do we really create this state of coherence where every human being has the best potential to heal and support healthy outcomes based on their context and their unique situation? So it's a really simple thing. If I look at, sorry, Mel, you're the one in front of me. So if I look at Mel, this human being and I look at you as what's right with you or what's wrong with you, you know, we've heard that mantra multiple times. Number one, you're the same human being, but how I look upon you as potentially healthy with this dynamic potential of a beautiful human being who has these resources or what's your strengths instead of what's your weaknesses? That I believe is a more rewarding, more effective way to look upon humans versus what's wrong with you? What's your differential diagnosis? In my Epic medical record, I have the 25 list of problems for you, your problem list. But how do we maybe put, and we've done that here, how do we put your goals, your health goals, at the top of that list so everybody sees what you want, what your goals are for your health, for your. Your personal health outcome. So I, same person, same health system, but how we look upon people, we shift from a pathogenic, acute and catastrophic care model to a salutogenic, what do you need to be healthy? So you need less things. And that's, that's really the financial model that we're trying to figure out. We have a 4.9. I always have to add this every year. Three years, it's, it keeps going up 7 trillion. Right now it's $4.9 trillion that really has the worst health outcomes of any of the industrialized countries. The WHO rates us 36 in the world, uh, for the most by far double as much of any other country for how much we spend in healthcare, which is really how much we spend in disease care. So when we just. Stop and wait for disease to occur without looking upstream. This is what we get. But we've created such so many rewards of such an economic model. No one wants to change, right? Because it's created this power of finance that, that we've created that doesn't give us the outcomes that we want for our communities, for our families, and for each other.

[00:13:19] Dr. Melinda Ring: When you were talking about that shift from the disease to health, uh. Brought to mind to me. For me, this idea of like, oh, it's like cognitive behavioral therapy, but for the healthcare system, exactly where we have to learn, we have to teach the, it's a train. Maybe we just need to put everybody through some CBT.

[00:13:43] Dr. David Rakel: We do, we need some, some, some therapy. We for sure, sure, we need some therapy to, right? You never would've designed a a, a system this way. It's not healthier and it's not a system, right? So how could we design a system for the health outcomes that we want? And that's our opportunity. That's this value-based care that's really excited to have our health system balance out.

[00:14:07] Dr. Melinda Ring: You have a track record of. Helping with successful shifts in healthcare systems, whether, you know, I know you were a big part of the whole health system in the Veterans Health Administration. We had Tracy Godda on the show to talk about the whole health evolution as well as Ben Klier. Uh, you were at University of New Mexico chair in their department. Now you're chairing Wisconsin, so you've been in many different settings. What are some of the lessons that you've taken from all of those different experiences that we should apply to this new effort to bring, not new but really necessary effort to bring Salu Agenesis to the US healthcare system? 

[00:14:55] Dr. David Rakel: I enjoy listening to Tracy and Ben, both who I worked with educate about this model, which is a beautiful model, right? It's the VA health system. The largest health system in America is like a little Norway. Everybody has access and we have combined, uh, populations to help us really research how to facilitate, um, that, uh, economic models, uh, that we want together. So generally, if you wanna make change, uh, you have to pay for it. And that's probably the quickest way to see how. Um, we're gonna make positive change down the road. And, and Ken Wilbury I think said, if you try and shift the belief system of a human being beyond 5% at any one time, they'll go insane. It's just too much. So we have to do this somewhat gradually, right? If we take a whole pathogenic system and try and make it salutogenic overnight, people are gonna be upset 'cause it's just. Too quickly. So we do have to go in this incremental process, and I think the VA is a beautiful example of, of moving ahead and really showing how we can do this. Because the pharmaceutical costs went down, the inappropriate opioid prescribing went down quality metrics with diabetes and hypertension management. When. Up. So that's a wonderful laboratory that's out front to show the rest of us how we can do this. And then we have all these other financial models of Oak Street Medical that was bought out by CVS for $10 billion or something like that. And what were they? They were a value-based. Geriatric group that actually showed how they can reduce hospitalizations and emergency room visits for that population. So that's the economic science that we need to really say, okay, how do we shift from that reactive model to the proactive model? And that's exciting, but we have to go. At a good pace, but we have to get started and, and actually do it. Which, you know, when money gets tight, people always go back to the old way that keeps us stuck in that system. It's always, okay, what makes money? Okay? I need more neurosurgery. How do I get more neurosurgery cases to my hospital? And we can't keep thinking that way. We have to look farther upstream

[00:17:18] Dr. Melinda Ring: For some people who may not. Know what the term means. Are you comfortable describing what value-based care means as opposed to the traditional model?

[00:17:27] Dr. David Rakel: Yeah, the traditional model we call the RVU model, which is, I get paid for taking care of hypertension, right? So the more hypertension I see, the more I get paid. The value-based model is really focusing on three things. How do I improve patient outcomes at a lower cost with a better patient experience? So what does the patient want and how can I give it to 'em at a lower, more efficient cost? So generally, if you wanna make money in an RVU, find it, fix it, capitalistic healthcare system, create more fear. Fear drives things. Fear makes us order more MRIs, do more tests, uh, refer maybe inappropriately to multiple specialists if I don't understand the person who's telling this story. So William Moler said it's much more important to know what type of person has a disease than what disease a person has. So we really have to get out of that fear-based model. And the best way to do that is to have. A kind physician such as you, Mel, and your team who knows you over time, and that reduces fear. It brings us more into common sense and it. Hey, you know, maybe I'll give this a little bit more time to resolve before we do all these things and that we call that the primary care ICU will see you next month, right? We'll give this, we'll give this a month of time to resolve, and then you'll come back to someone who knows you, who hopefully you trust, and then we'll go from there instead of basing healthcare and fear, which makes us do a lot of things. A recent statistic that I think really tells this story, and Salutogenic science wants less drugs, wants less supplements, wants less things, really. Some of those foundational elements that were taught in whole Health mind, body nutrition movement, those basic things, if we can do more of those, health is much more about what we do than what we take. 36% of Americans over age 60 or on five drugs or more, that's a definition of polypharmacy being on five drugs or more. So. What we're trying to do is create a science to reduce the number of needed drugs, because once we get people on that many drugs, they start to have interactions that we just don't know about, and we start to see downward harm when we actually have to incorporate more things to the human body to maintain its function over time. So. There's all sorts of opportunities to improve value, but when people are fear, they go back to what's worked in the past and what's worked in the past has resulted in that $4.9 trillion healthcare system that doesn't produce the outcomes that we want.

[00:20:10] Dr. Melinda Ring: A lot of that fear started when malpractice suits started to really become Yeah,

[00:20:15] Dr. David Rakel: That's right. A problem.

[00:20:16] Dr. Melinda Ring: In like the nineties and beyond, you know, in the, that sort of era where it was like, now all of a sudden doctors in healthcare systems were. Scared of being sued. And so they're like, well, now I'm gonna start ordering all of these tests, even though normally I wouldn't have. And now then it just escalated from there. We never got out of that. Right,

[00:20:37] Dr. David Rakel: Exactly.

[00:20:37] Dr. Melinda Ring: And also when you said that polypharmacy, including things like supplements, I think that's a really important point because I know you are. Also an educator for places like the Institute for Functional Medicine, and you know, you've done, you do functional medicine, you do medicine, you do bio, you know, you're putting it, you're really putting it all together. But when, so what's your feeling about yhe role of like functional medicine tests to get to the root cause of, you know, supplements instead of medications and Yeah. You know, like that versus like you said, MINDBODY meditation community.

[00:21:21] Dr. David Rakel: Yes. Thanks for asking. This is something I feel strongly about, um, because when you go into these different systems, you can see that not everybody, you know, I think the tenants, the philosophy of integrative medicine, functional medicine are beautiful 'cause it really encourages us to look upstream to address the problems before they become problems. Just like in western medicine where we do tests and then we prescribe a lot of drugs. There's a continuation of that practice in integrative and functional medicine where we just match a supplement to a beautiful multicolored test that tells me how unique I am. Actually, if I was gonna create a placebo tool, I would use one of those tests to use. To really prescribe placebo and look at the outcomes, and they would be damn good because we're creating a therapeutic ceremony to show, Hey, you're unique and this is how I'm gonna direct your uniqueness. That helps you transcend your suffering. That's creating a healing ceremony or a healing environment where it doesn't really matter what you prescribe after that, that you can create a ceremony to really facilitate healing. So that's salutogenic science. How do we do that without deception? How do we facilitate that ceremony? So I set someone up for those self-healing mechanisms, so I don't need to prescribe more things. So I see a little slippage back into the traditional Western model where we just, if we find ourselves just matching a supplement to a, a test. Then we have to pause and look and say, is this really shifting healthcare delivery in a way that we need to do together to really improve the health and health outcomes of our communities and our neighbors?

[00:23:06] Dr. Melinda Ring: Right? It's just, in a way, can be like swapping a comprehensive microbiome stool analysis for an MRI. I'll still use some of those functional medicine tests, but, uh, but to your point, oftentimes when I'm using them, it's. There I wouldn't, I don't know if I would call it a placebo effect, but it's, there is something when, like you said, like a, when a patient sees something on a piece of paper, then all of a sudden it's, it, it deserves their attention. And so I think, for example, many people feel like, you know, if a doctor tells them, oh, it's stress that's causing your stomach aches or it's stress that's causing your fatigue, they feel sometimes like. The provider is telling them like, oh, it's all in your head. Yeah. Which is not really what they're saying. They're like, no, stress has a real physiologic effect on every part of our body. And so for some people seeing on their a piece of paper like, oh, my cortisol is off, makes them feel like, oh, actually stress is really affecting me. And then they're willing to then engage in the meditative practices and peel back. So I dunno if I call as much as like. I don't know. Confirmation, not confirmation bias. Something. There's something going on there.

[00:24:25] Dr. David Rakel: No, I love how you frame that. No, it's really activating the healing response and I, I don't like that term either. Placebo. What we're doing is through conscious intent, facilitating a process where you move to a healthier place. Some might call that placebo. I like to call it activating healing response without deception. Tracy Godde, uh, uses that term as well, and I learned that from her, and I, I really like it. And that's also a reason why in the Integrated medicine text that you're an author in, uh, we use the evidence versus harm icon. So we look at the, the quality of evidence for benefits. So A, B, and C. A is meta-analysis, B is good human studies, C is expert opinion. And then we compare that to the weight of harm. One is there's almost no harm like eating broccoli. Two is reversible harm, like side effects from a medication. And three is a potential for irreversible harm, like major cardiac surgery that you could die from. And then we balance those together and we have an arrow that drives up or down. So generally a Mediterranean diet. Great evidence for benefit. Right, right. Very little harm. So that's gonna have a straight up, yeah, a one. Um, uh, supplements. Supplements are gonna have less harm generally than pharmaceuticals, so I think this model brings in the less harm of supplements, even though we might not have as good. Evidence for benefit for many supplements, but so much of what we do, we haven't even studied the process. Cleveland Clinic did some studies with functional medicine, I think were beautiful, but it showed the power of silver buckshot instead of silver bullet, right? Very rarely is there one thing. Sometimes, but rarely is there one thing that is the answer. It's usually multiple things together that have the biggest impact on improving health outcomes, and that's what I love to do as a super generalist primary care doc. Okay, here's the things that I know that will help us get better over time. Let's work on these, we'll follow up, we'll see how it's going, and that's such a cost fic, uh, efficient. Method. Do you know you're, you were a primary care doc before you, you, you went to be a consultant. Uh, if we say a dollar bill is how much we spend on healthcare in America, guess how much of that dollar bill goes towards primary care? This trust. Therapeutic relationship over time that's so effective at reducing costs. Guess how much of that dollar is spent in

[00:27:00] Dr. Melinda Ring: primary care? I, I would guess I would, I would guess a penny, which is now going away, which means it doesn't even exist anymore. 

[00:27:08] Dr. David Rakel: You could tell you're a primary care doctor 'cause it's actually 4.7 tens or a nickel. A nickel. Oh, okay. We still got those. Yeah, yeah, yeah. We still have nickel. Out of all the healthcare spending in America, only a nickel out of every dollar goes towards the most. And National Academy of Science Engineering and Medicine said this, they said primary care is the only aspect of healthcare delivery that improves health outcomes with more equitable outcomes. Uh, and that's the National Academies of Science and Engineering and Medicine. So. We're trying to increase that investment. So we have, you know, Northern European countries have about 35 cents on the dollar. Uh, the, when Rhode Island passed legislation to go from 5 cents to 11 to 12 cents, their return on investment was fivefold by reducing emergency room visits and hospital admissions. So a fivefold return on investment by increasing the investment we spend in primary care. If we just went. By 5 cents more, we would get a fivefold return on investment. So if we went from 5 cent a nickel to a dime, look at the, at the health benefits that we could go by. Just creating, trusting, caring team of humans that you go to for support. You, you remember Cheers the show and Norm went into the barn. Yeah. And everybody said, norm. Norm, yeah. You got it. That's what we need in healthcare. When you go into your clinic and your community. No. You know, think of the power of that. Oh, I'm home, I'm cared for. People know me. Yes. Never underestimate the power of being recognized as a unique human from people who care about you. Probably the most important investment that we can make in healthcare.

[00:28:52] Dr. Melinda Ring: So to the primary care model. I mean, I love that turn of phrase of the ICU. I'll see you in a month, but. People can't get in with primary cares. I mean, I think Mo you know, it can take a year to get in as a new patient into Chicago area. Yeah, yeah. And, and so like a lot of people just go to their urgent care now when they need it, which is the complete opposite of what you're talking about, that relationship. It's, it's, and so when you're talking about the investment in primary care, what is that? Is, is it? Is it is that it's investment making compensation for primary care more equitable compared to specialists so that medical students are more likely to go into it? Is it. Yes. Like what, what does that even mean?

[00:29:47] Dr. David Rakel: It's all of that, right? I mean, it's okay. I, I, I joke with the chair of radiology here at our university 'cause we hired more radiologists and primary care doctors in our health system last year. And you know, why, you know, are we really addressing the needs that we need? And it really helps us understand the difference between transactional care and transformational care. The business of medicine. If you look at Amazon Clinic, you know it has about 60 boxes there. That is a good example of transactional care, like urinary tract infections, simple things. There's even one there for growing your eyelashes. I couldn't believe it. Oh my god. There's a box you could click for longer eyelashes, but is that what we need, you know? The business of medicine is gonna allow for transactional care. It's gonna give people that convenience that they need for the simple things. But again, that artificial intelligence needs to be matched with authentic intelligence. And the authentic intelligence is a unique thing that only humans can provide for one another. So my prediction is that we're gonna get really good at at transactional care, but we're gonna. Expose the need for us to be human more together. And that is gonna require this new investment in humans being human people. I like to call it making space for grace so we can give life to life. And where in that transactional model is there space for grace? You know, we really need to go a little bit deeper, uh, into. That therapeutic cinema, we call it a a, a a state of liminality. That suspension, that Mel, when you go in and see your patient in that exam room, you're in this place of suspension where your interaction creates a dialogue that results in meaning that allows you to fall into a place of health and hearing, and that's a honored ceremony that. Artificial intelligence likely won't be able to do so. This investment is that, and we'll never be able to train enough of Dr. Rings or Dr. Kels to fill that need. So we have to do this through interprofessional teams out in communities. So think about it, you come in depressed in the olden ways. We had the bottleneck of the physician visit where I would just probably just prescribe an SSRI for your depression. But what if someone came and told their story of depression to a kind psychologist or a therapist, and then allowed them to really disclose their suffering to a kind human being? Would we need as much Prozac or sertraline or you name the drug after that? If we started with increasing access to that basic mental health need, that started with the most appropriate professional for that condition, that way. We can never see have a large enough panel to do this. Well, we have to create these interprofessional teams to help us manage and so we can work and learn well and work side by side for our communities. What do you think, Mel? I mean, you have a tremendous insight. This No, no, I think that's,

[00:32:55] Dr. Melinda Ring: No, I agree with that too. And there are these models where there's a mental health professional embedded in primary care clinics. Um, you know, I think same thing with dieticians and. We, but we also need like physical therapists or a chiropractor or somebody to help with the musculoskeletal and, uh, yeah, I, I, and, and health coaches too. The problem we have right now is what you alluded to that RVU model where all of those services are typically not covered by insurance, and so then they are only accessible to the patients who can pay out of pocket or, and even some who do elect not to like. You know, they're the, they just don't see the worth of that investment and think their doctor should be providing all of that care. So yeah, I'm worried about that disparities.

[00:33:45] Dr. David Rakel: Right? Yeah. I mean, you said exactly. Beautifully. Yeah.

[00:33:48] Dr. Melinda Ring: Dave, this has been such a rich conversation and I know listeners, I know I'm walking away. I know listeners are gonna walk away with a new way of thinking about their health, maybe a new way of thinking about their interactions. Either with their patients, if they're practitioners, or ways that they want to be with their doctors, nurse practitioners when they go in for their care. Before we wrap up, I do always like to bring it back to something personal because next level health is about helping people take their wellbeing to the next level. So based on your beautiful wisdom. What's one thing you would like to share to help our listeners reach their next level of health?

[00:34:34] Dr. David Rakel: So, how I see the world gets metabolized through my vision to my brain that stimulates emotions, that actually creates a neuropeptide, a physical, a physical object that then goes throughout my body to trigger a cascade of. Events that can result in health or disease or somewhere in between. So how you see it matters. Now, let me repeat that. How you see it matters. How you see it creates matter is, is what I'm trying to get at, and the whole process of seeing things through a positive lens. Versus a negative lens. And we've seen this in the optimism. Research could add six years to your life, but it also makes life so much more fun when we see the potential healing in another human being, or we see the potential joy and the love and we also really go deep into suffering and sorrow because it happiness is not about being happy all the time, or it's more of a content mindful sense of peace. And once I realized that. I can trigger that by seeing things in a different light, by seeing what's right with people or seeing the potential joy, or if someone's misbehaving, maybe seeing that they had a bad morning or their, maybe their dog of 15 years passed away that morning. Realizing that we all have a context that not only helps me create a soup. I'm an environment that hopefully bays my cells in a stronger, parasympathetic sympathetic balance that results in better achieve immunity. But it also allows me to do this work in a more sustainable way, and I think that's an important thing between empathy and compassion. Empathy means I have to fit you right. I feel your suffering, and then I have to put action to it. Compassion doesn't require that. Compassion means, Hey, it's me and Dave sitting in presence together. We're intimately connected, and when we're intimately connected, we agree to walk to a better place together. That's compassion, where we feel we're two human beings suffering together, co passions, two people suffering together, and we're willing to walk to a better place, and that's actually energizing even when we're dealing with very difficult trauma in someone's life and suffering. Perception that creates those types of neuropeptides and proteins is so much more fun than if we don't. Uh, so I would encourage us all to realize that your perception is your proteins, and it's fascinating that that non-physical thing can become physical just on how we see it.

[00:37:18] Dr. Melinda Ring: Well, thank you for sharing all of your expertise, your passion, your vision for a healthier future.You're always so optimistic, like it just gives me hope for the future. Do you have any, you know, other than your amazing textbook, do you have any other places where people can learn about your work or things that you want us to make sure we share?

[00:37:42] Dr. David Rakel: I don't listen to Mel's podcast. Okay. Thank you though for being alright.Listen to the podcast, to the guys, a wonderful partner through all these years. It's been so much fun learning from you.

[00:37:53] Dr. Melinda Ring: Thank you. And for everyone listening, if you enjoyed today's conversation, don't forget to subscribe. Share it with a friend, leave a review. You can find me on Instagram and LinkedIn at Dr. Melinda Ring and I'd love to know. If the concept of Salu Agenesis resonates with you or some other aha moment you had from today. So until next time, keep taking your health to the next level. Thank you for joining me on this episode of Next Level Health. I hope you found some inspiration and practical insights to enhance your wellness journey. Don't forget to leave a comment on YouTube or review on Apple Podcasts. I'd love to hear your thoughts and suggestions for future topics or speakers. Be sure to follow Next Level Health with me, Dr. Melinda Ring as we continue exploring the path to healthier, happier lives together.