Matt Smith, MD (July 20, 1979 - September 19, 2016) was Board certified in Physical Medicine and Rehabilitation with fellowship training and further board certification in Pain Medicine and interventional pain procedures. He was part of Alabama Pain Physicians, and practiced Pain Medicine, Wellness, and Performance Medicine in Birmingham, Alabama, where he lived with his wife, Meggan. In addition to his medical practice, Dr. Smith's professional interests included teaching at the University of Alabama, Birmingham, research, and the quantified self movement. He was also fond of strength training, cooking, walking around local trails, and paddleboarding. Some of his writing can be found on his website, Barbells and Stem Cells (www.docmattsmith.com).
Originally Interviewed by Dr. Jim Eubanks in February, 2016
How did you become interested in medicine, and specifically, what attracted you to the field of Physical Medicine and Rehabilitation (PM&R)?
First, regarding Medicine: I, like most physicians, felt an affinity for the practice of medicine since childhood. Ever since I realized that at some point I would have to get a job – probably sometime around age four or five – I thought that being a physician seemed like a great thing to be.
At the age of 19, I also had the special privilege of having a rare type of adolescent soft tissue cancer called a Ewing’s Sarcoma. I went through the whole gamut of radiation, chemotherapy, surgery, more radiation and chemotherapy, and all that. Plus, after treatment, I was able to experience a whole host of complications that are frequently only relegated to our patients, including relapse with metastasis later on. Prior to this experience, I had always had the vague ambition to get in as good of “shape” as I could. I played sports in high school and was fair to mediocre, but I never had a systematic plan of focusing on trying to make myself as good physically as I could. Once I had my health really taken away, my resolve to rebuild myself in spite of my newfound challenges was increased. This lead to an interest in the idea of rehabilitation, and, by extension, physical medicine.
While in med school, I was also fascinated by neurology. This was preceded by one of my mentors in college, who was one of my thesis advisors, and a great neuroscientist. So, I had this personal interest in rehabilitation that stemmed from my own challenges, and an academic interest in neurology. I would also come to really become personally interested in the phenomenon of pain, nutrition, and psychology, and how all of these are related. As far as how this translated into my interest in PM&R, to be honest, I did not even know what PM&R was until halfway through medical school. However, I had the privilege to have Dr. James Atchison (currently at RIC), as a guiding force and another mentor during my last year and a half at UF. I came to realize that PM&R fit nearly perfectly all of my interests. Anyone who is currently training to become a physiatrist or who is one already should hopefully easily see why.
Could you tell us about your work in interventional spine care, and what kinds of medical problems and conditions you address in your practice?
After my residency, I trained with Brad Goodman, MD and Srinivas Mallempatti, MD in interventional spine procedures in Birmingham, Alabama. I learned a tremendous amount with them and still do, in fact, as we still keep in touch and try to work together on a few things. After my fellowship, my first position at a practice of my own was with Chetan Patel, MD, a renown orthopedic spine surgeon and at that time chair of robotics for the North American Spine Society (NASS). He was also a great influence on me and helped me round out my understanding of total spine care. I also had the fortune to become good friends with a number of my colleagues who are physical therapists with further training in spine care. All of these influences, plus my own growing clinical experience, helped me to develop my current philosophy of spine care and (hopefully) ever-growing knowledge base and skill set.
As you may know, one of my main interests in spine care, and pain medicine in general, is how it is related to the phenomenon of the “metabolic syndrome”. The metabolic syndrome has classically been thought to be a constellation of somewhat related pathologies including glucose dysregulation, hypertension, central obesity, hypercholesterolemia, and whatnot. Well, it appears that one of the strongest correlations of spine pain and spondylosis, or degeneration of the spine, is the metabolic syndrome. In fact, one of our patients is more likely to have back pain with the metabolic syndrome than they are with bad MRI findings. Thus, for all of one’s knowledge of spine anatomy, if a physician does not understand the metabolic syndrome, then they don’t really understand back pain. What’s even more interesting is how other phenomena: anxiety disorder, sex hormone abnormalities, chronic opioid use, and even traumatic brain injury, also seem to be related to the metabolic syndrome. As I see patients with all of these now, it has been exciting to dig into some of the underlying, deeper pathology that seems to be linking what was heretofore thought to be unrelated pathologies.
To try and answer your question more directly, the kinds of medical problems and conditions that I address in my practice are somewhat wide-ranging. The brief answer is that, by and large, I treat pain of all stripes. Everything from pain from chronic pancreatitis to acute disk herniation, to fibromyalgia, to systemic lupus erythematosis, to various neuropathies. However, as I am also interested in the underlying physiology relating the metabolic syndrome and systemic inflammation to all sorts of chronic pain, we have developed a practice model that also focuses on treating other pathologies, or maladaptations, such as obesity, physical deconditioning, and various psychological disorders that are now known to be part of the many-headed Hydra that is the metabolic syndrome.
It is because I subscribe to this multimodal approach with a rehabilitation-first and systems based approach that I consider myself a Pain Physician only by way of Physical Medicine and Rehabilitation.
Thanks to data collected by the Global Burden of Disease 2010 Study, we now know that spine-related disorders are the #1 cause of disability worldwide. From your perspective, what are some of the most important issues we face as we attempt to tackle this growing public health issue? Do you have specific goals or hopes for spine care in the years ahead?
The number one thing to do is to stop smoking. There is incontrovertible evidence that this leads to microvascular changes leading to spondylosis and likely other degenerative changes.
Next is to address obesity. Obesity of course leads to mechanical disadvantages but, what is likely more important, it causes a body-wide proinflammatory milieu via the effects of visceral adipose tissue and various “adipokinins”. This, of course, is one of the reasons why spondylosis and back pain are related to the metabolic syndrome.
From a public health perspective, therefore, much more effort needs to be placed emphasizing the need for a good diet and regular exercise: including low level aerobic activity, mobility work, and – gasp! – strength training. Not to sound jaded, but ask your average physician how to do a squat. A real squat: glutes to haunches. Now, ask him or her not just how to do one (if they know how) but to do one themselves. Ask around. See how many can. Then see if you yourself can. You will likely be disappointed all around.
Now, go to nearly any developing country that has not yet adopted the typical developed world’s diet and lifestyle. Find the oldest individual that you can who is not near death. Ask him or her how to do a squat. Your chances are far greater that this individual will be able to show you how to do it better than your average medical student or attending physician. Also, measure their BMI and possibly their lean body mass. This may also be better than the average physician.
So, regarding public health, step one is to change this. Most physicians don’t practice what they preach. Until this changes, we shouldn’t worry about public policy because it likely will not do any good. Before we can change the world we need to change ourselves.
Regarding interventions, the most exciting stuff is of course the so-called “regenerative medicine”. Now, while injecting stem cells into disks is awesome and will likely improve in sophistication and efficacy in the years to come – and I am currently engaged in trying to bring this to fruition – we should not forget that we already have a tremendous amount of stem cells already. Kirkaldy-Willis and others since have shown that the spine can heal on its own. We also now have human models that show that smart exercise can expedite this. And we know from murine and other models that stem cells in the disk can also regenerate and lead to histological improvements that are spurred on solely by the right kind of exercise. Thus, while we will hopefully have ever better procedures in the years to come, I am still very bullish on our increased sophistication with old school physical medicine and rehabilitation.
In addition to your background as a philosophy major, you recently started a blog, Barbells and Stem Cells, which explores game-changing therapies like stem cells, new medications, and lifestyle changes. How do you incorporate your diverse interest in the clinic and as a physician in general?
Well, I touched on some of this in the earlier questions. To say it in a different way and perhaps elucidate on why I chose that name for my site (besides the fact that it rhymes and I thought it sounded cool) was because the needle that injects stem cells and the barbell are more related than many know. Progressive overload with a barbell or other means causes the “eustress” or good stress or “hormesis” that elicits our own cells to adapt to this stress. It is this same type of hormesis that lets us now grow cortical grey matter via constraint-induced therapy in patients with a stroke. It is this hormesis that precipitates better bone density improvements in osteoporosis with strength training than any bisphosphonate. And there are numerous other examples of how well-applied stress leads to better therapies than most pharmaceuticals or procedural interventions.
So, if my chief interest in regard to pathology is how the metabolic syndrome is related to the diseases seen with PM&R, my chief interest in regard to treatment is the smart use of hormesis.
PM&R continues to grow, what goals do you have for the specialty? Is there a particular direction you hope this specialty takes in the years ahead, or a role that you think it could serve particularly well in the 21st century healthcare system?
I would like to see the average physiatrist become well versed and skilled in the application of both barbells and stem cells, both professionally and personally.
I would love to see every AAPM&R annual meeting have a workshop showing physicians how to do a correct back squat, front squat, and deadlift.
I would love to see more cross-pollination between physiatrists, internists, and endocrinologists exploring how they are oftentimes treating manifestations of the same underlying pathology (the metabolic syndrome).
And of course, I would also like to see more advances in the procedural aspects of pain medicine. I would love to see in my lifetime a combination of smart procedures and smart uses of hormesis abolishing the need for opioids.
As for PM&R’s role in the 21st century, I think that it is going to be massive, if we focus on things such as the proper application of things old and new – things like barbells and stem cells. If I had to start over and pick a field to go into right now, I would choose exactly what I did. There is a reason PM&R is gaining in popularity. Our field is something of a hybrid of several other fields. Because of this, I believe that we are experiencing some hybrid vigor. If we follow this trend, I think that our field will be considered the vanguard of the most impactful revolutions in medicine.
What parting advice would you give medical students who are thinking about or currently pursuing PM&R as a career? How about specific advice for other healthcare professionals?
If you are pursuing a career in PM&R, I would simply say, “good luck!” I think that you have chosen wisely. I love this field and I hope that you do, too.
To somewhat diverge from my previous ramblings, I’ll give some other advice:
Be very, very good with money. Don’t spend it on stuff you don’t need. And you likely need much less than you think you do. Further, except for a few of you, while you are probably spending more money than your should on frivolities, you are also probably not buying what you actually do need. This includes healthy, tasty food that you cook yourself in a cast iron skillet and a squat rack. Change this.
With all of my health problems and other struggles, I have learned that the things that provide happiness frequently have little to do with money. Therefore, I try to not spend money on stuff that is not only expensive, but distracting. The Nobel Prize winning psychologist Dan Kahneman (and his deceased partner Amos Tversky) have shown that the average American household gets no more happiness in relation to money after they make more than $75,000 per year. You need to make sure that you can afford health insurance, rice and beans, and enough clothes to go to work and for walks outside. Other than that, the only things that have been shown to consistently lead to happiness are a sense of autonomy, mastery, and purpose. Focus on the latter.
In this vein, in addition to being good with money, you need to find a mentor. If you are a medical student, resident, fellow, or just starting out in your practice, find people who know more about something than you do and incessantly (and politely) learn everything that you can from them. Do this all the time, hopefully for the rest of your life. And when you have started to master something, find your own apprentices.
And, as the master of mastery, Robert Greene, has said: while you should always seek to learn from others, once you reach a certain point, you should be willing to break out of the purely master/apprentice system. I personally love private practice for just this reason. I learn stuff every day from my colleagues and friends. But I am responsible for myself and can safely say that I have autonomy, some mastery, and certainly purpose.
Furthermore, while my health is far from perfect, this is more than made up for by the fact that I have a loving wife and family. I hang out with them, deadlift, squat, press, do pull ups, walk, and read constantly. These are the things that make me happy and I have them in spades. I do not think that I am alone. Things like these are probably what makes most people happy. Humans really aren’t all that different on a fundamental level. If tomorrow my CPT reimbursements get cut horribly, while I wouldn’t be thrilled, it certainly would not fundamentally impact my life. On the contrary, if I couldn’t hang out with my wife or enjoy a book or the outdoors, I would be much worse off.
In short, if you can manage to have a good family life, enjoy sitting still, walking slowly, and lifting weights; if you can save most of your money and have purpose, mastery, and autonomy, you have a really good chance of being happy. And this will also likely make you better at your job. Happy doctors tend to be better doctors, in my experience.
Matt Smith, MD