PAH Podcast Episode: Interview with Dr. Josh Turknett
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Tommy: Hello and welcome to the Physicians for Ancestral Health podcast. My name is Tommy Wood and today I am joined again by my co-host, Josh Turknett. Say hello, Josh.
Josh: Hello, Josh.
Tommy: If people have been listening so far, we’ve had a couple of episodes and in the last episode you interviewed me a bit more about my background. Now, it’s time for me to turn the microphone onto you, Josh. Just to start with, I know we heard a bit about your background in the first episode, the introductory episode of the podcast, but maybe you can give us a brief overview of yourself and how your work has evolved to include ancestral health principles.
Josh: All right, sure. Well, it’s nice to be here with you again today, Tommy. As a bit of background, I’ve been interested in the neurosciences for a very long time and ended up going to college getting an undergraduate degree in neuroscience specifically cognitive or behavioral neuroscience and ultimately decided that I wanted to then use that to pursue a career in neurology.
I went to the medical school at Emory and then did a neurology at the University of Florida and chose that partly because they have a very strong behavioral neurology program. I’ve had a particular interest in neurological disorders that affect higher cortical function or cognition, things like language and memory and problem solving and so on.
After finishing residency, I went on to practice in Atlanta, which is my hometown, and practicing as a general neurologist. Meaning, I see all types of disease and dysfunction of the nervous system, so brain, spinal cord, nerves, muscles. It was several years ago now when I started getting really into ancestral health and the, first, it was initially through some random meandering around the internet which led me to Gary Taube’s Good Calories, Bad Calories, which basically said I didn’t know anything that I thought I knew about human health and nutrition.
So, then continued to go down the rabbit hole, ultimately realizing that I had to implement these ideas myself because I believed in them so much and made some significant changes in my own lifestyle and eating habits several years ago now. I think this was back in 2010. I had a number of excellent effects including the elimination of my migraines, which we talked a little bit about in the last episode.
But I’d been a long time migraine sufferer. Mine steadily worsened over the years, sure partly fueled by lifestyle as I went through medical training and so on, and also partly fueled by using the conventional way of treating it which oftentimes trades a short term improvement for long term worsening. But at any rate, I made these changes and I could actually still remember where I was when it first occurred to me that I hadn’t had a headache in weeks and I thought could this possibly be linked to these changes that I had made?
I got really excited. I called my wife and was like, “I’m thinking maybe I’m on to something.” But I didn’t want to get too excited then. But then weeks went by and months went by, no migraines, no headaches or anything. I was pretty rigid and strict initially too about the whole ancestral health principle. I was not doing any cheats or anything at that time and getting these wonderful results. That was pretty incredible
I started exploring that more and realizing that I wasn’t alone in this experience, that other migrainers out there had a similar experience after implementing these principles. I started using that with my patients now with success and ultimately realize that this was a message that needed to get to a wider audience not just the ideas that these ancestral health principles help migraine but just those ideas in general which I thought had power to profoundly impact all manner of conditions particularly given that most of what we see now are diseases of lifestyle and diet.
So, when I felt like the best vehicle for me to do so would be through the lens of migraines, I wrote a book called the Migraine Miracle that was published, I think, late 2013, about how to use these principles specifically for migraine headaches and launched an online community around that that’s continued to grow and is a place where I spend my time these days.
Part of this whole process was, like you said, trying to figure out how to incorporate these ancestral health principles because what happened to me after I had this realization that these were incredibly powerful things we can do but yet we’re in a system that for many reasons is not set up to deliver and implement them. What could I do? How could we make a difference within that context?
And so kind of led to a professional crisis that I think other people, other physicians in this community can relate to. How do you work and practice in a way that’s in line with your values? Part of that for me was trying to figure out just other structures and other ways that I could get this information and my expertise out there that was outside of the traditional medical clinic.
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That was the book and that was why I grew these online communities. That’s why ultimately I’ve transitioned out of the day to day practice. That’s where I am now in terms of figuring out how to take these principles that we all know in this community are so impactful and bringing them to a wider audience and, hopefully, in years to come help shape some structural changes to the system that would allow for their implementation as well.
Tommy: Absolutely. I think from the way you’ve approached things, there’s certainly a huge amount that physicians listening to this could learn in terms of how they may want to shape or change their practice but then also some of the principles that they could easily introduce with their patients that might get them some easy wins particularly if you’re talking about something like migraines. I want to get to that in a second, but to frame all of that, I’d like to ask you to tell a story that I heard you tell, and actually it was at Physicians for Ancestral Health winter retreat. I think it was not this year but last year. Is that right?
Josh: That’s right.
Tommy: I couldn’t be there sadly. I was just wrapping up my PhD so I couldn’t be there. I watched on YouTube afterwards and it struck so many cords that I have stolen this story and told it so many times with your permission because it’s truly excellent. To frame how we do everything and how we think we should be approaching health and disease, perhaps you could tell us how to win at Angry Birds.
Josh: All right. So, this talk that I gave year before last called How to Win at Angry Birds, it arose as how do we answer the question of why has there not been more progress in the realm of medical therapeutics in the past few decades? I went into neurology. I entered my residency in 2001 thinking that going into this field — this was shortly after we’d had the decade of the brain — that this is an area that’s poised to have all sorts of changes in the coming future and that would include new breakthrough treatments and so forth.
If you look back and see in terms of the treatments that we have available, there had been no breakthroughs since I started my residency back in 2001. In fact, the last significant breakthrough in neurological therapeutics — I’m talking about things that are a meaningful stepwise change from something before, not just another me too drug or a treatment that’s equal to something that came before, something that was a stepwise improvement – the last thing that came was in the early ’90s and there had been nothing.
That’s despite all this incredible progress that’s been made in other realms of technology. So, if we’d go back to what things look like 20 years ago, vastly different, including in research that’s been done in the brain.
We understand a lot more about the brain and neuroscience than we did 20 years ago, but that hasn’t translated to any meaningful benefits clinically in terms of what treatments we’re able to offer. That suggests possibly that there’s just something fundamentally wrong with the paradigm that we have for finding treatments. At least that’s one possible hypothesis or explanation for why we haven’t had any major improvements.
That leads to this story of the Angry Birds. This is a thought experiment. Imagine that an alien civilization finds an iPhone. They have no experience with the iPhone whatsoever. The game is loaded with Angry Birds. They decide that this civilization, they’re going to break into teams to have an Angry Birds competition. They’re going to meet back in a few weeks and see which team is better.
Team one goes off and decides that their strategy is they’re going to figure out how this game works. They’re going to break down the game to figure out how the game actually is coded and so forth to produce the end results. They do that. They realize that there’s code and then ultimately that it’s controlled by this machine language that’s specifying the state to state position of transistors. They developed this really robust understanding at the smallest level what’s actually making this thing tick. And so they decide, “We’ve cracked the code. We know how this thing works. We’re going to win this game by manipulating the source code in real time and the other team will have no chance.”
The other team, instead of figuring out how the game works, they just say, “Let’s just get really good at playing the actual game.” They get really good at playing the game. They learned how to work the slingshot and precisely where to aim it to get all the pigs and so forth. They get really good at playing the actual game of Angry Birds.
They come together a few weeks later to have their battle. I think anybody would be able to predict who would win, which would be the better strategy, right? The people who actually learned how to play the game, even though they had no awareness or understanding of how the game actually worked or was coded, they’re going to destroy the other team and in all likelihood the other team will just crash the program because there isn’t a computer scientist alive who could manipulate machine language in real time and keep the machine from crashing much less actually produce a meaningful game of Angry Birds.
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This approach to breaking down the game and understanding it at its source code, there’s plenty of value in doing that, obviously, that leads to tremendous amount of insight in terms of how everything works and in terms of if you wanted to build another game on your own and so on. But it’s not actually the right approach for understanding how best to win the game.
The mistake that the team made who took that approach was in thinking that intervening at the microscopic level, at the most reduced level of description, the smallest level of description possible, that intervening at that level would be a winning strategy rather than intervening at the topmost level which is the level of the game.
For me, this is a very apt analogy for what we’ve been doing in modern medicine for so long with this single minded approach towards looking for drugs or pharmaceuticals as the answer which intervenes at the reduced level or small level of organization rather than looking to interventions that apply at what I call a game level, so the topmost level.
The problem with that as was the problem with the team who’s trying to use this to win Angry Birds is, number one, we’re not smart enough to know how to do that. There’s no way, even in a system that’s much less complex than human biology, which is computers, even in that system we wouldn’t understand how to intervene at the smallest level in a way that we wanted to without unintended consequences.
When you’re talking about drugs, just the level of potency in terms of what we can actually do is very limited and constricted and thinking that we can sort of intervene in one’s tiny little level and have a broad impact is, I think, pretty narrow minded. And then you throw on top of that the fact that most of the conditions that we now see are not caused by any single one factor. They’re most typically nowadays diseases of diet and lifestyle that are multifactorial.
That paradigm of going after one single thing at the microscopic level could conceivably work in some cases when you have a single variable problem. But it’s not going to work at all in any condition where it’s multi-variable and systemic in origin. For me, that explains why there’s been this huge disparity between our understanding our ability. What we’ve done is basically gotten better and better and better at cracking the code, understanding how the game works at their reduced level.
We’ve taken a reductionist approach that’s worked well for our understanding. But the mistake has been in thinking that we should intervene at that level to produce the results that we want. That’s why that approach is especially nowadays a dead end and if we want to make the kinds of impact we want to make, it’s going to take understanding how to play the game.
Those of us who are doing that, and that’s why doing this for my own migraines and ancestral approach is game level approach to health which is why it has such a broader impact than anything that we would do at the lower levels. I think that’s both the story to help frame why we’ve been frustrated so long in medicine in terms of our progress in therapeutics while other domains of technology have advanced so much and an explanation for why these ancestral health principles are going to be so much more powerful and productive than our current tools.
Tommy: Absolutely. I think it says quite a lot that this spoke to me so much considering the fact that I have a PhD in neuroscience. What we do or what we did and maybe less so in my lab because I supervise — I had a slightly more of a game level approach. But what neuroscientists do is they just tinker with the source code rather than trying to figure out the source code as much as they can and then try and figure out some way to fix that, if you want to call it that.
And like you said, in the field of neurology, neuroscience, what progress have we made in the last 20 years? Very, very little particularly in adults, almost none at all, you could argue. I think that that approach is very powerful. And then as we relate that back to some of your expertise with migraines, maybe that comes together in what I wanted to ask you about was actually a talk.
Again, this is the first I’ve ever heard of you. It’s a few years ago now. You gave a talk with the Ancestral Health Symposium about migraines as a response to hypothalamic stress which I think feeds into our need to play the game of being healthy humans. So, maybe you can tell us about how you think those factors integrate or how mismatched it is between our brain or our senses, the things that we use to perceive the environment can then be affected and how that might result in migraines?
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Josh: I think that for a couple of reasons migraines can be conceived up as a disease of civilization, so emerging in civilized populations and not an issue with hunter-gatherer wild humans. That comes both from the fact that I haven’t found any records of migraines existing in hunter-gatherer populations and the fact that the ancestral approach is for me by far the most powerful thing that I’ve discovered for treating them.
As a disease of civilization, that would mean that they arise when there’s a significant mismatch between our current environment and the environment for wild ancestors. There are multiple lines of evidence that would point towards the hypothalamus either as being activated very early on in the migraine process or as degenerator of migraines. I won’t go into too much detail onto why that is but I would say that you probably make the best case if that’s where they originate.
If you then consider what the function of the hypothalamus is, it’s probably the one place in the brain that bears the brunt of this mismatch more than anything else. Its primary function is to coordinate all the processes in the body that maintain homeostasis, that maintain stable internal conditions even when the external environment is changing.
The definition of mismatch is that our environment is not matched to the one that we evolved in and so the part of the brain that’s going to feel that the most is the hypothalamus. It’s going to be having to manage these environmental conditions that we didn’t evolve under. For me, this is the most powerful and helpful model for understanding what helps and what doesn’t with migraines.
So, many of the most significant migraine triggers we know of can all be conceptualized as significant homeostatic stressors. So, things like disrupted sleep or disrupted circadian rhythms are huge ones. Stress, emotional, psychological stress is a huge one. And then I would argue another one would be the sort of problems with energy homeostasis that the person on a standard western diet is constantly dealing with, the blood sugar rollercoaster because when we see when all of these things are dealt with and addressed and stabilized then the migraines go away.
I conceive migraines as occurring when the homeostatic capacity of the hypothalamus is being strained in some way. Oftentimes it’s in ways that are additive so it may be in multiple different domains of homeostasis that are producing that strain on the hypothalamus and, ultimately, it’s overwhelmed and a migraine occurs. Using that has been a very effective model for understanding the things that they’re going to work the most for treating migraines.
Tommy: Great. I think that makes perfect sense, at least the model to think through when you’re talking about things that might trigger migraines. So maybe people listening to this, this may have patients who have migraines either as part of a general practice or even a neurology practice, maybe you could tell us what you found are the common pitfalls of treating migraines in a standard western medical western model versus the easy wins? You alluded to some of them, but the things that you really find work the best particularly as you’re starting with someone who’s trying to help treat the migraines.
Josh: I’ll start by saying that I think of when I started implementing these ancestral health principles on a broader scale, I realize that there were a couple of things that would stand in the way of people’s progress in certain instances. Probably the biggest of those was the role of what we call abortive medications. These are medications that you take to relieve an existing migraine. They can be over the counter medicines or ones that are by prescription.
Incidentally, the one that I mentioned earlier, the last major breakthrough in neurology was in the early ’90s and that was actually a migraine medication which is Sumatriptan. One of probably the biggest things that would stand in the way of progress was neglecting the role of abortive medications in terms of their ability to continue the migraine cycle.
There’s a phenomenon known as rebound headaches in migraines where abortive medications taken for migraine sort of confer a vulnerability to future migraines. It may help in the short term but make you more likely to have one in the next several days and that can end up being a feedback cycle that people can never get out of.
Traditionally, it’s been through that if took quite a bit of medication to do that. I think that we’ve underestimated just how little it takes for that to be a problem. And so I think that one of the pitfalls, huge pitfalls, in terms of conventional migraine care has been in under appreciating the role of abortive medications in perpetuating migraines.
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So, if I reflect back on my own personal experience and my own professional experience treating migraines in the conventional way for years, so often what would happen is somebody would come in with the occasional migraine, get started on migraine specific abortive medications and they might work to get rid of existing migraines but then they would continue to increase in frequency. Often we were turning this episodic problem into a chronic one.
If you would think that the last breakthrough in migraine that I mentioned in the early ’90s, we had this Sumatriptan, which is really the first medication that worked reliably well for a lot of people at aborting a migraine, that should have led to a pretty significant impact on reducing migraine headaches on the whole, right? But it hasn’t. In fact, if anything, I’m seeing more and more people with chronic migraines over the years.
I ultimately realize that we were trading this short term solution for a longer term problem. That’s a pitfall that is very common in the neurological clinic and can even be common in someone who’s trying to apply an ancestral approach if they don’t realize the impact that those abortive medications can make. One of the things and the folks that I work with is we try to over time minimize those as much as possible.
Because we kept seeing people, once that happened, just get over this hump and go from having them several times a week or whatever to zero once we got rid of that piece. That’s one of what I call the three pillars to migraine protection. One is eliminating rebound headaches or what I’d call medication induced vulnerability which comes from the abortive medications. The second being eliminating mismatched diet and behaviors which is the foundation of ancestral health principles. And then the third being establishing metabolic flexibility, which is oftentimes a byproduct of adopting an ancestral diet and lifestyle.
But in some cases, with folks with migraines, deliberate carbohydrate restriction to speed up the transition to fat adaptation and, in some cases, even ketogenic range, carbohydrate restriction can also be a really helpful additional tool. Those are the key principles. And then as far as the other pitfalls go, I think a lot of times what can happen is people can then focus a little bit too much on the diet piece and neglect the other lifestyle mismatches that are also important.
If we consider the migraines as a disorder of hypothalamic stress, it’s not just food that’s doing that. Sleep is, obviously, huge and being really diligent about getting not just good quantity but quality sleep as well. Stress and physical activity also being really important pieces not to neglect.
Tommy: That gives you a great framework to pretty much approach anything right. There’s the, I guess, the migraine specific aspect of the rebound headache but then everything else can be applied in a much wider fashion. You’ve already given us the answer here but in terms of your future projects, you’re branching out into not just focusing on migraines but focusing on overall brain health and cognition in general.
Like you said, you have background experience and knowledge in behavioral and cognitive aspects of neurology and neuroscience. So, what do you think that we could all potentially be doing to maximize our cognition, our brain health? I’d like you touch upon the dietary factor you talked about. Ketogenic diet, is that something that you see should be applied more broadly or is it something that you use as a short term tool to induce metabolic health benefit and then you can add carbohydrate back? How does all that fit in to your bigger picture of long term brain health?
Josh: For me, I do use a ketogenic diet. Particularly with the migraine population, I think it can be seen as a strategic tool oftentimes for moving people further and faster along the timeline of recovery. Generally, I think of it as a short term measure whether that’s weeks or months or whatever. That could be individualized. But I do have some folks who do it and then they’re so blown away by how much better they feel that they don’t want to stop.
I let them figure that out for themselves but I don’t necessarily, in my experience, it’s definitely not necessary in the vast majority of people to get them where I want them to be. I think the same in terms of the merits of a ketogenic diet just in terms of cognitive health and brain protection in general. I think that there are certainly evidence that would indicate that doing it periodically may confer some neuroprotective benefits.
I think it’s reasonable to cycle in and out of it periodically. At what frequency, we don’t know, but I think it’s worthwhile thing to do. But it’s probably not something I would — I don’t think there’s enough evidence to advocate doing it over the long term, indefinitely, but rather doing it on short term basis. And what was the first part of your question?
Tommy: The first part — Yeah, I mean, I would completely agree. I think as humans we have gone in and out of ketosis very regularly depending on food availability and where we are on the planet.
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But there’s very few populations where continuous ketosis is a normal thing. You think about the populations that rely solely on animal products who might be more likely to enter ketosis. They actually often have — So, when you think about the Inuit populations, they often have genetic mutations that prevent them from getting into ketosis even though the fact that most of their calories come from fat. I think there’s definitely some benefits from ketosis periodically. But whether that’s a continuous requirement I think is something that we still need to figure out.
The first part of my question was what are your principles for overall cognitive performance and health? I feel like they’re going to be very similar to what you recommend to your migraine population. But people listening to this, they want to be good physicians and parents and family members and friends for as long as possible, and how do we keep everybody’s brain as healthy as possible for as long as possible?
Josh: I totally agree as far as the ketosis goes. I think that actually highlights how we think about using the ancestral health. We’re starting with what have our ancestors done, what’s our evolutionary history, and saying, okay, first thing probably is to start there, to mimic that as our base line. And then if we have scientific reasons to think that doing something beyond that is beneficial then we go there. But until that evidence is there we wouldn’t necessarily recommend. I think that’s the approach we take with everything in this domain and that’s how we should be using science to inform what we do in matters of health.
As far as cognitive health goes, and this obviously is going to get back to the playing the game discussion, the unique thing about the brain is we have two things to consider. We’ve got the hardware, the wet ware, optimizing the biology. But we also have software layered on top of it that can change. And that’s the unique thing about the brain as an organ, is that it’s capable of this massive growth and we can shape that growth in ways that benefit our health.
Obviously, their fundamentals for just keeping the biological function of the brain healthy are going to be the exact same thing that I would recommend to someone with migraines particularly with adopting the ancestral health principles. But then on top of that, making the most of the software function and building the most robust cognitive apparatus that you can, my favorite things to recommend there are things like playing music, dancing, creativity or creative hobbies, play and social connections.
All of these things that we come pre-wired and ready to do and that have been traditional human endeavors for a long time, I think, are still going to be the things that will give the most benefits in developing and engaging the most wide ranging cognitive networks to boost cognitive function and to protect against degradation.
One of the things that I use to inform my understanding of both how to shape our learning process but also to understand what’s good for human cognition is to look at kids because you have, in children, their primary mission is to grow their brain. Many of the behaviors that they’re instinctually gravitating towards or towards that purpose or to try to build the brain and sort of rebuild a robust cognitive apparatus that will support being a fully functioning adult.
I don’t think it’s any coincidence that kids love to make art. They love to play. They love to make music. And they seek these things out. Unfortunately, I think we’ve been so conditioned now to thinking that the things that we find rewarding are bad for us because we live in a mismatched environment. We stop kids from doing these things that they really love because we think it must be bad for them because they like them so much.
But I would argue that the reason they love to play and run around and make stuff and do art and all this stuff that we spend less time in these days in our educational system, the reason they love to do that is because that’s what their brains find rewarding because that’s what their brain is seeking. I don’t think that changes as you get older. But what does probably change is that that process is no longer on a script.
When you’re born and your brain is developing, a lot of the stuff is scripted in your genes. You do the things that will develop the brain, and the best example that’s being language, which is why every child goes to the same exact sequence in acquiring language, is because that whole process has been scripted. But it’s also the perfect model for how to learn anything because it’s been designed by hundreds of thousands of years of evolution. Same is true for the other things that kids love to do so much. And so I still think that those are going to be the cornerstones of building the most robust brain possible.
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People, whenever they ask me, and I’ve had this question many times over the years, what should I do to protect my brain? I think they’re always expecting me to tell them to do crossword puzzles or to take some supplement or something like that. My answer is usually either to learn a musical instrument, learn a language or learn to dance or increase your amount of social engagement. Because those are still by and large going to be the things that tap into the most widely distributed amount of neural real estate which we know the more robust your cognitive networks are the more resistant they are to degradation and disease.
Tommy: Yeah. And there’s the perfect game level interventions, going back to that model you talked about. I completely agree. There’s always a temptation as a physician or a scientist to think of things in terms of biological pathways, what supplements can I take what, how was I going to intervene at the level of the source code when maybe that’s absolutely not the best way to improve brain or cognitive health.
So, now I wanted to dig down into that a little bit. You’ve built a site on teaching people how to learn the banjo called Brainjo and the whole idea is you’re leveraging the best parts of neuroscience to help people accelerate their learning so they can learn to play the banjo. This is very interesting to me specifically because I tried a whole host of musical instruments as a kid. My mom thought it was very important for me to learn to play a musical instrument.
I really hated being bad at it. When you’re learning to play an instrument, other people can hear you being bad at it. It was that which I found very difficult to deal with. I actually ended up spending most of my time singing both in bands and choirs because I could hear a piece of music and I could sing it straight back and would almost immediately sound like it was supposed to sound. Then at least I never had that part of being bad at it.
I’m very interested to hear how you leverage the best aspects in neuroscience so that people can learn a musical instrument like the banjo as quickly as possible and then maybe convince me that I can learn a musical instrument without having to spend so much time being really bad at it. Or maybe that’s just part of the process and just to embrace it.
Josh: It is to some degree. In fact, that feedback is a double-edged sword because it’s, on the one hand, you don’t like to hear yourself being bad. On the other hand, being in a feedback rich environment is actually great for learning because you know immediately when you’ve done something well and you haven’t. So, one of my missions, one of the reasons for launching Brainjo, which is a company that the mission is to design a musical instructional methodologies for learning how to play music that integrates the science of learning and neuroplasticity.
Basically, trying to take a first principles approach to how should we learn music. Part of why I wanted to do that was because I saw the failure rate with learning musical instruments is so high. One of the things that’s done that has reinforced this idea that it’s an innate aptitude. It’s something you’re either good at it or you’re not, which is also a version of what we call the fixed mindset.
I hate the fixed mindset because I think it’s apparently limiting and, in most cases, it’s untrue. And so I wanted to get a method that’s something out there for folks who wanted to do this to show that it’s not about the brain that you have but it’s about the brain you build and it’s about whether or not you’re using practices and methodologies that support the brain’s ability to change itself.
In my opinion, the biggest reason why the failure rate for music is so high is because our instructional methods have not been very good at all. Honestly, the whole science of how the brain changes itself which is the biological foundation of all learning is absent from education in general which is crazy, but it’s specifically applicable to music.
There are lots of different ways where you can use neuroscience to guide this process and establish best practices. You start with the end goal for whatever endeavor it is and defining that end goal in terms of the cognitive networks that you need to build to support that. For example, if you talk about the way music is traditionally taught, it’s almost always taught using the approach that’s been handed down through classical music.
Number one, it’s not a process that was designed with the learning in mind. It’s been around for a very long time. But it also wasn’t designed for people who want to do something outside of classical music, which is honestly what most people who were learning musical instrument are wanting to do anyways. From the get go, starting to build cognitive networks that don’t support the thing that you actually want to happen in the end.
The approach with Brainjo is the first set out what those networks would look like and then work backwards. Ultimately, the learning process particularly with skill learning like music, what you’re doing is building neural networks or sub-routines that increasing complexity. You breakdown the whole skill set into most fundamental components you can and what you’re trying to do is take you to those components, learn them individually to the point where they become what we’d call automatic. Basically, that they no longer require the conscious mind for their activation and then move on to the next skill.
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So, you’re trying to build these networks that are ultimately subconscious of increasing sophistication that support the thing that you’re trying to do. In that, the sequence in which you do it, when you decide to move from one to the next, is really important. And then along with that is the fact that once you’ve developed a new neural network, it’s gone from conscious to subconscious. That’s what happens particularly with motor learning where you have initially something you’re doing that you’re controlling with conscious mind then it becomes to where you can do it without having to focus at all. Just like all of us can drive a car without having to think about it.
Any time that happens, you’re developing a subroutine that’s no longer under conscious control. If you build one that doesn’t do the thing you want it to do then you’re in trouble. This is what so often happens, is that people end up building what David Eagleman who wrote a book called — I can’t remember the name. He refers to them as zombie subroutines. Meaning, they’re operating without any type of conscious control whatsoever.
And so the double-edged sword of that is that, A, yes, that means you can build all these behaviors of increasing sophistication because you no longer have to worry about them with your conscious mind by the same token they will operate. Those subroutines will run the same way every time depending on how you built them in the first place. You have to take a lot of care in the beginning to make sure you’re building the actual subroutines and that they’re doing what you want them to do.
And so that’s the overarching framework for how to think about the learning process in its entirety. That applies to music but also applies to other things. If you break the whole thing down into a series of steps, then you can also use principles that we know from learning and neuroplasticity to understand what’s the best way to learn new step and to move from one step to the next, things like how much to practice, when to practice, the role that sleep plays, and using other techniques like visualization and so on.
There’s a lot of other stuff that we can do to support the building of each of these subroutines and the most efficient and effective path possible. And what I would say too about the fact that you noticed that your playing was bad is a good thing. This is another soap box. If you’re able to hear when you’re off and when you’re not, and particularly if you’re able to sing, then you can play, you can learn a musical instrument. You can learn to play musical instrument by ear, which is what people were doing long before written music ever came about.
If you’re able to sing or if you’re actually able to recognize when someone is singing off, then you can learn to play by ear because all it takes is being able to match a pitch in your mind with the pitch that you’re hearing and telling if those are on or off. If you have that capability, which most everybody does, then they can learn to play by ear.
And then it’s just a matter of actually following a learning path that gets you to that point and that gets back to building cognitive networks that actually support being able to play by ear rather than being able to play by note or with written notation which is what the classical method does.
Tommy: That makes perfect sense to me. The fact that I didn’t undergo as intensive training in the musical theory as somebody learning music definitely hindered me later on when you go and maybe you’re auditioning for something either a part on something on stage or for a choir and you’re handed a piece of music and you can see the notes — I mean, I don’t play musical instruments but just basically to be able to sing whatever it is from sight. You can see the notes and just be able to sing.
I could never do that. I never taught myself to do that. But if you played it to me, I could immediately sing it back to you. But because it’s just expected that you should be able to look at the music and immediately sing it then I was stuck just because of that traditional way that things are supposed to be taught. And I never did that. Even though I know I can sing I was never able to take it any further just because of that thing that you’re expected to be able to do.
Josh: Yeah. The whole musical notation has been a pressing force for many people and has led so many people to give up who shouldn’t have and it’s just because it doesn’t belong. It’s being used in domains where it doesn’t even belong. It’s not only not useful but it obstructs the process.
Tommy: Fascinating. [0:39:19] [Indiscernible] but it’s great because that explains a lot to me personally. It makes me feel better about some things that I never learned how to do. Just because of your wide range of experience, I mean, I got to change tacks twice before we finish and the first thing that I wanted to ask you about was placebo. I know you’ve done a lot of research into the placebo effect particularly in terms of neurology, antidepressants and their trials compared to placebo, but also in the bigger picture stuff. I just wanted you to maybe give us your thoughts about the placebo effect, how that might be having benefit, and then maybe ask you a philosophical question which is that should doctors be able to prescribe placebo?
Josh: The whole conversation around placebos touches on a lot of different things and brings a lot of baggage that we have in thinking about the role of mind and psychology on health.
[0:40:09]
I think in many ways obstructs us from making progress in a lot of different areas. We know that the placebo effect is huge. The whole reason why we have placebo controlled trials is because we know that in any trial you do there will be a placebo effect.
And the placebo effect, meaning, simply expecting that something is going to be beneficial will make it more likely to be beneficial. We know that happens across the board. We also know that in most trials even in trials of drugs that work and that we use, the benefits that are seen are still primarily, are still disproportionately towards the placebo. The placebo effect is still the greater effect than the actual active effect of the drugs.
The point being is that the placebo effect, which is mediated through belief, is huge. And the knee jerk reaction that everybody has to that is that it’s not real or that it’s less real and not the same as a drug having an impact through another way, affecting a biochemical pathway, whatever. Ultimately, that gets to our issues kind of around the mind-body dichotomy.
We all feel as if our mental life is something separate from our physical body. We have this feeling that we have this immaterial self and that our subjective experience is not of the same stuff that’s of the rest of our body. Even for those of us that recognize on an intellectual level that this is not the case, that the stuff that goes in our mind is still a product of our brain, it will never feel intuitively like that to us. And you guys in the Nourish Balance Thrive podcast have some episodes about the power of mindset and so on.
The research on that is still on some level amazing. It’s still, no pun intended, mind blowing, some of the things that can happen from just changing mindset. I think the reason why we still feel like that is so surprising, is because we just, we still have this intuitive disconnect between thinking that our mental life can affect the happenings of our body.
But, in fact, it’s all the product of our brain and our brain is wired into everything. It makes perfect sense on a scientific level that the happenings in our mind can affect our physiology in many different ways. And the problem is that we still think of placebos, like I said, as less real, as not operating in the same way as another drug is operating. It’s not remediated by placebo in effect. When, in fact, at the biological level, there’s no difference. It’s still biology.
There’s all sorts of problems that arise from this but one of those is that, a, there’s this ethical issues around should we prescribe placebos or should we use treatments that remediated primarily through changing mindset or changing belief as if that’s something less real or there’s a problem with that. And that comes from this mind-body false dichotomy that we all carry around believing that it’s something less significant.
That has other implications in other aspects of health particularly in mental health. You also have many conditions and neurologists see this all the time, quasi-neurological or medical conditions that arise, they’re primarily — Thought disorders arise from mindset and we know this to be true but then if you couch it as such you have the phrase, “This is just in my head,” which means it’s less real, it’s less significant. It’s the same as just a placebo.
It’s this idea that it’s somehow different or somehow less real. And it’s not. It’s preventing us from actually developing treatments that would make a difference in what so often happens in those situations, conditions that are rooted in the psyche but have quasi-biological neurological manifestations, is that there’s no place, there’s no treatment, there’s nothing. People would just end up going from one doctor to another and never getting issues resolved.
In the placebo arm, we haven’t explored the potential of this type of approach nearly in the way that we could. There’s so much, I think, more left that we could be doing with this if we got smart about how to use it. But until we lose this idea that it’s something different or something less real, we probably won’t make any progress, which is a shame.
They could be very powerful tools and, to me, mindset, like we talked about before of game level interventions, is another game level intervention, right? The reason why placebos and changes in mindset are so powerful is because they’re operating upstream and they’re amplifying or activating or supporting our own endogenous mechanisms for repair and recovery in ways that drugs can’t do.
[0:45:04]
And for those of us in this world of ancestral health, we’re looking for the treatments to do that. We understand those have the most power. Anything that intervenes or acts in the realm of mindset is going to be along those lines. And so personally I want to explore those things to the fullest because they have so much potential and there’s so little downside risks that’s true of so many of the game level interventions. But that’s definitely true of anything that intervenes through mindset including placebos.
Tommy: Absolutely. And this kind of reminds me of a lot of the push back that I imagine people who are in our field in the ancestral health field will get which is that if you introduce a lot of different lifestyle based interventions, you can never isolate whichever one thinking that it might just be one. You can never isolate which one it was that had the biggest impact. And you can also — how do you know that some of it isn’t acting through placebo?
My obvious response would be great. Placebo is brilliant because you got a better fit with zero side effect. Thanks very much. I’ll take that any day. Is it a lot of the stuff that we’re recommending may just be creating a placebo effect that helps change people’s mindsets and is that okay?
Josh: Yeah. I think that the fact that that’s a question highlights the issue. Why do we care? It’s just as much an intervention as exercise. We shouldn’t actually be, number one, viewing it as different in kind. If it is, like exploring, how can we maximize that to the fullest? Yeah, I don’t think there’s any problem with things being mediated through placebo?
Tommy: There’s been some push back in terms of trying to implement trials into some of the things that we would maybe recommend, people trying to put together clinical trial where you change diet and sleep and maybe you give a couple of supplements if it’s for Alzheimer’s disease and there’s some things that we know can affect methylation, reduce homocysteine or supplement B12 or vitamin D, one of those things that we think might help.
If you change all of those things then, obviously, ethical review boards will say, “Well, hang on a second. You’re changing so much we don’t know which it was that caused the benefit.” The obvious response would be, “Oh? All these things we know are going to play a part.” I think that’s just part of the struggle we’ll continue to see as we try and get more evidence to support some of the things that we’re trying to implement.
Josh: I think too also, separating the practical and the pragmatic from the scientific, what you do want to know on one hand from a scientific point of view, what’s mediating this benefit, right? That’s where it’s helpful to be able to disentangle in certain cases. Is this being mediated through belief or is this being mediated through something else? That’s useful.
But from a clinical standpoint, from a practitioner’s standpoint, that doesn’t really make a difference if it’s conferring benefit. It reminds me too of some of the studies on acupuncture for things like low back pain where they do real and sort of the standardized approach and then compare to sham acupuncture and show that the real and the sham are the same. But both groups keep this really incredible improvement.
Whether it’s sham acupuncture or real, they’re both getting great benefit from it and it’s being mediated through belief and mindset but it’s better than what you normally get with other treatments. So, from a scientific standpoint it may answer the question of what that benefit is coming from. But from the standpoint of a person receiving the treatment, what do they care?
Tommy: Yeah, absolutely. I mean, that’s important. As scientists or in the field of science who want to better understand what it is that’s going on inside the body, as an example, and that’s part of the human endeavor is to learn and find new things out. However, when you have a patient in front of you, they don’t care what’s happening at the cellular level.
They just want to feel good. They want to not have whatever disease it is. They want to not be obese or not have Alzheimer’s disease or not get Alzheimer’s disease. They don’t care what’s happening at the cellular level. We do need to, you’re right, just separate those out and so maybe one informs the other but they don’t need to happen at the same time. I think that’s a really important overall approach.
Then, a different question that I thought might be helpful to some of the people listening particularly if their physicians are maybe thinking about reaching a wider audience or maybe changing the way that they practice, so you built two online communities now and I know you’re about to build a third. I know they shape the way that you work both to reach a specific audience and help those people but then also to create some passive income that’s allowed you some more freedom in terms of your career and what you’re able to do.
So, I was wondering if you have some tips on how to do this? Do you think that when people are starting to step out the mold of the traditional medical model, that they need to be doing more online stuff, building online communities? Is that an essential part of it? Whether or not that’s the case, if somebody does want to do that, do you have any tips on how they might start to do that?
Josh: I don’t think it’s necessary but it’s certainly an opportunity that’s there that’s emerged recently.
[0:50:03]
We live in a pretty incredible time in this respect where if you have something that can make somebody else’s life better, whether it’s a product or service or information that you have, that can make someone’s life better, solve their problem or whatever, you can connect with those people in ways that you could never have ten or 20 years ago, which opens all sorts of doors for people who have spent their lives developing expertise in things that can help other people.
So, first is just kind of stepping outside of the box and thinking of what’s possible outside of a traditional medical practice is useful and considering all that’s now available in that regard. And so certainly there’s lots of opportunity in that realm for the physician who wants to expand outside of the conventional practice. I think that the best thing to do in that situation is to just start developing your ideas, thinking about your own unique perspective, what’s the unique conglomeration of experiences and insights and ways that you can blend those together that’s unique to you and that could then translate into something that could help someone else.
And then start writing about those things. One of my mantras over the past several years has been always be creating. So, I start with just getting ideas out on paper and thinking about where those are going to end up later. That’s been a strategy that’s worked. So much of it is, once you have an idea or something out there that could benefit someone else, figuring out how to reach people with that is just the details. The major part is generating to begin with.
I would encourage anybody in this space who is thinking about that to just start by getting their ideas down and then figuring out at some point what they might want to do with that because it’s ultimately that kind of content reaching out to people that’s going to give you opportunities to do things outside of the traditional space and, in particular, for our selfish purposes of wanting to promote ancestral health. The more people, the more voices that out there spreading that message, the better, because that will mean it will reach more people.
I think if we’re going to see the changes that we want to see it’s not possible if we just all stay in the same, in this box of traditional medicine and because we’re just so limited in what we’re able to do for so many reasons. It’s going to take people putting their ideas out there and bringing their own unique perspective on this and showing how they might integrate ancestral health and so forth into their own area of expertise.
The more people who are doing that, the better. But on top of that, there are opportunities nowadays to turn that into an extra source of revenue or to transition completely into doing something like that and that there simply weren’t in before. I think too that one of the issues that professionals face and particularly physicians is that we have all this year of training and money and everything that goes into it that there’s a huge sunk cost fallacy that can come into effect.
We don’t want to do anything differently than what we’re doing because then we think, oh, well what about all that time and money and effort I spent into getting to this point? I think even though most people aren’t probably wired to do one thing day in and day out for decades, physicians generally tend to do that even when they may not want to largely because of the sunk cost fallacy.
So, cultivating an awareness of that bias, I think, is a healthy thing to do and maybe allow you to become a little more flexible about the things that you might consider doing outside of the traditional realm of medicine. I certainly now think of my life more in terms of what project do I want to work on for the next several years. I think that’s how I think about it from here on out rather than thinking I’m going to be doing one thing forever.
Tommy: Doing that forces you to learn new things. It’s just going to keep your brain healthier for even longer.
Josh: Absolutely.
Tommy: One thing that I know I’ve struggled with myself is less of the sunk cost fallacy and the fact that I sank less into my medical training compared to a typical US physician. Obviously, it does help because I don’t have that level of debt that you would come out of a medical school with here in the US. But transitioning over to something where you exist largely in an online space and then, therefore, it requires you to sell yourself to a certain extent.
Many physicians and many academic scientists, one thing they’re not very good at doing is selling themselves because it feels slightly unnatural. Something, as a conversation that we were having with other guys part of Nourish Balance Thrive, just over the last weekend, which I think helped me frame it slightly better was that at this stage you’re not necessarily selling yourself. You’re not out there. It’s not that kind of dirty marketing out to make a quick buck kind of thing which you might be associated with.
[0:55:00]
Actually, you’re in a place where you have something that you know will help people. Therefore, there’s almost an obligation on you to make sure that gets out to people. So, it’s not that you’re doing this as some kind of marketing scheme to make money out of people. You’re doing it because you know it’s going to benefit people. And the same thing would happen if you found something that cured a certain disease, which funny enough, some of these things, approaches, can do.
But if this is a drug that could cure a disease, it would be, you would be obliged to make sure that as many patients as possible got and then approaching some of these aspects of lifestyle and ancestral health, I think, are the most powerful things that we have for many disease currently. We are obliged to make sure that people find out about that and help them do that as much as possible.
As people transition into doing things like that, if you are member of Physicians for Ancestral Health or you want to join and become a member, we will help you do that. I know that I am very bad at marketing for myself so I’m lucky enough that I work with other people who can do a bit of that for me. If you’re a member of the society, if you create content, you’re on podcasts, we will through our social media outlets help to promote those things.
We’re still expanding that currently and I know that’s something that will get bigger over time. This is something we can help each other do. We’re certainly not competing. There’s far too many sick people out there that need our help. So, the more the merrier. We will help people, as part of the society to do that because I think that’s something we’re going to struggle to do because I know that I struggled with that. So, hopefully, helping people to do that will help them get over the hump and figure out how to best do that.
Josh: I think I was fortunate in some respect that I started out with trying to get the message out about migraines because I came from that place. It was really thinking, oh my gosh, I have something here that could really transform lives everywhere and it’s not out there. I have this obligation to do something about that. That made it easier particularly in that domain for me to get over the idea about selling and marketing and reframing it as I just need to get this message to the people who need it. And, yeah, we are certainly willing to help our colleagues who are trying to get this message out as well because we believe that it needs to.
Tommy: I think that’s probably a good place to wrap up this podcast. Maybe you can tell people where they can find out a bit more about you and your work, where they can go to learn how to play the banjo or learn how to cure migraines and interact with you about those things as well.
Josh: Not too long ago, I created a site that’s jturk.net. Partly because I was struggling so often with people saying, “What do you do?” They didn’t know I have a bunch of different projects that I really geek out about. That’s my central hub that organizes the stuff that I’m interested in, the stuff that I’m doing. There you can connect with the stuff, the Migraine Miracle and all the information around that as well as if you want to go to my stuff on learning how to play the banjo or other musical instruments, and as well as the most recently launched project which Tommy is also a part of which is called the Optimal Brain.
We’re talking about things we can do to optimize brain function, cognitive function and health and prevent against disease and degradation. That’s where I see my work going over the next several years. I’m really excited about that too. Jturk.net.
Tommy: I just went there and it looks great. Everything is in one place. I definitely encourage people to go there. Thank so much, Josh. We will be back soon and we’ll start by interviewing some other members of the society to hear more about what other people in our group are doing and, hopefully, people will be back to listen to the next episode. Thank you.
Josh: Thanks so much. I enjoyed it.
Tommy: Cheers.
[0:58:52] End of Audio