Dr. Victoria Maizes
Hi Andy.

Dr. Andrew Weil
HI Victoria.

Dr. Victoria Maizes
Did you ever imagine when you began and Integrative Medicine Fellowship that you'd be training colorectal surgeons?

Dr. Andrew Weil
Well, surgeons in general. I've been delighted when we had surgeons coming to our fellowship.

Dr. Victoria Maizes
It's true. It's been quite wonderful. And now across the country you could actually find an orthopedic surgeon, a cardiac surgeon. And today, our guest, Dr. Elizabeth Raskin, is a colorectal surgeon. So it's going to be great to talk to her.

Dr. Andrew Weil
And I understand she practices robotic surgery as well.

Dr. Victoria Maizes
She does and she has a passion for nutrition.

Dr. Andrew Weil
Great. That's integrative.

Dr. Victoria Maizes
It sure is. Let's get her on.


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Dr. Victoria Maizes
Dr. Elizabeth Raskin is a colorectal surgeon and the surgical director of the Margolis Family Inflammatory Bowel Disease Program at Hoag Hospital in Newport Beach, California. She was one of the first women in the world to perform robotic colorectal surgery, and she has a keen interest in developing technologies that can improve patient treatment outcomes and different options. Dr. Raskin is currently a fellow at the Andrew Weil Center for Integrative Medicine at the University of Arizona. Welcome, Elizabeth.

Dr. Elizabeth Raskin
Thank you so much for having me. This is a delight.

Dr. Victoria Maizes
Well, we're delighted to have you. And I think you're our first integrative surgeon on the podcast. So I'd love to maybe hear a little bit about your journey. What made you become a colorectal surgeon and how did you get interested in integrative surgery?


Dr. Elizabeth Raskin
Well, I think it takes me back to when I first had an interest in medicine, andI like this story because it has to do with my lineage in medicine. When I was four years old, my father was a fellow in rheumatology at Walter Reed Hospital outside of Washington, DC in Bethesda, and he used to practice his talks in the basement of our home, projecting his slides up on the wall.
And I would sit there at the age of four, just mesmerized by these seemingly abstract art pieces, as we saw slides of cells that were beautifully stained. They looked like masterpieces. And I knew even at the age of four that I wanted to be part of this secret society that knows what that meant. And so, truthfully, my journey into medicine started as an abstract art enthusiast.

And then as I entered more formal medical education, I started to realize that the thing that drove me the most or most interested me was using my hands and laying on the hands. But then as I was able to do my surgical rotations, it was very clear that my passion was in the art and the science of surgery.

when it comes to integrative medicine, I think I knew as early as a teenager that I was fascinated by other ways of thinking about health and healing. I was really interested in nutrition at a young age. I thought about going to naturopathic school before I entered the M.D. program, and so that was always in the back of my head that there was something that I knew that I wouldn't get from traditional osteopathic training that I wanted to continue to seek out.
And it wasn't until I had to take a pause in my life and reassess what I was doing in my career that I decided to commit to learning more about integrative medicine.


Dr. Victoria Maizes
That's such a great story.

Dr. Andrew Weil
So how do you use what you've learned about integrative medicine in a surgical practice?

Dr. Elizabeth Raskin
That's a great question, because this is the first surgeon that you're interviewing about that. But I think it starts with the relationship you make with a patient. So traditionally, when we're trained in surgery, we're taught to think about, you know, just taking care of the problem and then the patient moves on to see their primary care provider.

But truthfully, as an integrative surgeon, I think about the longitudinal nature of the relationship that I have with the patient, especially in the field of inflammatory bowel disease where I subspecialize my work. That is, is that getting to know the patient from the very beginning as we've learned in integrative medicine, the limnology of crossing the threshold into the patient's room in that first interaction that you have with the patient that allows you to engender trust. And in surgery, that is at the center of where our work is, we have to have that trust between the patient and ourselves because we're doing something that only very few people are privileged to do, which is to enter the body of some other human being. And we have to be trusted to care for them as we would want to be cared for ourselves. And so it starts when we first meet the patient. And then as we learn more about them, we'll ask really specific questions about what is most important to them because they're facing a condition that has gotten to the point that they're seeking surgical care.
There is more than just the disease at hand. We're talking about even the trauma that goes along with a diagnose. A diagnosis that might be colon cancer that was discovered after having symptoms for a while, or it might be a condition that has crept up and they've sought treatment for like Crohn's disease that ultimately gets to the point where they need surgery.

So we need to acknowledge what that disease has done to the patient and they need to explore that with us. And that is not something that I was ever trained in surgery. I was never trained to walk that path with a patient. And so learning in the fellowship so far has opened my minds to ways to connect to patients on a deeper level.

Dr. Victoria Maizes
That's really such a wonderful way to put it. And I think probably a somewhat unusual way for a surgeon to put it. And, you know, I know that one of the things that you have really worked on at your center is creating a healing environment and involving other members of your team as you care for patients. Can you tell us a little bit about what you're doing?

Dr. Elizabeth Raskin
Sure. And surgery still is a big part of what we do. But the larger aspect is that we're building teams around patients. And when a patient needs surgery, especially in the realm of inflammatory bowel disease, they need more than just a surgeon. They need a caring team that's equipped to approach multiple facets of their health. So this may start out with dietary counseling and nutrition counseling that a patient will receive from one of our expert dieticians.

Clearly, our medicine colleagues in gastroenterology have been playing a role in medical management of the patients inflammation and disease process, maybe even performing colonoscopy or endoscopy over the years. But we also have IT providers in our clinic, such as care counselors. Now, care counselors sounds like a kind of a nebulous term, but it's actually a euphemism we use for our social workers who are our therapists.

We found that patients receive help more often and in a better way when the term care counselor is used as opposed to social worker or therapist. It's a strange terminology that patients kind of retract from and say, you know I don't need to be supported like that. I don't need a crutch so that I can walk.

But what we use is also the term care community for our support group so that patients feel part of a community of other patients that are walking the same journey. And so those are some of the individuals that we have on our team. But we are now pairing with a traditional Chinese medicine physician who will be providing acupuncture both in our clinic but potentially also in our perioperative space, which will be a new step forward for our team.

We also have massage therapists, physical therapists, as well as psychologists that are working with our patients that may or may need surgery. So it is fairly comprehensive and it's an environment that I've never worked in before in surgery and a lot of it is just been this labor of love, of finding and connecting with practitioners in our area and finding that mutual interest that we have in healing patients.

I think one of the big things as a surgical resident and a surgical trainee is I was never taught that I could actually be a healer. We are taught to be kind of like mechanics on some levels and that the healing and take place in some other environment. But I really refuse to believe this. I believe that surgeons ought to be tapping into their capacity to be true healers and to heal patients on levels that they may not have had traditional training in.

Dr. Andrew Weil
Speaking of mechanics, tell us about your experience with robotic surgery.

Dr. Elizabeth Raskin
Sure everyone likes to know about the high tech stuff, which is really fun. And I took to robotics over 13, almost 14 years ago when it was really new technology and robotic surgery is it's not robots doing surgery but it is the it's a branch of minimally invasive surgery that allows us to use a surgical robot in for the surgeon to control every motion that the robot does.

So it is a rudimentary way of using robotics. There is no artificial intelligence really embedded into the robot except for a few little things. But what it allows us to do is to place instruments through very small incisions, typically eight mm a piece, and the robot has four arms. And this allows us to place a camera through one of the arms and then to have three hands, so to speak.

So through these small incisions within the abdomen, we are manipulating the tissue just like we would if we had a traditional open incision that has been used for hundreds of years. So what robotics has allowed us to do beyond the small incisions is to speed up the healing of a patient, to lessen the pain associated with surgical incisions, to have a quicker return of bowel function and the ability to start eating.

And so we are really scratching the surface over the past 20 years of robotics being available to patients in the United States. We were only starting to recognize what those full advantages are. I've been doing it for, as I mentioned, over 13 years and we lacked a lot of the newer, sophisticated technology that we use now, which includes Immunofluorescence.

We obviously are looking through high-definition 3D cameras, so we're looking at our instruments moving in three dimensions, which you traditionally in laparoscopy, don't do that because you're looking at flat screens. So it gives you depth perception which you don't traditionally have in minimally invasive surgery. So robotics is the future, but it's also the present and it's a little bit of the past we are hoping to see our robots get smarter and smarter so that there is a way to guide surgeons in ways of keeping surgery even safer than it is now.

Dr. Victoria Maizes
So you have to say, I started in medicine at a time when if you had your gallbladder out, you had a foot long incision across your upper abdomen and it was hard to heal. People were pretty miserable. And I remember when laparoscopic cholecystectomy so gallbladder removal began and there were a lot of surgeons who were not excited. They were like, “No, I need to see in the abdomen. I need to get my hands in there.” And I think there was some resistance to laparoscopic. And now, of course, you're describing the the next iteration moving from laparoscopic to now robotic. Is there a future where we have the robot with ten hands, like where are we going?

Dr. Elizabeth Raskin
So you're absolutely right about the pushback that traditional surgeons have had towards minimally invasive surgery. And in fact, really, when the first closest academies were being done or gallbladder removals laparoscopically, it was done by a German surgeon who was then kicked out of his own surgical society because they thought him using small incisions was quote unquote, Mickey Mouse surgery, only to reinstate his surgical society membership and to give him the highest honor about 20 years later when he was at the forefront of surgical innovation. So regarding robotics, what I think will happen is we will make robots number one smarter, number two, smaller, and number three, cheaper. So right now, robots are they're quite large and they're quite expensive and they're not available to the vast majority of people in the world.
And so how do we democratize this option in surgery for patients? Well, we've got to we've got to make them smaller and cheaper and smarter.

Dr. Victoria Maizes
And that means trained. Not everyone's trained to use them.

Dr. Elizabeth Raskin
That's right. So I've been part of a group of surgeons that have been training surgeons for over a decade. And now  it's available to be learned by our surgical residents and our surgical fellows where that just didn't exist when I started in surgery. And that was only, you know, 20 years ago. With that being said, it has enough momentum that robots are available in all continents except for Antarctica.
And the interesting thing about robotics is that it was first developed, the surgical robot was first developed to be used in what we call telepresence surgery, right? So to do surgery in really remote locations like the moon, in a battlefield. And as they developed this technology, they recognize, wait a minute, now, we could actually use this in our hospitals now. And so cardiac surgeons first adopted it and then followed by urologists and then general surgeons. So it's really a fascinating evolution.

Dr. Andrew Weil
Do you get any resistance from patients to robotics?

Dr. Elizabeth Raskin
I used to about ten years ago, because I think it was really unfamiliar and the notion of a robot doing surgery was stuck in their head from science fiction films over many years. And and truthfully, one of the neat stories that Robert Heinlein wrote was about a surgical robot in the story called Waldo. And it's all about him using robotic technology because he had myasthenia gravis.

And so 50 years ago or more, Robert Heinlein predicted what was going to happen in medicine. And now we have robots in most major hospitals. Our hospital has, I want to say, nine or ten robots and is used ubiquitously. So the pushback doesn't exist now. But in the beginning I had to really create that trust with a patient to say, no, this is technology. It is early in its adoption, but I will keep you safe. And it is an extension of the minimally invasive surgery that we do know how to do. And I'm very thankful for patients who trusted me to allow my skill set to grow.

Dr. Victoria Maizes
I want to ask you about low tech. You know, we've now talked a little bit about high tech. So all of us I know are passionate about nutrition. I think a lot of people don't realize how critically important nutrition is when you're having surgery, both your nutritional status, entering into a surgery and then your nutrition as you heal from surgery. Can you speak to that a bit?

Dr. Elizabeth Raskin
It is at the forefront of where healing, you know, what we need to do to heal is to nourish ourselves. And so when it comes to surgical nutrition, we have to look at each patient individually because we don't have the greatest markers to tell us, yes, no, somebody is a good surgical candidate from a from a nutrition standpoint and another person is not there aren't single parameters.

We have to use a constellation of parameters. And those include anything from protein levels like albumin and pre albumin looking at someone's BMI, but not exclusively because we can have patients with really low BMI or high BMI and it doesn't necessarily it's not necessarily a reflection of their nutritional status. In fact, many of our patients that I operate on are very malnourished because of the lack of protein, but yet maybe their BMI is quite high.

So what you see is a lack of muscle and protein content, but you have a large amount of adipose tissue. So patients have high obesity rates, but yet they're not well nourished. And that's a concept that is hard to get our minds around because we think of patients that might be big or bigger as being well-nourished, but it isn't necessarily true from the ability to heal.

Similarly, we'll have many thin patients that have perfect parameters when it comes to proteins, so everyone needs to be looked at in a very individualized way. But when we do think about surgery, we want to make sure that a patient has not recently lost a tremendous amount of weight because that is a predictor for poor killing and poor outcome.

So over the past, let’s just say, 30 to 60 days, has a patient lost 5 to 20 lbs, this is very common to see in patients who have obstructions from inflammation, whether that's from Crohn's disease or cancer or from diverticular disease. They may choose not to eat because their symptoms are so bad. And very rapidly you'll find that they have elements of malnutrition.

So we want to intervene as soon as we possibly can. So when we are meeting the patient for the first time, we're getting some routine lab work, but we're asking them questions about how they eat, what they like to eat, how often do they eat, Do they can they not eat certain foods in their mind? And to get a gauge, basically take a pulse on the patient from a nutritional standpoint to understand if they're not in a good range from a nutrition point of view, what can we do to alter that?

What can we do to optimize them before surgery so that they have the best chances of healing without potential complications? And so that's a little bit of the way that we look at our patients when we first meet them. We can also use imaging, we can look at CAT scans and look at lean muscle mass on a CAT scan and compare that to the amount of adipose tissue that a patient has. But there's no perfect lab test, unfortunately. So it is more of a gestalt.

Dr. Andrew Weil
You use mind body methods and your practice. Since the gut is so sensitive to mental interventions, it's been called the second brain.

Dr. Elizabeth Raskin
We absolutely do. I think this is an area where we are still growing, but there is a wide acceptance by both practitioners in our group, but also patients that they know that this is important to their healing, starting as soon as we can to get a gauge on how much stress they're under and what do they do to reduce stress, whether that's breathing techniques, meditation.

I will tell you Andy I have taught them your breathing techniques are good, both pre operatively and postoperatively and we’ll write it on the wall. Great to know the numbers. So you are having an effect on many patients that you're unaware of, but we go through the breathing techniques with them pre and post op and we also have been using a lot of aromatherapy with our patients to help reduce anxiety and stress and combining that with breathing techniques.

We're also working with several mindfulness meditation coaches, which I think is very helpful for a patient who has experienced trauma from having had a prior surgery that maybe didn't go as well or has had multiple surgeries over their lifetime, which is quite common in patients with Crohn's and colitis. So really recognizing that the disease has had a major impact on the patient.

And my job is not just to go in and take it out, but it's to learn how to help a patient heal themselves best. That may include surgical intervention.

Dr. Victoria Maizes
Andy maybe you could let our listeners know where they can find that 4-7-8 breath.

Dr. Andrew Weil
If you put my name into YouTube in 4-7-8 breath, you'll see a lot of videos of me teaching it. And Elizabeth, I have a question for you. Maybe a little off your practice. You're seeing end stage or very advanced conditions, consequences of inflammatory bowel disease. What's your gut estimate of how much of that could have been prevented if there were earlier medical interventions and that people had good information about how to reduce inflammation in general and help the gut heal?

Dr. Elizabeth Raskin
I would say over half of those patients would not have made it that far down the path that they would need surgery. And a lot of times I'll ask patients, why do you think or how do you think this disease first started? And many of our patients can even pinpoint a time in their life when something very stressful has happened and they may not have had the ability to to dissect it and to heal from it and to to find strategies to reduce the stresses associated with that.

I'll give you an example of physical trauma, a car accident, a death of a loved one. Many times these things will trigger a stress response that's so intense that down the road we're seeing conditions that fall into the rheumatologic spectrum. Honestly, as I've talked to my father quite a bit about this as he is a rheumatologist, but with inflammatory bowel disease, patients will say, I remember I was in high school and I had this abdominal pain and then I was diagnosed with Crohn's disease later.

So not exclusively, that could be prevented. But let's say we identified that early and then we had the appropriate ways to help a patient tackle this stress and help heal themselves. And then you coupled it with nutrition and nutrition counseling and sleep hygiene. These are these are all things that get so deranged as this cycle of disease is occurring.

That long story short, they get to the point where they're diagnosed and maybe they need surgery from the moment they were they're first diagnosed with Crohn's or colitis. But I do believe that these are conditions that can be healed in in different ways that we just haven't been successful in intervening early enough in the patients.

Dr. Victoria Maizes
I know that one of the things you've been experimenting with is virtual reality. So moving back to high tech, how do you find that useful?

Dr. Elizabeth Raskin
Virtual reality is clearly technology. Is this part of the high-tech part we're using a headset that provides images of landscape typically, or an experience that allows a patient to take themselves to a different place than where they are. Maybe it's the pre-op area, maybe it is the post-operative recovery room. Maybe somebody will even be doing this in the operating room as they're drifting to sleep.

But it's a way to have a patient experience, a more pleasant environment through visual travel, if you will. Maybe they're going through a meadow of flowers or flying over the Swiss Alps. It can also be in the form of guided imagery and guided meditation where you are seeing something and you're being guided in an auditory way as to how to relax.

And so I believe that this is something very powerful for patients to experience, especially in the preoperative setting, when they are ramped up with anxiety about being poked with needles. Being going under anesthesia is very stressful for most patients. They are afraid of letting go. They're afraid of having somebody else breathe for them. And then, of course, surgery.

What is what are they going to wake up with? How is their body going to be altered? How what kind of pain are they going to be experiencing? And so when they're faced with this, the anxiety and the pre operative area is very, very high. And you can tell the patient, relax, relax, everything's going to be fine. But nothing that says it as well as through the lavender fields of France.

Maybe we accomplish that with aroma therapy as we have been doing in making it making this a peaceful and comforting experience as a as opposed to so stricken with fear and anxiety. We've had a lot of positive results from our patients.

Dr. Victoria Maizes
What do you wish your surgical colleagues knew about integrative medicine?

Dr. Elizabeth Raskin
That's such a great question because I don't think I knew how my journey was going to unfold with integrative medicine. And I'll give you a good example. So I, I told you that I found integrative medicine as a as a fellowship or as a branch of of medicine, because I personally felt like I had hit a breaking point in my career where I thought I couldn't continue doing what I was doing.

 I was overworking, I was not sleeping. I lived in the same household as my family and my three children, and I never saw them. And I had patient after patient coming through the doors. And so I felt both that I was pushed into this form of what I call surgical savior ism, where I felt like I couldn't stop working because who else was going to help these people?

Dr. Elizabeth Raskin
At the same time, you become a little bit of a martyr, ready to throw yourself on the sword of the work that you do so you become unhealthy. And so when I started the Fellowship, one of the as you know, the first thing you're doing is taking a personal inventory of yourself. I wish that that was something that I did earlier in my life as I was going through surgical training.

But unfortunately, we still perpetuate the surgeon archetype in training of someone who works hard, never goes home and puts patients before anything else, including their own health. And the problem with that is that if you were trying to be the best healer and provider that you can be, how can you give what you don't have? How can I give them a way to heal themselves when I myself was suffering so badly?

And so that that first week in our residency at the University of Arizona was so powerful because it really emphasized to me that I had been neglecting myself for decades, and I thought I was a pretty healthy person. I've been a marathon runner and I eat really well. But I realized that I slept I slept about 4 hours a night if I was lucky.

And I've been doing that for four decades, and I thought that I had to be like that to be a good surgeon, because we model ourselves after these pioneers and these fathers of surgery that are that are glorified in textbooks, like, you know, William Halsted, who never slept and operated like crazy, but meanwhile was a cocaine and morphine addict.

So so not perpetuating the myth that in order to be a surgeon and a healer, you know, to be a to be someone who can take care of patients, that you have to be like that, there is a different way to be. And this is something that I really have been trying to emphasize with my other colleagues, residents and students, that you can be both healthy yourself and be a surgeon.

But it takes a lot of effort. You have to have boundaries. You have to really prioritize things in your life. And I can truthfully say and Andy, I think you'll be happy for this. I sleep about 8 to 8 and a half hours a night.

Dr. Andrew Weil
That's great.

Dr. Elizabeth Raskin
I have never been more well-rested in my lifeI have never had better sleep in my life. And I feel like a better provider because I have taken care of myself, even though it's been a few years since I have done that, I am now actively feeling myself while I'm trying to heal other people.

Dr. Victoria Maizes
That seems like such a beautiful place to end this conversation and we're so grateful to have you in our fellowship and we're so grateful to have you modeling this healthier way of being a physician and a surgeon. Thank you.

Dr. Andrew Weil
Yes, thank you.

Dr. Elizabeth Raskin
Thank you for having me. It's it's really been my pleasure. Thank you.

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