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The Nocebo Effect: When Our Words and Beliefs Make Us Sick

Most everyone knows about or has heard of the placebo effect; the seemingly magical ability for our bodies to feel better or overcome illness from a belief in a treatment that has no effect.

It’s one of the things in medicine that we are always wary of, especially when selecting treatments associated with alternative medicine. After all, no one wants to waste time, energy, or money on something that isn’t supposed to work. It feels like you’re getting scammed, even if the end result is positive.

However, there is a lesser known effect that I believe is more harmful phenomenon that isn’t being discussed enough. It’s more pervasive in the entirety of healthcare, and it’s societal ramifications can have massive implications on outcomes related to your own health.

We’re talking about the Nocebo Effect

Nocebo, No Bueno

Where positive beliefs about a treatment lead to positive health outcomes in placebo, nocebos occur when negative beliefs about a treatment or condition lead to negative health outcomes.

We don’t really think about nocebos because in the context of healthcare, we are not really encountering clinicians or practitioners who are intentionally trying to to make us feel worse. It’s just a poor business model.

Nocebos affect us in much more subtle ways. They happen when patients have false or exaggerated beliefs about a treatment, condition, or situation, and these beliefs can often come from well-intentioned providers or social media influencers.

Here are some of the examples of known nocebic responses in society:

  • People who think they are sensitive to MSG and feel sick after eating Chinese food with suspected MSG, but feel perfectly fine eating MSG-rich snack foods. David Chang tackles this in his series Ugly Delicious on Netflix. You can watch the clip here (Warning: uses the F-word a few times). I’m not saying that people can’t be sensitive to MSG (probably really uncommon), but if you are sensitive to MSG in Chinese food, but not Doritos, then you’re not sensitive to MSG, you’re likely expressing a nocebo.
  • Patients who take a placebo pill in a drug trial and hear a list of potential side effects are much more likely to experience those side effects compared to patients without hearing the side effects. [Source]
  • In 1998, a teacher in a Tennessee school reported a “gas-like” smell inside of a school. The school was evacuated, and the ensuing panic from a suspected gas-leak led to over 100 students/staff going to the emergency room with 38 of them being hospitalized over-night. It turns out that it was a false-alarm and no leaks or chemicals were detected so the illness was attributed to a mass psychogenic illness. [Source]

But remember this because it’s super important:

People experiencing nocebos are NOT faking their illness. Their symptoms and experiences are very real, but the cause of their pain or illness is not what they think it is.


Our minds exert extraordinary influence on our bodies, but our minds are easily fooled for the better with a placebo, or for the worse with a nocebo.

Are Doctors Creating Nocebos?

One example we see often in chiropractic are beliefs about X-ray or MRI findings. Many patients after getting X-rays and MRI show signs of disc degeneration or disc herniation. Disc herniations in particular are known to cause radiating arm and leg pain, especially in the acute phase of injury.

Doctors frequently talk about disc herniations and tell people that they can’t play sports anymore or lift heavy things because they have disc herniations.

But the evidence is overwhelming in showing disc herniations don’t necessarily cause chronic back pain. In fact, most disc herniations are completely asymptomatic!

By the time we are 50, we will all have disc degeneration, and most of us will have bulging discs and we will walk, run, and exercise fine without any pain!

A large study using MRI on patients without pain showed that common MRI findings associated with pain are present in PAIN-FREE people as we age.

But if we have taken the patient with a disc herniation and convinced them that their back is weak from herniation and to avoid exercise, we are predisposing this patient to nocebo to one of the best things for the chronic back pain patient….EXERCISE.

As clinicians and healthcare providers, we have to be extremely judicious with our words when interacting with patients. We are responsible for knowing when something has life altering consequences and making the appropriate recommendation for care. On the flip side, we have to be informed and know when a diagnosis is probably self-limiting and allow the patient to feel empowered that they’re going to get better; with or without our help.

Combating Nocebos

None of us are immune to the effects placebo or nocebo because of the powerful influence that beliefs have on human physiology. Our brains love to create patterns out of noise in order to make sense of the world, and the easiest way to make sense of the world is when our perception matches our beliefs.

It is important that we have strategies that reduce the impact of nocebo because nocebos can decrease your ability to recover from chronic pain and illness.

I’ve seen so many patients come into the office that have become so scared of normal human behavior that they may as well wrap themselves in bubble wrap.

This isn’t a way for a human being to live.

So how do we counter the effects of nocebo? Here are some major factors I’ve seen in practice:

  • Never Make Your Diagnosis Your Identity: You would never willingly allow someone to steal your credit card and social security card, but you should be even more protective about what you allow to identify as yourself. When people make their diagnosis their identity, they become resigned to accept all of the possible negative consequences of their diagnosis as an inevitable part of their life.
  • Embrace the Idea That Your Body Is Resilient: One of the first things we teach patients in our office is that their body is capable of healing itself. Having a belief system that your body is capable of facing challenge and enduring allows people to have a condition or illness and not allow the condition to hold them back.
  • Don’t Trust Health Providers That Scare You Into Treatment: It’s one of my biggest pet peeves in the world when I hear other providers using a patient’s condition to scare and coerce people into procedures. I having patients coming in each week that have doctors telling them that a small herniation is a risk for paralysis if they get into another accident and that the only solution is surgery. I’ve also had patients whose chiropractor told them that they had the worst spine they’ve ever seen because they had some signs of age related disc degeneration on their X-ray. This. Is. MADNESS

As healthcare providers, we have to ensure that our words don’t compromise the ability for a patient to get better. When we use fear and scare tactics to coerce people into taking treatment plans, we not only abusing patient trust for financial gain, you are also compromising the outcomes of patients who simply want to get better.

We have to do better and help all of our patients combat this insidious plague on our patients by empowering people to have faith and confidence in their ability to heal.

Cervical Degeneration and Cervical Vertigo

Cervical vertigo is a controversial entity in the world of balance and vestibular disorders. It has generally been a diagnosis of exclusion when a patient is feeling dizzy but has no diagnosable pathology in the inner ear or brain.

The reality is that problems in the cervical spine are commonly linked to feelings of imbalance and disequilibrium. Cervical spine problems are rarely tied to the spinning rotational vertigo of someone having inner ear pathology. Most people with cervical “vertigo” really have which can include feelings of being really off balance, shaky, or a tilt like feeling of motion.

A 2018 study looked at how a degenerative problem in the neck can be associated with a diagnosis of cervical vertigo:

Mechanoreceptors in Diseased Cervical Intervertebral Disc and Vertigo

The study looked at patients with neck and arm pain related to cervical disc problems presenting for surgery. The patients were divided into patients with and without a complaint of vertigo. The patients with vertigo were examined to rule out other causes of vertigo like vestibular neuritis, benign positional vertigo, or stroke.

The research team examined the discs from patients with vertigo, without vertigo, and a control group of cadavers with no disc degeneration. The findings were really interesting.

In patients with vertigo, there are large increases in mechanical receptors in the degenerated discs compared to the patients without vertigo, and to the control group. These Ruffini Corpuscles help detect movement and position from your joints and muscles to help tell your brain what your joint is doing in space. Free nerve fibers are responsible for transmission of stimuli usually associated with pain. You can see the distribution below:

Patients with vertigo had significantly more Ruffini Corpuscles in their degenerated discs than the non-vertigo and control group. What does this mean for dizzy patients?
Patients with vertigo had significantly more Ruffini Corpuscles in their degenerated discs than the non-vertigo and control group. What does this mean for dizzy patients?
The data from the above chart in bar graph form showing increased receptors in the vertigo patients.

As expected, the patients with neck pain only, and neck pain with vertigo have a similar increases of free nerve fibers compared to controls. That’s probably why their neck is hurting.

However, a big reason why this study is interesting is because many people in the world of rehab and manual medicine would usually associate dizziness with a decrease in mechanical receptors in their spine, not an increase.

So what gives?

We don’t know exactly what this means, but it’s possible that increased density of these receptors may be transmitting excessive or erroneous information to the brain about the joint position.

The same group did a follow up study after they had performed disc surgeries on these patients. You can see the link to the study below:

Cervical Intervertebral Disc Degeneration Contributes to Dizziness: A Clinical and Immunohistochemical Study

During the study, they performed surgery on 50+ patients and 25 patients refused the surgery and received basic physical therapy and cervical collar recommendations. You can see the results below:

Comparison of patients with cervical dizziness and neck pain getting surgery vs routine physical therapy and neck bracing.

You can see that the patients who had the neck surgery showed clear and long lasting improvements in both neck pain and dizziness compared to the conservative group which implied that the degenerated disc was the probable source of bad sensory information to the brain.

So Is Surgery the Right Answer for Cervical Dizziness?

Maybe for some cases. If you have radiating arm pain with weakness tied to a badly herniated disc, then surgery might be able to help resolve both complaints, but there’s still a lot of research that needs to be done. Surgery is a BIG deal, and generally reserve that for really bad herniation cases with clear signs of neurological deficit like weakness, loss of reflexes, and atrophy of muscle.

The good news is there are a lot of ways to address cervical dizziness beyond routine physical therapy, and they have really great outcomes. One method is by improving the curve in the neck. A randomized trial of curve based rehab compared to routine physical therapy showed significant improvements in neck pain and dizziness at 1 year.

You can read some more about cervical curves and dizziness at this link:

Working on your curves: Long term outcomes from fixing military necks

A randomized clinical trial of cervical curve rehab on cervical dizziness

There’s also numerous cases of cervical dizziness that have no signs of degeneration in their spine. This is especially prevalent in patients with dizziness after whiplash and head injury in young athletes. These patients seem to do well when we focus on the upper neck where the injury is likely to affect the ligaments of the craniocervical junction.

Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial.

Long story short, degeneration of the cervical spine doesn’t have to be a sentencing for dizziness. It’s a risk factor, but it can be modified with the application of effective conservative interventions for the neck.

Whiplash Disorders: Why You Should Get Your Fat Neck in Shape

Whiplash Disorders: Why You Should Get Your Fat Neck in Shape

 

Read Time: [7-8 min]

I know it’s a little bit of a crazy headline, but today we’re going to talk about how a fat neck can contribute to chronic whiplash pain.

But I’m not talking about the width of someone’s neck. The neck I’m talking about can be thin on the surface, but have fat tissue build up in places where it shouldn’t. Namely, inside of your muscles.

It’s helped us to reveal a problem that many doctors miss when looking at conventional MRI findings.

Don’t Put So Much Stock in Disc Problems

For better or for worse, injuries from auto accidents are usually made or broken by MRI findings. That’s why your attorney has likely pushed you to get an MRI even though your doctor may have chosen against it.

If your doctor is like me, they avoid too jumping to MRI’s too quickly because sometimes it can really cause more harm than good. MRI’s give you the most highly detailed images available to the average consumer, but those extra details can be counterproductive.

In a patient’s eyes, an MRI report can be intimidating and scary. It’s common for most MRI reports to say things like:

  • Disc herniation
  • Degenerative changes
  • Stenosis
  • Loss of disc space
  • etc

Which is fine if you’re a health care professional and you need to know what’s going on. However, a lot of patients will look at these words, do a quick google search, and end up looking like this:

 

There’s a couple things to remember when seeing some of your MRI findings:

  1. Many of these findings are seen in normal aging
  2. Just because it’s on an MRI doesn’t mean it’s causing your pain or condition

To add more insult to injury (pun intended), things like herniated and degenerated discs are very disempowering as a diagnosis. In most cases, those findings are going to stay with you throughout your life, and that’s okay because even healthy pain-free people will have it throughout their lives too!

….even healthy pain-free people will have have herniated and degenerated discs throughout their lives too!

Whiplash and Fatty Neck Muscles

Generally we all wish we had a little less fat around our waist lines. In recent years, researchers have been seeing that fat can build up in muscular tissue and is associated with problems of aging. You can read some more about the science behind this problem in a great article on the Strength Theory Blog here.  This includes chronic pain which is the major concern for patients with whiplash.

Some recent studies are starting to show that identifying fat build up in your neck muscles can predict how well someone with whiplash will recover. [1, 2, 3, 4]

If you don’t want to read the abstracts, here’s the summary:

Patients with greater fat build up in neck muscles after an accident are more likely to have more persistent whiplash symptoms.

This runs counter to people with herniated discs because the presence of herniations is generally a poor predictor of pain.

Normal vs. Fatty Muscle Tissue

 

The problem with fatty muscles is that they don’t work the same way as lean muscle. Fatty muscle tissue is weaker in strength and endurance than lean muscle tissue.

But if you’re in pain, you don’t really care that much about your strength and endurance. You just want to feel better. As my friend Morpheus from the Matrix says:

What if I Told You

When muscle tissue becomes dysfunctional, your body loses a valuable neurological input to the brain that helps to modulate pain. That’s why exercise is such an effective form of medicine for people with various types of pain.

On top of that, when fat builds up in muscle tissue, it has neuroendocrine effects on the muscle tissue itself. These effects include:

  • Reducing sensitivity of muscle to insulin (Translation: muscle won’t eat as much sugar as it normally does)
  • Reducing Kreb’s cycle activity of muscle (Translation: muscle won’t use energy as efficiently)
  • Increasing the release of pro-inflammatory cytokines (Translation: more inflammation around muscle –> More pain)

Ultimately, fatty muscle tissue effects how the muscle contracts, how the muscle eats, how the muscle digests, and it predisposes your muscles to pain and inflammation.

While the evidence is still pretty new , it does seem to reflect why people who are stronger and have more muscle seem to be more resilient to pain problems.

Unlike Bad Discs, This Problem is Fixable

Fatty muscles can result from prolonged periods of inactivity. So it seems like a pretty simple fix. Move more, exercise, and get stronger. A small study on exercise for women with whiplash disorders show that neck exercise can reduce fat content in neck muscles and improve someone’s prognosis, so it does look like this problem is fixable. [Source]

However, one of the things that triggers inactivity after a whiplash accident is the immediate pain itself. When you have a whiplash, even small amounts of movement tend to be painful or instigate symptoms. The thought of exercising just sounds….painful.

So what can you do after an accident? Fortunately, these same rules apply with or without an MRI.

  1. Get the initial pain under control – There’s no shortage of therapies that can help control pain. Some use ice, heat, TENS, acupuncture, spinal manipulation, massage,  meds, etc. In order for you to get your body moving, you have to overcome the fear of movement that pain can cause.
  2. Position Matters – the ability to control the position of the neck is a key piece in normal movement. Developing this control depends heavily on establishing normal structure and normal positioning of the neck. This is where a structural approach to chiropractic plays a major role in recovery.Abnormal loading of the joints in your neck from Atlas Displacement Complex can contribute to pain, but it also can lead to Secondary problems like vertigo, headache, and brain fog after a whiplash.
  3. Gradual Progressive Loading – As the neck feels better and your positioning improves, you will want to gradually increase the strength of the muscles in the neck. Basic neck exercises like the chin tuck and chin nod can help train the small deep muscles of the neck. As the muscles get stronger and more functional, you will protect your muscles from fatty degeneration.Starting slow and gradually building up the resistance and endurance of your neck muscles is a key step in getting a good long term result after a car accident.

With a great understanding of the problems associated from chronic whiplash, we can utilize better tools to make sure that you don’t become a victim to chronic pain.

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Why Does My Head Always Tilt to the Side?

Head tilt

Read Time: [5-7 minutes]

How do I know if someone has an Atlas problem? Can a regular person see it?

Head tilting posture is something we’re used to seeing with curious puppies, but it may be a sign of a problem in the central nervous system. This can be one of the most important signs of poor neurological activity even in the absence of pain or symptoms.

Head tilt

Image from paper in the journal Laterality. Source: http://www3.canisius.edu/~noonan/research/researchreports/human_head_tilt.htm

Poor Head Position = Poor Interpretation of Gravity

Poor head positioning is one of the most important postural findings I look for in a Structural Chiropractic Examination. From a clinical perspective, it’s a lot more important than something like slouching. For the most part, people have the ability to recognize and correct a slouching posture when they want to. When it comes to a persistent head tilt, most people have no idea when it’s happening. It’s also a posture that is related to things like head injury, whiplash, or a balance problem.

When you have a persistent head tilt, you typically don’t know that your head is tilting because in your mind, it’s perfectly straight. This is an underlying indicator that your brain is working inefficienctly.

When you really think about it, posture is primarily your brain’s response to gravity. Whatever your body experesses as a straight posture is how your brain thinks it needs to exist in a gravitational environment. That means that a crooked head position means that the brain is getting bad input, which is leading to poor output.

Garbage in, garbage out

What does garbage out look like to the body? Garbage out expresses itself as Secondary Conditions like:

  • Headaches
  • Facial pain
  • TMJ
  • Vertigo
  • Balance Problems
  • Syncope (Dysautonomia)

All common problems experienced after a concussion or whiplash injury.

Why Head Tilt?

So what does head tilt have to do with concussion, whiplash, and all of these Secondary Conditions?

When your head and neck is exposed to a force, it can affect one of 3 systems in the body that control and regulate your balance and posture.

  1. Visual and Ocular system
  2. Inner ear/vestibular system
  3. Neck/Spine Proprioceptive system

Together these 3 systems integrate into your brain so that your brain knows how to regulate your body in space.

Your vision and movement of your eyes make sure that your head stays level. Your ears tell your brain if your head is moving. Your joints provide information on if your limbs or your spine are moving.

This system works best when all 3 give the same information. If your eyes and muscles say one thing, but your ears say another, then it creates a problem for the brain to process.

The 3 systems that form the Balance Triad

The 3 systems that form the Balance Triad

When you take a blow to the head or neck, then these structures can become damaged and start to malfunction.  We can see this malfunction manifest as a persistent head tilt to the side.

Head tilt may not be the cause of these problems, but it is a clear and obvious sign of a breakdown in this system.

It’s easy to see how a blow to the head can affect the neck because the two structures are connected via the top bone in your neck called the Atlas. In our Wellington office, we handle this problem by re-centering the head on top of the neck again utilizing the NUCCA procedure.

When the head is centered, then it’s almost like a re-boot to the system to make the brain work normally again.

Not All Head Tilts Cause Pain

Notice that not all head tilts cause pain, but head tilt is almost always a sign of a problem in the brain. Lots of people can go through a bad car wreck and not feel any pain immediately. However, the structure of their spine and the function of the brain has changed. This means that a problem can develop over time due to chronic malfunction of the nervous system.

That’s why everyone should get checked for a Atlas Displacement after an injury even if there’s no pain or symptoms present.

Not All Head Tilts Are a Neck Problem

Not every head tilt is related to a problem in the neck, though there is almost always at least some contribution from the neck. As we discussed earlier, there are 3 main systems that dictate your sense of balance.

There are times when I have done my best effort in correcting someone’s neck that a head tilt persists. That’s why it’s important to work with a team of professionals that are capable of addressing this problem.

  • Optometrists/Vision Therapy/Neuro-opthamology – These professionals are trained in addressing the ocular system. It’s a rapidly growing field thanks to our growing knowledge of concussion and how it affects the eyes.
  • Vestibular Therapist / Functional Neurologist – Special types of chiropractors and physical therapists are trained at rehabilitating problems in the inner ear. They use special assessments and exercises to restore normal function of the inner ear.

Remember: No one therapy cures all. An interdisciplinary approach is often the best way to solve many of these complex cases.

 

 

What a 10 mph car accident does to the neck

What a 10 mph car accident does to the neck

Pain after a car accident can be very strange and confusing. Take a look at these examples from my office and tell me if this reminds you of a situation that you or someone you know have been in.

Person A: Healthy and fit 37-year-old man in a car and gets hit at 45 mph+. The impact drives his car into the car in front causing extensive damage.

Person B: Healthy and fit 29-year old woman. Sitting in line in a parking lot when another car runs into the back of her at 10 mph or less. Minimal damage to the car and wore a seat belt.

Which one do you think had a worse whiplash injury and had pain immediately and which do you think just had soreness that they wanted to to get checked out?

Both had substantial biomechanical changes on their x-ray and MRI, but only one had a significant amount of pain immediately after the incident.

If you guessed that Person B with the parking lot bumper tap had the most pain, then you win! Congratulations on using the article title to your advantage.

The Deceptive Nature of Pain

Pain is one of medicine’s greatest tricksters. To this day, researchers and scientists don’t have a strong grasp on the nature pain disorders.

Why is it tricky? Because the pain someone feels isn’t necessarily related to the amount of damage in the body. Patients with fibromyalgia have crippling pain despite not having any visible damage to their bodies.

On the flip side, you can have someone like the image below with a broken neck and walk into an office with 3 days of shoulder pain after hitting his head. Thank you to my favorite radiologist, Cliff Tao, DC DACBR for letting me share this case.

Image credit to Cliff Tao DACBR http://www.clifftaodacbr.com

Show this to a doctor or health care provider if you want to watch them squirm. Image credit to Cliff Tao, DC DACBR http://www.clifftaodcdacbr.com

 

Pain is the most important factor to a patient, but it can be the most deceptive factor to a clinician. When it comes to taking care of people after an accident, we have to measure a patient’s function regardless of their pain status.

What Happens to the Neck After an Accident?

Insurance companies will only consider it a accident-related whiplash injury if you see a doctor within 14 days of the accident. So if you have no pain after the accident or the pain wasn’t bad enough to drive you to a physician until day 15, then you didn’t have a whiplash (I know how silly it sounds).

But going back to the previous example, we know that both Patients A and B had biomechanical flaws as a result from trauma to the spine. Despite the fact that there were 2 very different accidents and 2 different pain statuses, there are similarities in what can happen to the neck even after the smallest collisions. Take a look at the video below which simulates an accident less than 10 mph.

What Happens to the Neck in an Accident?

After watching the video, you can get the impression that a collision at just 5-7 mph causes rapid movement of the head and neck.

Despite the fact that your body is encased by a 2 ton metal box, it’s easy to see that even though the vehicle stops moving, there is still a transfer of energy into the body. When you’re wearing your seat belt, it causes a rapid deceleration of your body, but your head will continue to move forward and backward very rapidly.

In fact, a large enough force to the neck can actually produce a concussion even if there’s not direct contact to the head! These accidents would need somewhere around 90 G’s of force to the head.

While that would cease to be a small accident, the smaller 10 mph accidents can produce 3-5 G’s of force which is enough to damage the tissues of the neck. The way your head accelerates and decelerates can put 3-6 G’s of force into the cervical spine. This force gets transferred into the ligaments, muscles, discs, and joints of the neck more than any other piece of anatomy.

While the body can tolerate large amounts of force in brief periods, a large amount of force applied to a small region of anatomy as seen in a car accident can damage the tissues of the neck.

Whiplash
Ligament Injury

Ligaments are like the rubber bands of the spine. They can be stretched, but once they stretch too far, they can’t go back to normal again. As ligaments are damaged, scar tissue is used as a patch, but it’s not as functional as the stuff you were built with.

Just like when you sprained your ankle as a kid and that ankle never worked the same, damage to ligaments of your neck can happen the same way. Fortunately, true sprains of the neck take a lot of force and don’t happen with most accidents.

Muscle Strains

When muscle works beyond it’s capacity, or gets stretched beyond it’s end range, it forms small tears within the muscle belly. That’s why there’s no consensus as to whether you’re better off knowing about a coming accident and bracing, or if you’re better off being surprised.

Either way, damage to the muscle tissue can happen depending on the nature of the collision.

Muscle strains can be painful, but they can and do heal with time. Strain to muscle tissue is one of the most common sources of pain from whiplash injuries and resolve well with chiropractic and exercise.

Disc Damage

Accidents are one of the most common ways that people under 30 can suffer herniated discs in the spine. When the force of an accident overcomes the resistance of the disc materail, small tears in the disc can result in the inner fluid spilling into the spinal canal.

Sometimes this results in a pinched nerve, but most of the time it does not. A disc problem doesn’t have to be a big problem. Many people have disc damage and have no idea because it’s not symptomatic.

Structural Shifting

The muscles, ligaments, discs, and nerves of the neck help dictate the Structural Positioning of the spine. The force of an accident can deform one or all of these tissues leading to abnormal positioning of the head and neck.

This leads to abnormal neurological input to the brain and what manifests as poor posture (slouching, head tilt, antalgic lean). While poor posture is not the problem that needs to be treated, it’s an objective sign of a nervous system is operating at less than it’s full capacity.

Remember That It’s Not About Pain

Remember at the beginning of the article we talked about how pain can be deceptive. The reason I wanted to point that out is because you can experience damage to all of the above structures and not feel an immediate onset of pain. Pain is just tricky like that.

Whether you feel immediate pain or not, your neck should always be evaluated even after minor accidents because it gives the earliest and best opportunity to correct a silent problem.

Talk to Dr. Chung