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Scot: Make sure we got a little check-a-roo, testing 1, 2, 3, 4. Troy, how are you doing?

Troy: Testing 1, 2, 3, 4, 5, 6, 7.

Scot: Wow, yeah.

Troy: It's perfect, just . . .

Scot: It is perfect, just beyond perfect.

Troy: . . . beyond.

Scot: Beyond perfect. What we do . . .

Troy: Podcasting excellence.

Scot: What we do goes into realms of perfectness that have never been explored before.

Troy: Yeah, breaking new ground here.

Scot: You know, sleep is such an important part of your health. It's one of the core topics here on the show. And I know, Dr. Madsen, you've struggled with this a lot. Have you ever considered that it is . . . do you think you have, like, difficulty sleeping, or do you have insomnia? I mean, how would you define your sleep issues?

Troy: I mean, I've definitely struggled with sleep, and I think it's probably more shift work disorder. I work in an ER. I switch from days to nights. But I can remember so many nights, 3:00 in the morning, staring at the ceiling and thinking, "I cannot sleep and I have to work at 7 a.m." And it's just the most frustrating feeling. And I think a lot of people out there have had that feeling and had that experience. And maybe it's from shift work or maybe they have insomnia.

Scot: All right, Dr. Kelly Baron is a part of the Sleep Center here at 91Â鶹ÌìÃÀÖ±²¥. She's a clinical psychologist who's specially training in behavioral sleep medicine. Insomnia, how does that differ from just not getting a good night's sleep?

Dr. Baron: So insomnia is defined as difficulty falling asleep staying asleep, or waking up too early. If it's happening at least three times a week and if it's happening for at least three months, it's considered chronic insomnia. And insomnia also has to cause some sort of negative effect on your life or even just frustration over poor sleep. But, you know, you're having awakenings and you feel fine, then that's not insomnia.

Scot: Okay.

Dr. Baron: And so, you know, I would say yours during the shift work, that's kind of a special category. But, you know, you are having it frequently enough that it might flag some interest in intervention.

Scot: So insomnia is just an inability to fall asleep. You really want to but you can't, and it happens two to three times a week.

Dr. Baron: At least three times a week to be considered diagnosable. Certainly, there's sort of more mild forms or that sort of thing. And, you know, lots of people have a couple of nights a month that they have trouble sleeping. But if it's happening at least three times a week, then that's where we would flag it as a disorder.

Scot: All right. So then, can you just improve your sleep health? You know, can you just make sure the room's darker, it's a nice cold temperature? Would that solve insomnia or is insomnia something a little bit more difficult than that?

Dr. Baron: You know, some people have insomnia that's just situational and it'll improve. Like, you know, the first night before starting school or that sort of thing, or going through a stressful time. But what we think happens is that, you know, people start with a predisposition toward having disrupted sleep with stress. And then, usually something kicks it off, a precipitating event. And then what happens is the insomnia gets a life of its own. So it's like the stress over not being able to sleep. People become physiologically stressed out when they go to bed. If you've ever had that feeling where your heart starts pounding when you get into bed or you start to worry.

Scot: Yeah. And you lay down and you're like, "Oh, man. I just dread this because I'm not going to fall asleep. I'm just going to be laying here all night. I don't even know why I'm doing this," that sort of thing.

Troy: Because that's the worst feeling.

Dr. Baron: And that's terrible for sleeping. You can't try to sleep. Sleep just has to happen. And so, what happens is it gets a life of its own. And then people do things that make sense in the short term, like, try to nap or have a little more caffeine. And then, what happens is it makes your sleep worse and it develops this pattern of chronic insomnia. And that's what our treatment addresses, actually, is the stuff that happens once you started sleeping poorly, basically.

Troy: And as your looking at treatment, if someone comes in, like, myself and, you know . . . or someone who's not a shift worker who has a regular schedule and they tell you, "Hey, it's three nights a week at least. I just cannot sleep. I lie there staring at the ceiling, counting sheep, counting numbers, whatever it is to try and fall asleep," what's your first step? Are you looking at medication with these patients or other interventions?

Dr. Baron: Well, I'm a clinical psychologist. So I can't prescribe medication. I'm going to actually end up working with physicians a lot to taper people off of their medication. So the main treatment that we offer for insomnia is called Cognitive Behavioral Therapy for Insomnia or CBT-I. And in the last couple of years, it's gotten a lot of press for how effective it is and it's recognized by the American College of Physicians as the number one treatment for chronic insomnia. It should be a first line.

Scot: Wow. Really?

Troy: And before medication, don't even think about medication. Try CBT-I first.

Dr. Baron: Before medication. Now, I'm not totally anti-medication. You know, there are some people that have tried the CBT-I that didn't improve or some people that prefer that route. And that should be conversation with their physician about the pros and cons. But, you know, these medications, they've got side effects. They're not as effective for all patients. And then not only that, a lot of people prefer a non-drug treatment if they could.

Scot: Is this a form of mindfulness then?

Dr. Baron: Not exactly. So it's a form of cognitive and behavioral treatment. So the main components are sleep restriction, stimulus control, cognitive intervention, so sleep-related worry, and some relaxation training. And so, basically, we're trying to get people on the right schedule for their sleep need. And so we start by changing their schedule and then teaching them some techniques to relax and fall asleep.

Scot: And you can figure out what somebody's ideal sleep schedule is? I mean, does that mean, like, I should be going to bed at 9:00, getting up at 5:00, or I should be going to bed at midnight, getting up at 10:00? Can you tell me that?

Dr. Baron: So the most interesting thing is what we do is we look at their scheduling, look at when they're actually sleeping. And that's really the best way.

Scot: Oh, sure.

Dr. Baron: And then . . .

Scot: Bum da bum bum.

Dr. Baron: You know . . .

Troy: Work with what you got.

Scot: Yeah.

Dr. Baron: Yeah, exactly, like, when you're actually sleeping. And then, basically, we start by reducing the amount of time they're spending in bed. So it's not helping anybody to spend 9 or 10 hours, or even 12 hours in bed and only sleeping 6 hours. That's just giving them all this time to worry and stress. So we reduce that time in bed and help them really feel that drive to sleep. It's kind of, like, the opposite of what they're trying to do and it's very effective.

Scot: Because you can't force yourself to sleep. It just has to happen as you've told us before.

Dr. Baron: Right.

Scot: Yeah.

Troy: So let's say I'm someone who . . . I'm hesitant to admit maybe I've got a problem here. But I think maybe I do and I'm having some struggle with sleep. But it's tough for me to get that motivation to go into a clinic and meet with someone like yourself and go through CBT-I. Are there any online resources or anything like that you might recommend someone try first?

Dr. Baron: So there are plenty of books and online resources. You know, we frequently use some books, like, "The Insomnia Workbook." There's a book called, "Quiet Your Mind and Get to Sleep." It's rather well named. And then there's several different online versions. I'm not sure if all of them are available commercially right now. But there's some online apps. There's CBT-I Coach. There's "Sleepy-O" and "Shut Eye," some good names there.

Troy: I mean, this is great because, you know, for me, just even as an emergency physician, it's not unusual. I see people coming in on multiple medications for anxiety, depression, stuff to help them sleep, all these things. And I'm sure a lot of these medications are necessary. But it's interesting for me to hear from you that the sleep medications really aren't first line, that maybe I can point people towards some of these other options, maybe trying some of these books and reading, and obviously, meeting with you before really going to sleep medications.

Dr. Baron: I think the benefit of meeting with somebody is that you can get a more thorough screen for other sleep disorders. So, certainly, these online programs and the books, I've had a handful of patients pick them up before they came in to see me. And every once in a while, they're cured before they even get in the door, if my waitlist is long enough. But, you know, these also, they take a lot of commitment and, like, actually doing these techniques, like, making yourself stay up later and get up earlier is really hard. You know, oftentimes, you have to do them for a couple of weeks before you see the benefit. And a lot of people give up on them before they've actually had enough time to get better. And so by the time they come to see me, they say, "I've already tried that." Like, the whole getting out of bed when you can' sleep, have you guys tried that one?

Scot: Uh-huh, yeah.

Dr. Baron: And nobody likes doing that.

Scot: No. It's terrible. It's cold out there when you're not under the covers.

Troy: Not good.

Dr. Baron: You'd rather just stay in bed and try to sleep. But actually, that's one of the most effective treatment techniques, is if you're not sleeping, don't stay in bed. Get up. Watch something. You know, read a book. Don't work. You know, don't check your emails. Do something else. Listen to a podcast. And then . . . not this one because this one is very interesting.

Troy: This one will not put you to sleep.

Dr. Baron: And then, you know, they come in, they say they've tried this and it turns out they tried it for a night or two. You know, you have to do this consistently. You've got to get up in the night if you can't sleep and then get up at the same time no matter what. And if you do that for a couple of weeks, you'll see an improvement. But if you do it for two nights, you'll just feel tired for those two days.

Scot: I think that . . . So, you know, you would refer to this as sleep health. I refer to it as sleep hygiene. You corrected me that the new language in sleep is it's sleep health. And I keep drawing this parallel between just health-health. Like, I can't go to the gym and expect that one workout, I'm going to, all of a sudden, feel better, be stronger. And it sounds like sleep is the same thing. I can't expect that I get out of bed and try some of these things once so that it's going to be better. It's going to take a few weeks. It's going to take some time.

Dr. Baron: I really like that. You know, sleep is really all about the pattern. And just because even you have one bad night, just like if you skip a workout or that sort of thing, you just have to get back on track. You know, it's not about perfection. It's about trying to establish these good patterns. And I think the most interesting thing is that I see people who are trying to do everything right, all these sleep hygiene things, no TV, blah, blah, blah, and they still can't sleep and they're like, "Why can't I hack this problem?" And it's because it's not all within your control.

Scot: And I think another health analogy, tell me if this is right or wrong, is, like, sometimes you might need a personal trainer or a health coach to help you through some of these things. It sounds like you're my sleep health coach. Like, you can make it a little bit easier. I could read the books and try do it on my own, and some people are successful. But it's going to be a little bit of an easier path maybe with a professional who'll help me through it.

Dr. Baron: I would think, you know, probably if you have a more severe sleep problem as well, that's really time to go and talk with a professional. So, you know, maybe it came to somebody who has diabetes and other health conditions, and doesn't know what they're doing in exercise and really needs to go meet with a trainer to get on the right path.

Troy: So my take-home from this is I need help. I've admitted it. I recognize my problems. How long would it take someone like myself to get in for an appointment with you or in a typical sleep clinic?

Dr. Baron: It really depends. But, you know, usually within a couple of weeks you can get in and see me. And then, you know, doing things, like, you can start on your own, like, keeping a sleep logged. Bring that into your appointment. So either bringing in your Fitbit data or keeping, you know, a sleep record, that really helps me to see. Because when somebody says they're not sleeping, really, you need to see the pattern before you know what to change.

And then, treatment is usually four to six sessions. They have done some more primary care-friendly versions that are one or two sessions that are also effective. So even just getting a couple tips is useful. And then, you should know that the treatment is very effective. It's 75% or 80% of patients improve with that treatment. So, I mean, that's a huge number. And I think, you know, most people, even if they're happy with being on their medications, they should at least consider it and give it a try because maybe they don't need to be on them.

Troy: And insurance covered? Do most insurances cover this or is it something people typically have to expect some expense with this?

Dr. Baron: Most insurances cover it.

Troy: Right.

Scot: Well, sleep is super important. We talk about it all the time. So, hopefully, this will help you get your sleep health in line. It's always fun to have a conversation with Dr. Baron. Thank you for coming by.

Dr. Baron: Thank you.

ER or Not: Mountain Biking Went over the Handlebars

Scot: Time for "ER or Not?" That's where we throw out a scenario to Dr. Troy Madsen and get a definitive answer, sometimes not a definitive answer.

Troy: Yeah. Sometimes I hedge.

Scot: Whether or not, you should go to the ER for something so you can play along at home if you'd like. So you're out mountain-biking and you go over the handle bars on your mountain bike doing about, I don't know, 15, 20 miles an hour. ER or not?

Troy: Well, this is going to depend a lot on your injuries. So you could over the handle bars, you can get some road rash, get scraped up. You're going to be fine.

Scot: Okay.

Troy: If you had a severe concussion, so if you're having a severe head injury, lose consciousness, you're confused, vomiting, absolutely get to the ER. In terms of orthopedic injuries, if you feel like you broke something, it hurts really badly, you could go to an urgent care, get an x-ray there. Certainly, if you came over and landed weird on your ankle, having a hard time putting weight on it, also another reason to get probably to an urgent care just for an x-ray, so . . .

Scot: Not in ER, but an urgent care? Okay.

Troy: Exactly. So here, my number one concern was going to be the head injury. I think the other things, you can kind of make a judgment call for the orthopedic injuries, get to an urgent care. But head injuries, that's the big thing for me.

Scot: Okay. So if it's a head injury, ER. If it's something else, then start at the urgent care.

Troy: Probably start at the urgent care. And again, the head injury is going to depend on the nature of the head injury. But loss of consciousness, confusion, vomiting, all reasons to get right to the ER as soon as you can.

Facebook Changes Algorithm to Reduce Reach of Sensational Health Claims

Scot: Facebook updates are algorithm to reduce reach of sensational health claims. This was an article that I found in inc.com, "Inc. Magazine." A lot of misinformation is spread over social media and a lot of that is health claims that aren't backed by evidence or they're promoting maybe remedies that could severely harm people. Some of the ones that I found out there in the world is that if kids with autism drink bleach, that it could actually cure their autism. You see a lot of stuff about essential oils and parents using that instead of taking their child to the doctor to sometimes very terrible consequences. Drinking certain smoothies might cure cancer. Those are all some of the claims.

Those are all kind of extreme examples though. And I think most people probably wouldn't fall for that. Where it gets a little murkier is when it's an article in a magazine or a publication that you trust, like, I don't know, "Time Magazine" maybe, that is making some health claims that aren't necessarily backed by evidence. So we figured, since Facebook is updating their algorithm, perhaps, Dr. Madsen, you can help us update our algorithms so when we see some stories or some questions we can ask ourselves to determine whether or not this is something I should put some, you know, trust in or validity in.

Troy: And this is tough. I think even as physicians, we struggle with this. But ideally, it needs to be backed by some sort of research, and research, ideally, in a reputable journal. There are a lot of journals out there that will publish just about anything. So that's where it becomes really tough.

But, number one, a lot of these claims you're seeing, there is no science behind it. So it would be great, number one, this article should hopefully reference some sort of study. You should be able to link to that study and find it, and read the study yourself or at least read the abstract that's just the summary at the start. And from that, you can draw a lot of conclusions. We're talking about a series of five people who did something and they're saying, "This had magical effects." That's not a good study. If this is a randomized, controlled trial where you had, say, 200 people who tried one thing and 200 who did another thing or just did what they would normally do, and the 200 who did the thing that made a difference, you know, then you can say, "It's a pretty decent study."

So you should at least be able to find a study, find some evidence, look at it yourself ideally, you know, in a large, reputable journal, like, "The New England Journal of Medicine," "Journal of the American Medical Association." Those are big journals and those have gone through a whole lot of review by experts before they were published.

Scot: And I'd say even multiple studies would be better . . .

Troy: Exactly.

Scot: . . . in that article referenced.

Troy: That's a huge thing. Nearly every one of these sensational claims you're going to see is if it's based on anything, it's based on a single study. And we see this so often. You may have heard about vitamin D and the effects of vitamin D. And this was based on studies and even additional studies. But then, they did a huge study and it basically showed no effects. So, even stuff as healthcare providers that we're telling people to do and we're saying these things have a big effect, you find after multiple studies and rigorous studies that they're misproven. You got to figure a lot of these claims that are coming out based on really small studies or just some anecdotal evidence, there's really nothing behind it and it's not going to work.

Scot: Let me jump in as consumer of this and see if you agree with some of these statements. So I think if you look at an article or a claim, or something that wants you to click on something, if they want you to click on it or buy something, you should be automatically skeptical of it.

Troy: That's right. I think that's a good rule of thumb.

Scot: Yeah. The second thing is I think that you should just generally be suspicious of anything you see on the internet because we know that this false information tends to get spread a lot more quickly. Like, I think considered innocent until proven guilty, it's guilty until proven innocent.

Troy: Yes. And that's our approach in science. You need to approach things with a healthy dose of skepticism and you need to question them. And if it just doesn't make sense, it probably doesn't work. Bleach is not going to cure autism. You know, some of these ridiculous claims that are just, as you mentioned, not only ridiculous, but harmful.

Scot: And then, there are some other claims that are a little less ridiculous that seem like there might be some validity to them. Again, I think just approaching it with skepticism at first and go, "All right, well, that's interesting. Let me see if I can find any place else that's talking about this in the same way" in addition to the rigorous just looking to see if the information has been published in a reputable scientific journal. The other thing to look at is, are you emotionally reacting to the story in some way? And that's, I think, another good hint. Like, fear, disgust, surprise, people that are trying to get you to click on these stories and believe these claims usually try to invoke of those types of emotions.

Troy: Exactly. I mean, so much of this . . . everything that's out there, it's trying to get you to click on things, like you said, purchase things. If it just seems like just a claim that doesn't make sense and, as you mentioned, if it's something where it's trying to evoke anger, fear, whatever it is, to lure you into reading the article or getting a product, then it's most likely nothing that's valid.

Scot: I do want to jump in. There was a fast company article that talked about this top 10 list of shared articles that they found three-quarters were either misleading or included some false information. One of the stories was in a "Guardian" article called "Is Everything You Think You Know about Depression Wrong?" It was found not to be credible and potentially harmful. The author suggested that most cases of depression are not due to chemical imbalance in the brain but from a lack of fulfillment in one's life. And the scientist went on to say that the article was never backed with links to original sources, which you've already told us to look out for, or research to support its findings. And then the article goes on to say that "It's an excerpt from a provocative book written by a lay person who is very clearly anti-psychiatry." So there was no evidence presented except for cherry-picking to make the case. So that's something else to look forward to, you know, is who wrote it, are they an expert, those sorts of things.

Troy: And even the expert piece can be challenging. You can have people in positions of authority who are cited as experts in this area, again, who have no evidence to back up their claim. That's why I really get it. If you're going to be looking for something, try and find what evidence they're basing that on, look at the evidence yourself. And as you mentioned, Scott, it should be evidence that's not from a single study. It should be replicated multiple times and that's what we really look forward in medicine, is something like that. And even with that, years down the road, we may find with better studies that it's disproven.

Scot: And then the very last, I think, piece of this puzzle is probably if you read something, don't act on it. Don't start sharing it until you figure out whether or not it's, you know, really the legitimate real deal. Because if you're going to now change your behavior as a result, you could change it in a very dangerous way, so just . . .you just got to be really careful. And probably, I think, the other thing is you can't just scheme the headlines and take that as gospel. You do have to read through and be a -- what is it -- a critical consumer . . .

Troy: Exactly. The headlines . . .

Scot: . . . of this type of stuff.

Troy: Right. And the headlines are very often misleading. And even if the authors of the study saw the headline, they would probably say, "Wow, that's not what we were trying to say."

Scot: And if you want to take a look at either one of those two articles we just talked about in this segment, you can go to the show notes, links to both the Facebook changing their algorithm article and the fast company article about how a large majority of health news shared on Facebook is fake or misleading, even reputable sources, you can get those in the show notes.

Just Going to Leave This Here...

Just going to leave this here, it's our opportunity to just kind of talk about whatever happens be on our mind. It may be health-related. It might not be health-related. Just going to leave this here, so I've talked about it on a previous episode, I'm taking Tai Chi in the part over the summer. That's an eight-week deal. And the most challenging part of Tai Chi in the park next to not doing the opposite of what everybody else is doing, like, everybody's turning left, I'm turning right, is just accepting that I'm new with this and it's going to feel awkward, and it's not necessarily going to be something I'm like, "Wow, this is great. I feel so refreshed afterwards right away." You just have to dedicate to the process, go through it, and these little breakthroughs will happen.

And I think I bring this up because it's the same with if you're starting a weight training routine or if you decided you want to start running, you're not going to feel these great benefits right away. And you just kind of got to grind through at it first, and then one day, you're going to be doing Tai Chi and you're going to be, like, "Whoa, that movement felt really cool." You're going to be out running and you'll be, like, "Wow, this feels easy today." And it can be hard to get over those mental hurdles especially when you're starting out. So that's what I want to share.

Troy: I can relate to your Tai Chi experience. I don't go to Tai Chi, but I did go to, like, a hip-hop workout. I just wanted to say . . . Everyone knew what they were doing. Seriously, you could see everyone in the mirror. I was intentionally at the back of the room and my wife was there with me. She thought I was making fun of the class by what I was doing. I said, "No. I was really trying. I wasn't just looking like an idiot to make fun of it," and I never made it back.

Scot: You never made it back?

Troy: I didn't stick with it. So I didn't, yeah.

Scot: I've heard three times. I've heard you should do everything three times. I wish I could remember exactly what the saying was. The first time, to try it, the second time, to get past the awkwardness, and the third time, to see if you like it, something like that.

Troy: Okay. That makes sense.

Scot: Yeah, try three times.

Troy: It's the same way we teach procedures to residents and medical students. We follow these mantra of see one, do one, teach one. So it's the whole three times things, and then it starts to stick. So I'm just going to leave this here.

New socks are great. I love new socks. I know this sounds so nerdy, but I got myself some new socks recently. And I know this sounds weird coming from a doctor, but I don't buy a lot of stuff for myself. But I bought some new socks. If you want to treat yourself, get some new socks. It's like this special treat for your feet.

I like having comfortable shoes. The shoes I'm wearing right now are actually running shoes made to look semi-professional. I have gotten comments on them where people are like, "Nice shoes." And I don't know if they're, like, making fun of them or what. But new socks are great. If you're looking for something as a special treat, get some nice comfy socks.

Scot: And one of the best parts of new socks, I knew I made it in life. I knew that financially, I was finally secured in my life when I could actually throw out my old socks before they were completely hole-ridden. That's a very joyous feeling, is while getting the new socks and throwing out the old socks.

Troy: Yeah. It's like one of those things when we just are, like, "Well, no one sees my socks. Why would I care?" But it's just like so nice to have comfy socks.