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Evo Terra: Meditation and mindfulness practices have become rather mainstream and commonplace over the last decade or so. But do they have a role to play in modern medicine? We'll find out with the help of Dr. Robert Underwood, the Chief Medical Officer at San Juan Regional Medical Center.

This is Celebrate Health, the podcast from San Juan Regional Medical Center. I'm your host, Evo Terra. Dr. Underwood, thanks for joining me.

Dr Robert Underwood: I am glad to be here, Evo. Thanks for having me on.

Evo Terra: So, you are the chief medical officer of a hospital and you're into this weird meditation stuff. Can we talk about that for just a second?

Dr Robert Underwood: That is an accurate statement. I've been meditating for some time before I was in this role probably. But yeah, it's been an experience and I think that it's been beneficial to me, but I think it's beneficial to others. Like you said in the intro, it's becoming more and more known, more and more mainstream, more and more recommended, especially in the world of burnout, resiliency, we hear that in almost every occupation, not just in medicine. And so, I think there's been a lot more people looking at it and trying to understand what does it really do for people.

Evo Terra: Beyond just being interested in things, because we get interested in things, we have fads and we have these trends that hit, what does the science have to say? What are the peer-reviewed journals talking about meditation in this day and age?

Dr Robert Underwood: That's a great question, and even that doesn't have a straightforward answer. You know, let's look at it in the western world, meditation and zen Buddhism and that kind of stuff really kind of came into the western world probably somewhere in the '70s, whereas it had been going on for millennia in some of the Eastern cultures. And so, we started to feel that this was having a benefit, but there really wasn't a lot of evidence behind it other than how people felt. Then, we can get back to that because that may not be a bad thing, even if it is a placebo effect. Does it hurt? Probably not.

So, there are a couple of people in a book that I recently read, and it's actually called Altered Traits, and it's almost a giant meta-analysis of the data that have been done in studies and trying to put together the information of, "Okay. What does it do? What are the changes neurologically that people are seeing and that we can actually prove?"

And the reason I say this is interesting in terms of what you asked about what the peer-reviewed journals, there's one study that they did. They were trying to accumulate a whole bunch of articles about loving-kindness meditation. And they found 231 articles on this subject that happened to meet their criteria. Of that, they eliminated 201 of those articles because they did not hold up to what we consider the scrutiny and discipline behind true peer-reviewed research. And even of those 30, they found that there were only eight of them that didn't cross reference each other. And so, it went from 231 studies down to eight that actually met all of the criteria.

So, the point I'm trying to make here is that we're still lacking in a lot of hardcore data that's out there that shows what it does long and short of it. Now, we can get into through functional MRI, through EEGs and through blood testing, some of the things that it does do where we are seeing a decrease in activity in the amygdala. The amygdala is part of the brain, it's kind of the the guard tower and it is worried about danger and it develops stress. And it's the amygdala that might be part of why in human nature, right, that we have something that worries us. And then if it worries us enough, it starts to become an intrusive thought. I'm sitting here, I'm doing my work, I'm trying to write a report, and then all of a sudden I find I'm thinking about that thing again. And those types of things that perseverance or rumination on a subject is part of the drive of the amygdala.

And so, what they have found through mindfulness-based meditation is you can actually start to temper what the amygdala is doing and start to hold that down after a series of meditation. Now, that's one of the problems with some of the research, is we look at treatments as dose-dependent. Okay, we say, somebody meditates, well, okay, does that mean they meditate every day? Does that mean they're professionally trained? Does that mean that they went on a retreat and now they come back and say, "Yeah, I meditate." So, again, you have to do it in proportionality to the really skilled meditators who are out there versus people that do it on the side.

However, there's good news, is that even folks who do just a little bit of meditation on a relatively regular basis do have some improvement in their day-to-day stress responses. And that has to do with stress that they ruminate on, but also a stressful situation, how they respond to it, and how quickly they come back to a baseline. So, those are some things relative to mindfulness meditation especially.

So, it's really kind of interesting. Because as a physician, as my colleagues that I work with, we want to know if we're going to make these recommendations and help people do this, what's the evidence? Where is the evidence before I say that it's scientifically based? There are decreases in cortisol. And so, of course, everybody has heard of cortisol now. It's a chemical that's especially released in stress. Also, inflammatory cytokines, decreases in those as well. So, those are things that we do see as evidential improvement for those with a regular meditation practice.

So, just a couple, and that is just scratching the surface. Does it cure any disease? I can't say that the evidence is there yet that states that. There is evidence that states that chronic diseases that cause a level of suffering, even physical suffering, can be more tolerated by those who meditate regularly. So there is evidence of that. So, just a couple of thoughts based on a very broad question that you started with.

Evo Terra: Well, that's going to lead to a broad answer, but I'm glad to see that it's not just it should make you feel better. We actually can point to some things that we know with some degree of certainty that that actually can have the outcome. But you brought up even moderate meditation can make someone feel better or lower the stress response or smooth the amygdala out or lower the cortisol levels, right? All of that can happen. But I mean, how casual is too casual, I guess, is my question when it comes to meditation. Is there such a thing?

Dr Robert Underwood: I don't know that there is such a thing. And part of this gets back to maybe what we were talking about is a placebo effect, right? If it makes me feel better and it helps me and I perceive that I'm handling stressful situations better, does it really matter? The answer is it's a benefit, so we'll go with that.

But some of the studies, they look at regularity, 20 minutes a day up to an hour a day. Some, especially those who are Buddhist monks, that it's hours a day that they're seeing these traits in. But in general, at least a couple of times a week in 20 minutes or so is considered to have at least a little bit of lasting impression. There's one study that said cumulative 30 hours of mindfulness-based meditation really helped with handling anxiety situations and, after an anxious situation, then coming back to your baseline and not being stuck in that rumination and perseverance on the subject matter.

Evo Terra: Right. You brought up the word mindfulness to go with meditation, and I even said it in the intro. But I think people have a good understanding, or at least they can picture in their mind when someone is meditating. I'm not so sure everybody can picture in their mind when someone is being mindful. Can you talk about that for just a moment?

Dr Robert Underwood: So, mindfulness, there's lots of words for it and an interesting subject, I guess, is what I'm saying. Because we take it from some of the Eastern philosophies and the word that is used in Sanskrit as well as in Pali doesn't exactly have an English translation. And so, mindfulness or awareness are often the same. And so, mindfulness in general, when we're talking about it, is just being aware of how am I feeling and almost being objective with your own circumstance mentally and physically. What is my body doing? What is my mind doing? And am I paying attention to it? And then, you can start to ask the question, "Okay. Well, why am I responding that way?" And we get a little deeper into the philosophy and then it starts to be, "Okay, I have a decision to make about my response to the situation because what is making me anxious isn't the situation, but rather my response to it."

And so, that's a little bit about mindfulness. It can get a lot deeper and much deeper into awareness. And you were right, there's lots of different kinds of meditation. There's chanting meditation; there's mindfulness meditation, which we've already talked about; loving-kindness meditation, and many others that are out there. And the other thing that a lot of the studies have found when you dig deeper is the different kinds of meditations actually have different results in terms of what they benefit.

Evo Terra: That's interesting. Now, what happens when I lay down to meditate and I fall asleep and I take a nap instead? Is that still okay?

Dr Robert Underwood: It happens. I don't think that there's anybody, me included, that haven't fallen asleep during meditation. You want to focus, and that's part of awareness as well. And one of the things they've actually been able to show with evidence from meditation is our ability to focus on a single task and get away from multitasking through awareness meditation is improved with time and with regular practice.

And so, A, you can do that. Laying down is a way that you can meditate, but that's also one of the reasons why we often talk about posture in meditation, that you want to align your back and your neck and your head, so that there's kind of a straight line while you're sitting in meditation. And that could be sitting in a chair, sitting on a cushion which is a much more traditional way to go about it. I'm 60 years old. I don't sit in the lotus position anymore, I guarantee you that, nor do I know if I really ever could, even when I was young and more limber. But laying down, of course, increases your risk of falling.

Evo Terra: Sure. But I would also think, as a physician, you're not going to tell somebody to sleep less and take less naps, right?

Dr Robert Underwood: Oh, absolutely not. No, your sleep is an important part of our physiology.

Evo Terra: All right. So, I'm hearing everything that you're saying here we've got some benefits to a variety of things. This doesn't necessarily treat any disease. But let's say someone has an inflammation of their rotator cuff, meditating is not going to repair the rotator cuff. However, meditating, mindful meditation, might make them reduce the amount of ibuprofen they're having to take to keep the inflammatory response down. Is that a fair statement?

Dr Robert Underwood: I would say that it can improve the meditator's experience of the pain, which really sounds kind of philosophic, but that is one of the things that the evidence has been able to show, that people who meditate and, in mindfulness meditation and body awareness meditation, they are able to basically understand their body's perception of the pain and ameliorate it somewhat. And so, that is one of the things that has been proven out through the evidence in meditation.

There are conclusions that we can draw that if we reduce inflammatory cytokines, that would be the effect, but it's not going to be the same effect as using an nsaid non-steroidal anti-inflammatory medication like Motrin. And one of the things that I'm always sure to tell people is, "Hey, talk to a provider. Because we're not snake oil salesman. We're providers. We're doctors and other providers who are out here. And we need to do a full analysis and understand the entirety of the problem that any patient may be having. And we're not going to say that, "Oh, we'll just go out and meditate and it'll go away or your shoulder cuff will somehow be miraculously repaired." So, you're right about that.

Evo Terra: Anything else you want to talk about before I wrap things up?

Dr Robert Underwood: Again, I want to come back to two primary points. One is the concept of making sure that you talk to a medical professional about what you're trying to accomplish and what your issues and medical concerns might be. And maybe meditation could be part of a solution to your overall condition.

The other is, I would say, again, kind of coming back, the evidence is starting to play out that there are benefits, there are lasting benefits. We're being able to see that in a chemical makeup of our blood. And we're also able to see that in a functional MRI, which is looking at how the brain functions with some long lasting benefits to that. But I kind of come back to what we said at the beginning, is even if we don't have all of that evidence and I feel better, or you feel better with a regular meditation or mindfulness-based stress reduction process, then do it. Really, in the end, if it makes us feel better, if it helps us manage our disease states in a better way, then that's a great thing.

Evo Terra: And I think that's a great place to end the conversation. Dr. Underwood, thanks for joining me today.

Dr Robert Underwood: Yeah, absolutely. Thanks, Evo. I really appreciate being on.

Evo Terra: And once again, that was Dr. Robert Underwood, the Chief Medical Officer at San Juan Regional Medical Center. Thank you for listening to Celebrate Health, the podcast from San Juan Regional Medical Center. For more information, you can visit sanjuanregional.com. I have been your host, Evo Terra. Thanks again for listening, and we'll talk again soon.