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0:12
So today's topic is going to be the structure and function of nevi or moles and melanoma.
0:21
So these are my conflicts of interest. We are going to be watching a video from Your Health University in the middle of this presentation. All of these videos are on YouTube, they're free, and they're designed to educate the public. I am a former pastor and you can probably see some of that in the talk today.
0:40
I'm a veteran. I'm an American. I'm a horrible dancer, and besides that no other known conflicts of interest.
0:47
Okay, so we're gonna be talking about moles, or melanocytic nevi. And we have moles, all of us have moles, and there's no problems with them. And then depending on which study you read, between ten and twenty percent of us, have these atypical moles, and we're going to be going into that throughout the lecture, and talking about that. And then we have the Big Bad: the melanoma, the ounce per ounce the worst cancer you can probably get. And we're gonna then talk about diagnosis and management.
1:18
Now we are a family of DOs in here, osteopathic physicians, so because of that, this is going to be an interactive lecture. Because the rule of the artery is...
1:30
Come on now, the rule of the artery is...
1:33
One more time, because I was pathetic: the rule of the artery is...
1:38
Thank you. So does that mean sitting down, hunched over, bad posture, shoulders forward? Any part of our nervous system is activated right now, ready to receive knowledge, or information or even believing that you can, on an unusual topic of dermatology. Okay, so this is a big black box of medicine: Dermatology. We see it all day long, but unless you're a dermatologist, people have precious little training in it. So when we have pictures that are not necessarily anything to do with medicine,
2:11
we're gonna mimic those. If you have injuries, please don't and if you're watching this from home, please play along. The more you get activated, the more your structure and function is primed to take in knowledge, the more you will take this knowledge in, and be able to apply it to your patients, to your family, to your loved ones.
2:32
All right everybody up. People at home, up!
2:39
If you have injuries, please don't participate, okay?
2:45
Arms up in the air. Victory! Victory! Come on, victory! Do you guys know that if you stand like this for two minutes, you will actually have measurable increases in the testosterone in your body.
3:02
Two... minutes... But look at the posture! You probably have good posture. Your spine is probably in alignment. You are active. Your quads are probably firing. Your hamstrings are probably firing. You're probably breathing a little bit deeper in. You have just won the race of life. You are physicians who've dedicated your lives to helping others,
3:29
so that they can live a life, that is not inhibited by anything physical,
3:36
spiritual, mental. All right, thank you. Let's have a seat. We're gonna be doing much more of that. The more testosterone you can stay, Stanny!
3:49
All right, success without fulfillment is the ultimate failure. - Tony Robbins. We just got back from a Tony Robbins conference. The guy's brilliant. I'd highly recommend him to anybody in this room. It's a bucket list experience of life.
4:04
All of us have quote-unquote reached success by society standards. We're educated. We're physicians. We're helping people. We have that prestige. And yet if we leave our offices every day,
4:19
recounting the failures of the day,
4:22
recounting that one out of 20, 30, 50 patients that we saw, that we didn't do perfect by, didn't say the right thing...
4:31
God, we suck.
4:36
Structure and function is reciprocally inter-related.
4:41
We need to be able to have fulfillment in our lives, in our jobs. We must look at our failures critically, so that we can see what's our part, and what we can do better.
4:54
But we also have to measure that equally by what we've done well, and focus on what we've done well so that we can grow, not only as humans but also as physicians. We are all quote-unquote successful in this room. If we are not fulfilled then I'd highly encourage you to reach out to your colleagues in this room, med school, wherever you're at, and work on that. Because it is, I agree with Tony a hundred percent, it is the ultimate failure.
5:27
Back to our lecture. Moles. Moles are comprised of melanocytes. Melanocytes technically are derived from neural crest or neural tissue, embryologically. Moles occur on virtually all people and increase with age, until the fourth or fifth decade of life. There is a correlation between the number of moles and sun exposure. So the more sun exposure that you have, the more moles that you will develop. And... moles can have a life history of going from junctional to compound to dermal.
6:03
Initially, the mole cells are at the dermoepidermal junction. Okay, so that's between the epidermis and dermis.
6:10
That's a junctional nevus because it's at that junction. Later the cells are called, at the dermoepidermal junction, and they actually will go down as well, and that's a compound, and then all the cells are in the dermis, and the note of the mole can be a dome, polyploid, or pedunculated, a dermal nevus. That's a junctional. Good example. Want you all to notice how nice and symmetric this is.
6:35
It's not asymmetric. That's one of our criteria. We'll go through this later. The borders are nice and crisp. We know exactly where this thing starts and stops. B for borders. The C for color. There's basically two colors here, a little bit darker in the center, and then a nice even brown all the way around for color. That's one of the C's for color. The diameter, I think it's the weakest one. And I think that they did this one, just because they needed a D, but diameter
7:02
it's small, supposed to be less than the size of a pencil eraser. And then E is the most important for all of our moles. E is evolving. If something is growing or changing, you have to evaluate it. So E for evolving. This is example of a compound nevus and a dermal nevi.
7:22
Now there are moles that we are born with. We all know this. These moles can be pretty small, or they can get to be giant. There's all sorts of debate in the dermatology literature about if the very big moles have a higher incidence of malignant progression into melanoma. And it does seem to be, that if they are very big, there is a higher malignant potential within that nevus or in that mole. So we do have to be careful with those.
7:52
But they can be small. They can be medium, or they can be large. And obviously moles like this should get referred out to dermatologists, and what we are looking for in there, is change. Change, change, and change. Because obviously you can't biopsy that, and get a representative sample of everything that's going on within that [inaudible].
8:16
And just like in our own lives, we have our bucket lists. The things that we always want to accomplish. As our life goes from baby to old, and as these moles go from young to old, we will be changing. Our priorities will change and it's amazing to me, how many times physicians spend so much of our time,
8:44
concentrating on other people, getting them healthy, helping them through their journey, that we've never actually taken the time to spend five minutes on what we want from our lives. Our careers, our bucket lists. So one of the action items that I'd encourage all of us to do, is spend five minutes, just five minutes, instead of texting or social media or whatever, five minutes. What are your bucket lists?
9:15
How do you want to evolve as a person, and check in with those. They will change throughout our lives.
9:22
But if we don't know where we're going guys, we will never get there. All of us started medical school, and when we started medical school, we knew we had to graduate, and then take boards, and then get a job. We had a path, and because we saw that path, we engaged and we did it. And then we float through life.
9:43
I'd very much encourage you to write down the roadmap of where you want your life to be. Not in negative terms, because what you focus on grows, but in positive terms. Where do you want to be? What is your bucket list?
10:01
All right, everybody up. This is part of engaging our nervous system. All right, hands up in the air. I'd ask everybody at home, and here close your eyes. Hands up in the air. I want you to think of just one thing, that you want out of this life. One thing that you want at the end of your career to say that you did well.
10:26
One thing in your family that you want to accomplish.
10:31
One societal norm that you want to change and pivot towards health. I want you to visualize it. Feel the emotion of what that is going to feel like.
10:44
Let the structure of your body, and the shape of victory, of
10:51
accomplishment of goal setting, let that be the mirror and the telescope into your soul and future. Success without fulfillment is the ultimate failure.
11:13
All right, thank you for engaging.
11:16
Just out of curiosity, how many people have thought about where they want their life to go in the last year. How many people?
11:25
Nice, nice. Let's keep it up.
11:32
Deathbed thoughts. Because at the end of the journey, I keep hearing this from people who do hospice, and take care of a number of people who are at the end of the road. What do you wish you did more of in life? What do you regret? And from what they tell me not a single one of them say they wish they worked more. They wanted to contribute more. They wanted to grow more. They wanted to experience more. They wanted to change medicine, change society, change all of those things.
12:01
If we let the structure of our life follow our dreams, the function, every step along the way of the journey, it will get there.
12:11
All right one more, time up and up, come on guys!
12:17
Victory, are we ready to learn some derm?
12:23
There we go, all right, thank you!
12:26
All right. Now, we already went through moles, and what we went through up to this point was just what a normal mole is, and they can look differently, normal moles can look differently, they're not big deals. Now we're going to start pivoting in this lecture series, to what a typical or unusual moles are. First one we're going to talk about is the halo mole, or the halo nevi. What happens here, is that the melanocytes start to be eaten by our body's immune system.
12:55
Then you have to ask yourself, the gatekeeper, the guardians of our bodies are going after these melanocytes for a reason.
13:03
When this happens, and it happens in children, it isn't necessarily a bad thing. We all know that the immune system especially in childhood is changing drastically through the years, and the body is eating this one particular mole.
13:19
I personally recommend biopsying the mole that is being eaten and send it to a dermatopathologist, or a pathologist who specializes in just seeing skin. And then I recommend doing a full-body skin exam on the child, to make sure that there are no other moles that you're concerned with being melanoma. When they happen in adults, though, that is when you really have to pay attention, because they should not be happening in adults.
13:46
When they happen in adults, you need to send to a dermatologist, and you need to have them looked and screened, because that means the body's immune system is turned on to eating pigment cells for some reason. And in adults they have a much higher likelihood of a melanoma somewhere in the body, that the body is trying to eat. So halo nevi in children are not necessarily bad. I still think we need to do a full body skin exam.
14:12
I still need to think we need to look at them. But if nothing else is concerning, I would just do serial monitoring.
14:19
Halo nevi in adults have to be referred to a dermatologist for close, close observation and biopsy. And this is what they look like. If you see right here, all of this is the host or the body's immune response eating those melanocytes, and that's causing regression of the mole. and when you look at this under the microscope there is going to be some atypia of the cells simply because the immune system is coming in and eating the mole cells or the melanocytes.
14:48
but a dermatopathologist has to spend a good amount of time making sure that this is not melanoma, and you need to spend a good amount of time making sure that melanoma is not progressing somewhere else in the body.
15:00
You have not arrived. You haven't arrived at this lecture yet. It's not done. Nor have you arrived at any part of life. You are not finished after residency, after getting married, after children, after retirement. If you're not growing you are... Come on guys, if you're not growing you are... Dying. Every aspect of our life. If we're not reaching goals, if we're not striving to learn more, to become more, to help more, to contribute more, our bodies crash.
15:34
It's one of the things that I see most commonly in the medical profession, is I'm done with residency. I am due patients, I am due a country club membership, I am due a car, I'm due all of these things. And I find it being horribly detrimental to our own health, and that will translate into health of our patients.
16:00
A spitz nevus [inaudible]. These are very concerning lesions, because there can be a completely normal spitz nevi.
16:10
But it is very hard to tell those apart under the microscope from melanomas. So years and years ago they took the best amount of pathologists in the world, they put them all up on stage, and they handed them a bunch of spitz nevi, and they looked at them underneath the microscope, and they said, "Oh these are spitz. These are spitz. These are spitz." All of those patients died from malignant melanoma, because it's very, very hard to tell a spitz nevi apart from a melanoma under the microscope.
16:41
So these guys are kind of the red herrings. You have to pay attention to these, and even if the pathology report says, "Just a spitz nevi, you don't need to do anything with it." They probably need to be cut out, and then monitored. They're most common in children or adolescents, and they usually appear suddenly, and they can look like a basal cell cancer. So just kind of this red bump, that is present there. The clinical behavior appearance and histologic appearance may mimic a melanoma, and
17:11
should be removed for full evaluation. So you've got just this little dome shaped erythema, this [inaudible] right there. It's pretty small. It came on fairly quickly, and when you see things that come on fairly quickly in dermatology, you should be somewhat concerned. Quick, fast growing things could be quick, fast growing cancers, and if you get a diagnosis of this spitz nevi, please have it cut out. Sometimes these can be eruptive where people get a ton of them all at once, and
17:43
then that's when a university setting probably needs to get involved, into how we manage and treat these.
17:51
Martin Luther King. Amazing man. I think probably if we were to pull this room, one of our personal heroes were probably the majority of this room. But I want you to look at the structure and the function here, of this.
18:07
It's an amazing picture. We've got an American flag in the background, kind of blowing in the wind.
18:14
We've got microphone here, delivering a speech, "I Have a Dream" speech.
18:20
We've got a nice tie, press shirt, and he was also a pastor.
18:28
But did that make the man? See, we walk into an exam room with doctor on our title and white coat on.
18:37
We've got all of the establishment behind us.
18:41
Establishment establishment establishment. Establishment behind us.
18:48
And none of that matters. Shouldn't matter to us, and it shouldn't matter to our patients. But how we knock on the door, how we give a handshake, how we try to look into their souls,
19:03
that's what should matter. And for this man, while all of this is nice,
19:08
he is what makes this whole picture. He is what made history, and we, who we are, not our credentials,
19:17
should be what interacts with our patients. And I think all this talk about over 50% of physicians are burnt out, over 30% of physicians are clinically depressed?
19:30
I think all of this, and why I'm spending so much time talking about this, on a dermatology lecture is because we have our foundation wrong. Our structure is completely off, and it leads to our function being burnt out and depressed. If we rely on the white coat, if he relied on this, or this, or this, or this, he wouldn't be the man that he is. And he still lives on because all of us know who he is, and all of us live in a society changed by him.
20:10
And I think if we walk into our rooms,
20:15
knowing that it's not the white coat or the doctor, it's our ability to connect with somebody, and then we celebrate that at the end of the day, I think those statistics will start to change.
20:27
Structure and function are reciprocally interrelated.
20:32
Now we're gonna talk about blue nevi. And blue nevi I put at the end of kind of the atypical section, before we get into atypical nevi,
20:41
because they kind of look like melanomas, but they are not, they're completely benign. We do not have to worry about them. They are elevated, they're round, and they are dark in color, and I still biopsy almost all of these regardless of what the patients tell me, "They've been there their whole life," because they look like melanomas. They may appear in childhood or young adulthood, and they are completely benign. So if you get a biopsy back that says blue nevus and
21:07
you just have to watch it to make sure that it's not growing or changing afterwards.
21:12
But if you look at this, that is black. That is black, black, black, and it's dome-shaped. And if patients might be poor historians or they just don't know, you biopsy these every single time. And at the end of the lecture we're going to talk about how to biopsy a pigmented lesion to give you the best chances of an accurate diagnosis.
21:38
Victimhood is a daily moment-by-moment choice.
21:42
We all know this but, when we leave work at the end of the day pissed off about one patient, that one insurance, that one lab test that we couldn't get back, that one whatever? We are choosing to be victims in that moment. We are choosing to let whatever happened from childhood to that moment that tells us internally that we're not good enough,
22:06
that life is supposed to be hard, that all these lies that we tell us, we're using that one out of a thousand choices, that didn't go perfect reinforce a story of negativity in our lives. And that's the only option there, guys. Otherwise we would take the 99% of successes and let that be our story.
22:31
It's a lot easier to live being suppressed, than it is to live up to your potential.
22:40
If we are spending our time and I'm guilty of this as well, thinking about that 1% that didn't go perfect, we ought to really be asking ourselves what structure are we creating? And what function in our lives will that address?
22:57
Nelson Mandela. 27 years in prison for trying to do the right thing. 27 years! And when he got out of prison and they asked him, "Weren't you pissed that you lost this much of your life?" And he says, "Why would I be upset?"
23:17
"They gave me 27 years to prepare and practice to change the world."
23:27
I hear doctors all the time griping about how long it took to become a doctor. How much we have to fight with insurance companies. How much we have to fill in the blank?
23:39
27 years! And we're upset because we have to get on the phone and do a [inaudible] and we let that drive us into the ground?
23:47
Is it any wonder that over 50% of us are burnt out, over 30% of us are clinically depressed?
23:59
How we speak to ourselves, is how we will speak to others. If we are constantly focusing on the negative, on the thing that didn't go perfect, on the way medicine is set up, or the government or whatever and then we knock on that exam room door and we walk into that room, after we've just yelled at ourselves,
24:23
how are we going to talk to patients? Do you think we're gonna be able to flip the switch and all of a sudden be there, and be like, "Hi! I'm Doctor Anderson, thanks for coming in!"
24:34
How many of us, when we make a silly mistake that isn't a big deal call ourselves idiots?
24:40
Call ourselves worthless? Why in the world did you do that again? Come on, dummy!
24:47
"Hi, I'm Doctor Anderson and I'm an idiot."
24:52
"How can I help today?" As we all know this, we all know we walk into a room with a loved one, and they're having a horrible day,
25:02
we can feel it. We can sense it. You don't have to be a [inaudible] to do this you have to be a human to do this. And we wonder why our patient interactions are going south?
25:14
That's because we just called our self an idiot. We just set up the entire structure of that next exam to beat us into the ground.
25:27
Gandhi. Look at him. He's so weak, he can't even move.
25:33
Look at that smile! Because this man understands that structure and function are the same topic.
25:46
Amazing.
26:10
Okay, so today we're going to be talking about the concept of an atypical moles or dysplastic nevi. Now there is some debate in the dermatology community about how we treat these, and how we diagnose these. So it is important for you to have a conversation with your local dermatologist to find out what treatment is right for you for each one of these diagnoses. Now all of us have moles and
26:37
we don't need to do anything with those moles, except for monitoring them. And if we ever see that they are growing or changing then you need to come into your local dermatologists and ask them if anything needs to be done for these moles. And we've all heard the term melanoma, and melanoma is the term for skin cancer. It's a very bad skin cancer. You do not want melanoma at all. So in between the concept of a normal mole and a melanoma
27:07
there is the concept of the atypical nevi or atypical moles and we
27:13
classify those based off of mild, mild to moderate, moderate, moderate to severe, or severely atypical moles. Now when you get closer to the mild, or mild to moderate, there is such a low biologic potential of those turning into a skin cancer called melanoma that the general consensus among dermatologists is we don't need to do anything with those, except for monitor them to see if they're coming back.
27:40
When we get to moderately atypical moles, there is a lot of debate within the dermatology community about what needs to happen. So what I encourage you to do is talk to your local dermatologist about the diagnosis that you've been given, as well as what is appropriate for you, for your individual healthcare condition, and overall picture of how your moles look to determine if that moderately atypical mole needs to just be monitored, or if it can be excised.
28:10
And once we get to a moderate to severe or severely atypical mole, the general consensus among dermatologists is that we need to cut those out. So, we need to excise them and cut them out. But no matter what you do, what you decide to do, after a conversation with your dermatologist, for any of these atypical moles, you do need to look at them every month in the mirror to see if they are coming back.
28:37
So if you see darkness or pigment, or the scar is bumping up and looking abnormal from what it did look like then you need to go back and talk to your dermatologist.
28:47
So no matter if you're monitoring the mild, or mild to moderate, or you're cutting out the moderate to severe, or severely typical moles, you need to look at those every month in the mirror and see if they're coming back. And then whether you've had one or whether you've had twenty, we do recommend that you have a full-body skin exam every year for the rest of your life by a dermatologist. And that's kind of a minimum recommendation.
29:13
Now the more of these atypical moles that you have, the increased risk you carry of developing a melanoma either in that atypical mole or somewhere else in your body. So you really need to look at your body every month in the mirror and see if anything is growing or changing. Your dermatologist wants your help. Nobody knows your body better than you do. And the more you help us help you, the better everything will turn out for you.
29:43
So, I encourage you to have a conversation with your local dermatologist about what is appropriate for not only future monitoring, but also how to take care of each one of your atypical moles. As always, we thank you for allowing us to help you become comfortable in your skin.
30:06
Thank you for watching this video and for becoming interested in your health. You can find more information in the description below that relates to not only this topic but also websites like yourhealthu.com or Your Health University, or Doctors Quarterly, that's going to have a library of information that we are going to be developing over the years so that you can find information on the topics that you are interested in. Because remember, an educated patient is the best patient and
30:36
you have the power to control your destiny.
31:18
So the atypical nevi as the video said,
31:22
once you have an atypical nevi, they're usually graded based off of how they look under the microscope. So how much atypia is there, and we kind of use two different criteria for grading those. One of those criteria is cytologic, so what are the individual cells look like? Next is architectural atypia. So does one side look like the other? It's the same way we define a melanoma, and as we said in the video
31:49
if you have a mild, or mild to moderate, the biologic potential of those is so low to become a melanoma that we usually recommend just monitoring them unless they look like they're coming back. If they look like they're coming back, we usually excise those.
32:03
Moderates are all over the place on recommendations from the east coast to the west coast. One of the big problems with the concept of atypical moles, is that there is no consensus on how to grade them among dermatopathologists. So one dermatopathologist might call something, uh, severe and another might call it a moderate. The president of the American Academy of Dermatology a few years ago actually
32:29
summed it all all up very well. And he said one person, one dermatopathologist's melanoma is another dermatopathologist's moderately atypical mole. It's quite a scary statement. So in my practice, I usually recommend cutting out the moderates or above. Patients obviously have a choice to do that or not do that. But that's what I recommend. And a mild or a mild to moderately atypical mole, I usually just leave them alone unless they come back.
32:53
There are a lot of patients who don't like the concept of atypia at all, and they want them cut out. And so if they do, we will do that.
33:02
The more of these atypical moles that you have, the increased incidence you have of developing melanoma somewhere in your body. And actually, if you just have one of these atypical moles, you have an increased risk of developing melanoma later on in your life. So I would encourage people that if you have patients who have even one, and especially if they have multiple, to be seen by a dermatologist, because they just have such increased risk of developing
33:29
melanoma somewhere on their bodies during their lifetime. And then there's the Atypical Mole Syndrome, and there are some criteria up here, and there are some debate, or there is some debate among dermatologists about how much or how many melanomas you need to have? How many atypical moles you need to have and what risk that conveys. But these are some of the more accepted ones. Definition is melanoma in one or more first-degree relatives, more than 50 moles with many of those being atypical and
34:01
then the histologic characteristics of the atypical moles. And they say if you have this, you have a hundred percent chance of developing melanoma some, sometime in your life. So these are definitely patients that need serial monitoring, sometimes full-body skin examination with photography, serial photography and those sorts of modalities. And this is an example of a patient who has this Atypical Mole Syndrome. This is not
34:26
uncommon for what comes into dermatology practices all day long, and we look at these patients, and we say which one do you not biopsy? And so these are very difficult patients to try to discern which one needs a biopsy, and actually right here is a superficial spreading melanoma, which you can barely see.
34:50
Patient should be referred to dermatologists who have this syndrome, or who have atypical moles that grow on them. You can do total body photography and biopsy. Patients should be educated on proper skin care as well as staying out of the sun, and what an atypical mole or melanoma looks like. And then suggest screening of relatives because this is, uh,
35:12
genetically passed down. You have to earn the right to be heard. I've always loved this one. This is what we've been talking about all day long. [inaudible] it's not the white coat. It's not the doctor degree. It is not anything other than talking to yourself well, treating yourself well, knocking on that door and trying to earn the right to be heard with each and every patient. And I think when we focus on that thought, on that whole series of events, of good posture, standing up straight,
35:45
good handshakes, I think it's really hard to get burnt out. I think it's really hard to get clinically depressed.
35:53
If we set ourselves up for failure,
35:56
not, I'm sorry, if we set ourselves up for success, not failure like most of us do. I go to these conventions. You guys go to doctors' conventions, you're at one now. How often do you walk up to doctors telling amazing, wonderful stories about patients who they've helped?
36:16
It's almost non-existent. It's always complaining about our horrible lot in life, and then we wonder why we don't enjoy our jobs.
36:29
You have to earn the right to be heard, so guys one more time, let's stand up, let's try this.
36:35
Let's walk up to somebody with a warm handshake. I'm not talking about a cold, yeah, I mean I want you to hold that and
36:45
osteopathically figure out what's going on in their hand. Look into their eyes and celebrate their humanness.
36:54
Come on. Good handshake, "Good to see you, brother. Thanks for coming."
37:13
All right. Yes, [inaudible], all right, so please have a seat.
37:20
So then ask yourself in that manufactured situation we just did, ask yourself if that handshake was the handshake that you could start your patient encounters with? The soulfully looking into the person's eyes without an agenda, just an introduction of one human to another.
37:42
And if you're at home watching this I suggest you do this with a neighbor, a loved one, not just a handshake. Handshake where you're trying to sense everything about that person in on or who they are.
37:59
Melanoma. This is a malignancy where the melanocytes turn into cancers and melanomas, the Big Bad of melanomas is when they start to acquire depth.
38:12
It can metastasize to almost any organ, and once the melanoma metastasizes, ounce per ounce, it's probably the most deadly cancer you could possibly get.
38:23
The incidence of melanoma has tripled for Caucasians in the last 40 years. A lot of that is due to tanning bed use.
38:31
High instance, highest incidence is in Australia and New Zealand because of the ozone, the ozone being depleted. It counts for 75% of skin cancer deaths in the U.S. That's an enormous statistic. Average age of melanoma, 63. Most common cancer in women aged 20 to 29. That's crazy. Most common, 20 to 29.
38:58
People who do not tan or sunburn easily are at an increased risk. So those are the people who burn, with you know, the sun comes on the TV, and they get a sunburn, kind of like me.
39:10
The more sunburns you have the more UV exposure you have, the higher your, your risk is. And it's thought that those with intermittent UV exposure could have the highest risk, particularly Colorado. Because we go for a little bit of cold, two or three weeks of cold, and then all sudden the sun's out. So our melanocytes, the, our body's ability to prepare for the next dose of UV damage, and get a little bit of a tan to protect our DNA, that
39:36
doesn't happen for two or three weeks. and also we get the beautiful day in the middle of winter, and then everybody has a sunburn, and then nothing for two or three weeks, and then beautiful day, sunburn. That probably is the worst because it never gives your body a chance to prepare for the next hit.
39:52
The ABCDEs of melanoma.
39:56
So we went through this earlier, and we went through asymmetry. We want things to be perfectly symmetric. We want their structure to have organization to it. If the structure is half hazard, It's like a teenager. You don't know if it's gonna hop out the window in the middle of the night, and steal your car. Because they have no organized structure to their behavior. Right? So if one side is behaving exactly like the other side it is behaving, the chances are that it's healthy.
40:28
Border irregularity, you, look at this. Nice, crisp border. Look at this one over here. You can't really tell where that border stops or starts. It's all over the place. That's almost scalloped. You can see it jagged all over the place. You can even see this other color here. This white area is probably regression where the body's trying to eat it, and wall it off.
40:48
Color variation. You know, that is not evenly colored, and that is again, the structure is off.
40:58
Diameter, we want them to be small, but the most important is evolution over time. We do not want things evolving. We want them to kind of stay the same, if anything get a little bit smaller, and slowly fade off into the distance. But evolution, change, is the biggest thing that we are worried about. And that is why we are doing those videos. It's, they're free, they're on YouTube. I'm not making any money off of this.
41:22
It is to try to get people to understand that they need to take care of their health. For far too long in America and throughout the world, doctors have hoarded knowledge. It's ours! Come to us and we'll be the dissemination of everything wise in medicine. That era is if you didn't get the TPS report, it is gone. The, the era of us educating so that our patients do not need us is here. Thank goodness.
41:54
So the ABCDEs of melanoma, they are not perfect, but they are a good tool for us to help educate our patients, and educate ourselves, and help us to perk our ears up. Other factors, when the structure is off.
42:08
If you have solid skin, it's probably fairly healthy, because skin has connections with each other. Cancers are nothing but misbehaving teenagers that are not forming connections with anybody else because they're antisocial. So you rub them, and they bleed easily, or they all serrate, or they have other sorts of problems or symptoms. They're not
42:31
functioning like normal skin should because the structure is off.
42:35
So you have these erosions, scaling, bleeding, loss of normal skin lines, the structure is off. You cannot predict it because it is unpredictable. It's a cancer. And that applies to melanoma or squamous cell or basal cell. It is not the normal structure of the skin. And I think when you start to look at dermatology and say, "Huh, is this normally working?" Spot a dry skin and you put lotion on it ten times a day for two weeks, and the skin doesn't turn normal, is it dry skin?
43:10
Come on, guys. Dry skin. Doctor [inaudible] you, you did dry skin, you, um, put lotion on the spot ten times a day for ten days, and it's still the same, is it dry skin? [inaudible]
43:23
All right. Well the answer is no it's not, because lotion would have made it better. If it's fungal and you do an anti-fungal for three months, yeah, it's still there, is it fungal? No. If it's a pimple, and it's been there for three months, is it a pimple? No, well, maybe if you're picking at it a ton, but probably not. Pimples go away in a week or two. This guy will be gone soon, hopefully. So it's all, is it structurally sound, if it is, then it will be functioning properly. If not, reassess.
43:56
So melanoma types, we're gonna go through this relatively quickly, are superficial spreading, lentigo maligna, nodular and aeral lentiginous. The superficial spreading is the most common type, usually occurs in men on the trunk, and women on the back of the legs.
44:12
This is the common distribution of superficial spreading and kind of the evolution of superficial spreading, and then finally developing depth. And again when a melanoma develops depth, that's when they are super deadly, and that's when they can metastasize easily. So depth is the most important thing. And I want you guys to remember depth is the most important thing, except for one thing and I'll talk about that in just a minute.
44:40
And that even though it looks like it has depth is just superficial.
44:46
Nodular occurs in the fifth and sixth decade, these are deadly because they grow quickly and they acquire depth.
44:53
You can kind of see life cycle of these as they get bigger and bigger, and have more and more depth to them.
45:03
Not symmetric. The borders are all messed up, the colors all messed up, the diameter's messed up, and I promise you this is growing.
45:11
Lentigo maligna. Sixth or seventh decade on chronically sun-exposed areas,
45:17
these can either be superficial or they can have depth, kind of the life cycle, as they go through and then this is a perfect example. This is fairly blatantly obvious, and I think all of us would recognize this is not right, but it's not symmetric. The colors are all over the place the borders all over the place, the diameter is huge, and that should be evolving whether or not the patient tells you it is or not.
45:43
Now I want you to think about this, because we're gonna talk in a minute about biopsy.
45:49
How would you biopsy it? I want you to raise your hand. I just want you to think. How would you biopsy it?
45:58
Then there's the acral, these are on the digits and
46:02
that is obviously very, very bad.
46:06
So melanoma evaluation. Refer all lesions that are specific, suspicious, for melanoma to a dermatologist.
46:15
Biopsy should include an evaluation of the deep dermis. So there's different ones. There's excisional, there's incisional, and there's punch, and
46:23
then there's my favorite and I'll talk about that.
46:26
The most important prognostic factor for a melanoma is
46:31
depth, except for one thing. I'll talk about that in just a second. Anybody know what that one thing is besides depth?
46:40
Nope. Nope. They're very important on the pathology report, what is the most important thing about a melanoma?
46:53
Nope. Say again? Nope.
47:00
No. The most important thing for anything in medicine is an accurate diagnosis.
47:07
Alright? Please, please, please, do not sacrifice an accurate diagnosis for trying to get depth, or mitosis or ulceration you can see, but please remember, you have to get the diagnosis. That is the most important thing for survival. Next is depth.
47:29
When these get deep and go down into the body, and these are changing all the time. In fact, I just had to change the the number here, once they start to acquire a depth of 0.8 or more, that's when we start to consider the sentinel lymph node biopsy. Which is where they inject dye. They follow the dye to the nearest lymph lode. They take the lymph node out and they cut out the melanoma, and taking the lymph node out does not do anything for the survivability of the patient for
47:55
melanomas. All it does is help you stage, so you can give your patients an accurate, a reasonably accurate portrayal of the projected course. Other evaluations, can do LFTs, chemistry, CBC. I don't do any of these. Okay, I don't do imaging, I don't do CBC, I don't do any of these things. If they don't need sentinel lymph node
48:18
criteria, so if it's not point eight or above, I don't do any of them, and those are kind of national standards. If they need sentinel lymph node, I sent them to people in town who can do the surgery of sentinel lymph node, and stage and then they decide if all of this is necessary.
48:34
So the melanoma management, is cut it out with huge margins, as much as you can, wide and depth. Obviously there are limitations, and obviously too much is too much, but you want to cut it out wide and deep when possible.
48:49
And there's lots of other things coming down the road for immune therapy. I think all of us realize that stem cells and immune therapy and genetic modification is the history or will be the history of medicine, because if we can actually program into our DNA or that DNA is in our immune system or whether it's in our individual cells to heal, there is no better self-healing, self-regulatory mechanism than fixing the DNA and the damage, or the stem cells to replace,
49:17
so all of this stuff, these vaccine trials, everything like that is pointing that way and it's a really exciting time in medicine to be managing, and to be looking forward [to]. And then there's close follow-up. At least yearly, full body skin examinations, teach the patients how to look at themselves and how to monitor themselves.
49:36
Success without fulfillment is the ultimate failure.
49:41
I would encourage all of you to think about this.
49:45
Each and every day. And success for melanoma mandates that we have an accurate diagnosis. So, let's just say that this, is a concerning lesion.
50:05
Okay? Now let's say it's about ten times smaller.
50:11
Who wants to do a punch biopsy for this, don't raise your hand, okay?
50:17
Who wants to do an excisional biopsy, oh, so you, you do two or three margins, you cut it all the way down to dermis, you sew it up and you send it off.
50:26
Who wants to do a shave biopsy, we just kind of scooped the top off in shape?
50:34
So the number one thing for
50:38
melanoma for survivability is an accurate diagnosis, so we can get the sucker gone.
50:45
Punch biopsies are not good. Let me rephrase that: Punch biopsies are horrible ideas. Let me rephrase that: Punch biopsies should not be done. Unless you can take a punch biopsy that goes all around the lesion and you can get a representative sample to the dermatopathologist. Remember what we spoke earlier, when you're diagnosing an atypical mole or a melanoma, it has two categories that we use: one is how the cells look, cytologic atypia. The other is architectural atypia.
51:25
So let's say that you were to take a punch biopsy right here. And right here, it shows, actually, these look pretty good. This spot looks pretty good. And that spot looks pretty good because maybe it's a mole, it hasn't turned malignant. All the rest of this is malignant. You've just killed the patient.
51:48
If you are going to be doing a biopsy to rule out melanoma, you have to, have to, have to, must to, have to, stomp on the ground, okay? This is gonna be on a test, Called "Your Patient's Life." You have to get as best as possible a representative sampling of the lesion, so the dermatopathologist can not only see the cellular atypia, but they can also see the architectural order or disorder to the lesion. Does that make sense?
52:24
So I do not care one bit if you see something you say, "You know what?" If you can do an excisional, you can do that, but the problem with doing an excisional biopsy is, if it has a lot of depth to it, the sentinel lymph node might be off later on, because you've altered the lymphatic drainage.
52:47
Now the pathologists love that, because they want a foot of skin on either side of anything you send, whether it's a millimeter or bigger. We all know this, and we all know why, so it's not a dig on pathologists, I love you guys, but sometimes it's just not practical. And God forbid you think something is a melanoma and it turns out to be something completely benign, like a seborrheic keratosis, then you've just subjected your patients to a surgery for nothing.
53:11
But you're not going to err on that. You're not gonna kill somebody with that. You might give them an unnecessary surgery or unnecessary scar. But remember the number one thing for melanomas is make the,
53:23
make the diagnosis. All right. So what I do for these, the vast majority of times, I do a shave. And if I think it's a melanoma, I'll do a deep shave so kind of a saucer-ization.
53:37
Because, if I do a sample of something that's a melanoma and I don't exactly get depth, if you're doing any sort of reasonable shave removal, you're probably going to be below point eight, which is where we start thinking about sentinel lymph node, so you're gonna get the the depth that matters at least. And most importantly you're not going to be missing the diagnosis. So guys, shave. Shave, shave, shave, or an excisional, but do not
54:04
take a small sample, and send this off and get it back, and say it's good. Now one other thing: How much of a lesion does the dermatopathologist look at under the microscope?
54:17
How much of a lesion do they look at? Who thinks about 50% of the margin?
54:22
40%? 30%? 20, 10, 1? Less than one percent. It's actually less than one-half of one percent. So when you get biopsy reports back that says margins are clear on a shave removal or a
54:39
scoop biopsy? You are making a gamble with somebody, that based off of less than half of one percent,
54:48
that we actually have clear margins. Do not, do not, do not, pay attention to that. Do not ask your pathologist to write if the margins are clear for malignancies.
54:59
That's just bad. And it confuses people. And if they leave your clinic and go somewhere else and someone doesn't know this, they might say, "Oh, it's a melanoma, looks like has clear margins. You're good!" Not good.
55:15
All right, everybody, let's stand up one more time.
55:20
Hands in the air, victory! We can do this!
55:25
We're looking for the asymmetry. We're looking for the borders. We're looking at the color. We're looking at the diameter. Most importantly, we're looking for the evolution of it, will it change? We're looking for knocking on the door and celebrating our successes. Warm handshakes, earning the right to be heard, holding their hand, looking at them in the eye, and
55:48
celebrating our successes so that that grows, not our discontent or our depression.
55:56
We are holding hands.
55:59
We are partners together. Knowledge was meant to be given to people so that they could take it, and take control of their health.
56:10
So this is going to conclude the formal portion of the lecture, if there are any questions, please let me know. Sir?
56:18
Questioner: A couple questions. When you cover this spitz lesion,
56:26
since it comes back spitz, is there any advice on how wide [inaudible] the decision [inaudible] should be, and the other question is
56:39
if you're doing a shave biopsy on what looks like to you, a melanoma, and you go deep, you scoop it out,
56:50
the, what is the pathophysiology of that as far as what the reactivity of
56:59
the lesion itself, since it is already an abnormal [inaudible].
57:07
Does it then become more aggressive, and
57:12
then for you, as a practitioner,
57:17
should this, you know, if it comes back positive on the melanoma, do you,
57:23
do you then, recommend us that we move in a very swift manner and getting a hold of the dermatologist, that they take care of? Thank you for the questions. I appreciate if, you know, if I skip over one of them then, please, let me know what I missed. So, the first one was a spitz nevi. So this is an ear. This is a face. This is a child's face. So, the question was how much margin should you do? I would probably excise this with three millimeter margins. If it were on the trunk
57:52
I would probably do five to ten millimeter margins, depending on family history, how concerned I was for this, and the cosmetic area. So that's probably what I would do for, for this. Now the next question was for melanoma. So after the biopsy, once you have something that has been biopsied, does that increase the malignant potential of that melanoma? So the answer is no, it does not. That, that holds true also for basal cells and squamous cell cancers.
58:23
And we've actually studied this, so people people say, "Well I shouldn't biopsy it because it's going to increase the risk of metastasis and therefore it's going to hurt the patient." And, and that's not a concern. What is a concern, it's a great question though, and it's been asked so many times that they have studied it, what is a concern is to get an accurate representative sample of it, so that the dermatopathologist can make an accurate diagnosis.
58:46
That is by far number one, and then my suggestion is whenever feasibly possible, have it definitively treated within 30 days. Now, we all know that there are social factors and logistic factors of getting someone to have it done, but I like having these done. Because for nodular melanomas you have 30 days to cut it out after diagnosis before it increases the risk of metastasis. That's how quick nodulars grow. So that's the answer of that, and did I miss any questions in there?
59:21
Questioner: Well, what do you, you only recommend to the patient, they do their own follow-up, and have them come back you, or do you since it's a spitz, want them to come back to you for routine follow-ups for a period of time? So that's a great question. So what about follow-ups? So whether it's a typical moles or spitz, or melanomas, I recommend a minimum of yearly for the rest of their life. And here's the reason for that: a skin exam, besides them coming in, there's really no risk.
59:53
It does cost a little bit of money. But it's not like you're doing an invasive procedure like a mammography, or I guess that's not invasive, but you understand what I'm saying? It's nothing that is going to harm the patient. And that yearly exam not only allows us to look at them serially and get used to their skin, but it also lets them know, hey, this is important, I probably should look at myself at least once a month in the mirror.
1:00:15
If you do this at 12 years of age and you never see that patient back,
1:00:20
chances are they're never going to develop good habits for their body or for their life. So I recommend at least yearly for the rest of their life. Now some of my patients literally grow a cancer every month for their whole life and obviously for that there's a much shorter return to clinic schedule. And some have had one basal cell ten years ago, and we see them once, once a year, and just kind of do the, the blessing and they leave.
1:00:52
Questioner: [inaudible]
1:01:05
That is, now if I think it's a pimple, you know, I'll have them come back in two weeks or something like that, and hopefully that's an area where telemedicine can really be beneficial to us for, "Hey, you can take a picture in two weeks and if it's gone, everybody's happy." Hopefully that will be coming down the pike more and more. But yes, I take a biopsy, I have to know what I'm treating to be able to treat it accurately, because if it is technically a melanoma,
1:01:27
it's much bigger margins than that. But one of the things is, even if it says spitz, spitz or nevi, benign, my opinion, they all get cut out unless there's some other mitigating circumstance like on an upper eyelid or something crazy like that. But remember the world leaders, the experts of the experts, got it all wrong when they were given the slides, and that all those patients died of malignant melanoma. It's yeah, did that answer the question? Questioner: [inaudible]
1:02:10
Yeah okay so the, the first question is, if you do this shave, and it comes back as a melanoma, and then you have them come back in and you cut it out, then yes, that's typically my role. There are a couple of times a year as a dermatologist, I see something, and I am just convinced it was melanoma, and I will cut it out there with deep on the spot, because I think it's nodule, and I think it's horrible, and I don't want
1:02:30
to wait another minute. Last time I did that it came back as a pigmented basal cell cancer, by the way. So, but it's gone. It's out. It's fine. But yes, that's the order and then the second question is... Questioner: [inaudible]
1:02:47
Yes, so 99% of what I do is shave biopsies or shave removals, and there is a role for punch biopsies, especially for inflammatory disorders. So what is this rash? Because a lot of times the inflammation goes deep into the skin and the pathologist has to see that. And a lot of times these shaves is just taking out the epidermis and a little bit of dermis and it's not as much as needed to see the inflammatory infiltrate that is found in that specimen.
1:03:14
Alopecia, hair loss, if you're doing punches for that, that's another great example of where we can do a punch, and guys, on, let's say that this was only three millimeters, which it's not, a punch is a great, so let's say this diameter is three millimeters, a punch is a great, if you do a four or five millimeter and punch it out, they're going to get all the depth and the whole representation. I'm not saying that punches are bad. But let's say that this is three centimeters,
1:03:38
which honestly it looks more like it is that, and you just take a little punch of this area right here, that's what's horrible. That's what we can't do. Does that make sense? Okay.
1:03:52
Questioner: Excluding a melanoma or something that you feel more confident that is a squamous or a basal or something,
1:04:02
you didn't mention, uh, liquid nitrogen. Is there a rule for that, for us anywhere? Question is, is there a role for liquid nitrogen? In skin cancers? And the answer is no. So we used to be, way back in the day, before me, so 30, 40 years ago, people would put a thermometer basically in the skin, and freeze the skin down to very, very cold. Minus 50 degrees for, and hold it there for eight minutes.
1:04:33
So you'd have to keep freezing and keep freezing, and there are different protocols for this, and that would
1:04:40
reasonably take care of a lot of squamous and basal cells. But the pain is atrocious, and the scar is miserable. You've completely and forever destroyed the structure of that skin.
1:04:54
And with Mohs, and with radiation, with other things, ED&C is even better, scrape and burn, is better than that. I think for 99.99% of the time, cryosurgery for non-melanoma skin cancers is just simply not appropriate. I don't think it's ever appropriate to freeze a mole or a melanoma. If you see a mole and want to get rid of it, do not freeze it, do not laser it, the only thing that happens to a mole is a
1:05:21
representative sample of the whole thing gets sent off and put in a bottle. Do not, do not, do not freeze your moles. Do not freeze your skin cancers, please, it's bad, bad, bad. Only thing that happens to moles, is you remove it, put it in a bottle and send it to the pathologist. Every single year, in fact, I had one a couple weeks ago, I looked at it in the microscope and said, "Whoa, this is not right." Sent it off to the university and it was a, it was an amelanotic melanoma.
1:05:49
Questioner: Yes, the question was not, it was excluding,
1:05:56
uh, cancerous lesions, it was about the other side which you just answered, right? So yeah, so excluding cancerous lesions, yeah, I freeze actinic keratosis, seborrheic keratosis, warts, a host of things all day long, every day. Because the liquid nitrogen is designed to kill keratinocytes. Remember keratinocytes die at minus 20 degrees celsius. And the melanocytes die at minus 4, and that's why you get all the pigmentation issues. Because in order to kill the keratinocytes,
1:06:25
which is what liquid nitrogen is supposed to be used to kill,
1:06:30
you have to freeze it much lower than the melanocytes. Now fortunately, the melanocytes are usually a little, have a little bit of depth right in that dermoepidermal junction, so there is a little bit of thermal protection by depth ,and the keratinocytes are at the top portion, but you have to think about these things as you're freezing them, what you're trying to target, and what it is.
1:06:49
Pre-cancer's fine, about 80% of them are taken care of with an 8 second freeze-thaw, and other things. Sir? Questioner: [inaudible]
1:07:05
Yes, sir, so the question is, I see a lot of people with seborrheic keratoses which are pretty nasty, and please talk about that. So, eruptive seborrheic keratoses, and seborrheic keratoses are those waxy, they feel like, they look like they were like, stuck on, like a kid just went up with stickers and stuck 'em on, come on. If those are eruptive, so you didn't have very many, and all of a sudden you have a hundred times what you did over a month or two, you do need to look at GI malignancies.
1:07:31
So you do need to send to our GI colleagues to make sure. Now if they've gradually developed ten a year for their whole life, then that's just their wisdom spots, they're barnacles on the ship of life. Now what you need to do is, you need to look at your local carrier determination from Medicare, let's, you find them on there, and they will tell you what is medically necessary to freeze these by. And the state of Colorado,
1:07:53
it's usually, they're intensely itchy, that they're bleeding, that they're getting ripped off with clothes, we do not treat these and bill insurance for them if they just don't like how they look. And by the way, you cannot see one on a patient, just as a favor freeze it, and don't charge them or the insurance. That's called incentivizing them to come into your office. Because they'll make up a runny nose or earache or something, to get some of these cosmetic ones treated for free.
1:08:23
You have to charge them cosmetically to do it. There's lots of ways to remove these. There's even a prescription medication that just came out for it. But I might prefer it as liquid nitrogen and I would prefer to have them back two or three times. If they're irritated and they meet local carrier determinations with your insurance to freeze them, then you can charge for it, but remember,
1:08:43
you are signing a contract with your insurance company, and the patient is signing a contract with the insurance company, and you have to follow their rules, and not put words in their mouth to make an extra buck. And you have to do it properly, and you can't treat cosmetic things for free. You need to have a consistent policy in your clinic for what is cosmetic, and what the charge is, And that needs to be universal across. If you're treating cosmetic things for free, that is illegal,
1:09:10
that's incentivization for medical services, and you are not doing right by your patient. And I'm not saying you were doing that, I'm just saying, I want to state that very clearly, that we have to, we have signed contracts, and if you don't like the contract, get out of the insurance, but don't break your contract. Questioner: Can you ever find melanoma inside of an SK [seborrheic keratosis]?
1:09:33
Can you ever find melanoma inside of an SK? Absolutely! And almost every derm conference that I've been to, has somebody up there who's been practicing medicine for 50 years saying, "Look at this picture! It's an SK, everybody [inaudible]!" And it's a melanoma. You know, these things are tricky at times. And there's lots of tools to kind of differentiate between what is a seborrheic keratosis or an SK,
1:09:55
and what is a melanoma. But I promise you none of us are perfect. And it's all subjective at the end of the day. But, usually the savior for everything in medicine is...
1:10:07
Earn the right to be heard, and reassess everything. So if it looks like a duck, and smells like a duck, and acts like a duck, it's probably a duck. But if you treat something... Yep. So sometimes what I will do for things that I'm not quite sure about is I'll freeze them real quick with liquid nitrogen. And that's to test to determine response to treatment, and that is in the local carrier determination,
1:10:28
it's appropriate. And often times when you freeze a seborrheic keratosis lightly, you'll see these little, like milia cysts, like little things light up, because a seborrheic keratosis under the microscope has all these little, like, milia cyst type things, cystic structures that are there, and it'll differentiate from melanoma. The other thing is, you can freeze it like you normally would, and have a 10 or 15 second freeze-thaw, maybe a 5-second freeze-thaw
1:10:53
time if it's really thin, and have them come back in a month. If it's a melanoma, it's not going to do much to it. If it's a seborrheic keratosis, it will have done a lot to it. Now, don't give it a three minute freeze thaw cycle, it's going to take all the pigment out of it, I mean be reasonable with that. But, absolutely. The follow-up is the savior of medicine. It allows us to reassess. It allows us to say, "Gosh, that was dry skin!
1:11:20
I told him put stuff on 10 times a day for 10 days ,and they have, and it's still there!" "That might be a basal cell cancer!" "That might be fungal!" "That might be this," and it gives us that chance to be human and reevaluate. Questioner: Do you know what prompted you to transition from pastor to dermatologist?
1:11:41
*Laughs* I thought I had a calling from God, so I did it. Questioner: [inaudible]
1:11:58
Fantastic questions. So the question is, do you include an ophthalmologic exam for patients with atypical moles, or perhaps even melanoma? Yes, so if you've had a melanoma, I want you to yearly see your eye doctor. I want you to yearly see your OB-GYN. I want you to yearly see your dentist. And I want you to see your hairdresser all the time, and tell all of those people, "Hey, I've had skin cancer before, a melanoma. If you see something weird, let me know." Because the more eyes on the better.
1:12:27
So, yes, now the atypical mole syndrome, you know, there's some different criteria for that, but yes, that's a good idea, because I think the statistics are 20% of people with atypical
1:12:38
melanoma syndrome, the, that we are the familiar typical melanoma, so all sorts of different names for, about 20% of those will develop ocular melanomas in their life. And you know that there's lies, there's really bad lies, and there's statistics? Okay, we all know this, but the point is, is that if they've had melanoma or they're in that syndrome thing, then once a year for the rest of their life, see an ophthalmologist for a full eye exam. It's a great question.
1:13:07
All right, guys, please, when you are having, circling that drain, when you're wanting to perseverate on that one thing, go into the bathroom, close the door, do the victory, and force yourself to think in your mind of five things that you can have gratitude for. Gratitude is 100% the cure for anger, for depression, for almost any negative thing. Next time it happens, doesn't mean minimize what's happening, but be grateful for the good things, the good patients, the people you've helped.
1:13:38
Stand with the posture. By the way, the Wonder Woman posture does the same thing for testosterone for two minutes, and then you might have a better chance of earning the right to be heard, rather than bringing in all the negativity that you were knocking yourself down by.
1:13:56
Thank you.
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