Robotic Hands and Toe-Fingers w/ Dr. Kyle Bickel

Episode Information

August 13, 2020

Dr. Kyle Bickel talks about cutting edge technologies used in hand surgery, replacing fingers with toes, and his love of coffee.

Topics Include:

• Initially rebelling against the idea of following his father and grandfather into medicine as a teenager by declaring fine art as his college major
• Realizing that he didn’t have the skill to earn a living as an artist, so he switched to pursue a career in medicine
• Doing immunology research at UCLA prior to medical school, which satisfied his creativity as he was creating antibodies to treat cancer
• Choosing reconstructive surgery because it satisfied his right/left brain attributes by allowing him to be analytical and creative
• How hand surgery is not unlike his first love of sculpture, as he has to reconstruct a functioning hand
• How transplantation works and how he can borrow other body parts like toes to make functioning fingers
• Advances in robotic prosthesis and how they’ve come a long way in the last 10-15 years
• The incredible mission work he’s done providing medical and surgical treatment to people in countries like Bolivia and how those communities have welcomed him so generously
• How he developed a love of coffee while training in Europe and has a handmade Italian espresso machine and can make latte art
• His general hand advice like being careful of getting infections from manicure instruments, keeping your hands clean and warm to prevent frostbite, and to maintain flexibility as you get older
• How at The Hand Center of San Francisco he uses the latest in minimally invasive and arthroscopic surgical techniques
• How medicine has embraced almost every technology except for information technology, which Doctorpedia can help service
• How much are he took in producing videos for CarpalTunnelSyndromepedia and how he hopes it can be a comprehensive resource for patients
• The misconception that carpal tunnel syndrome only comes from typing on a keyboard and how to prevent it

Highlights

• “It became apparent after a couple of years of going down the starving artist student pathway that I would probably always be starving as an artist and that it was a very, very difficult and insecure way to make a living. And so after a couple of years of that, I decided to go back to my default position, which was to apply to medical school.”
• “It’s called monoclonal antibody production and some of the best in the world – the most effective drugs in the world – are actually made by that process. We were in the lab (one of the few labs at that time) that was on the ground level of developing that technology. So it was very exciting as an undergrad to be involved in that, and it got me very excited about medicine.”
• “I really believe that had to do with the specialty’s unique ability to combine the right brain/left brain attributes that I have and that I wanted to be able to continue to use. Some people are much more analytical and more scientific and other people are much more creative and visual. I’ve always been someone who likes to have one foot in each of those different areas.”
• “Hand surgery really allows that to be manifest in a very real way because there’s an enormous amount of creativity involved. If you can imagine a mangled hand, a person who had their hand and their forearm mangled in a piece of heavy machinery and patients are brought to you and your job is to take that mangled extremity and to somehow find a way to reconstruct it so that it as closely as possible resembles a normal functioning hand.”
• “My wife and I like to travel and so you go somewhere and you’re a tourist and you try to be polite and you try to be understanding and to adapt to their culture. But they still view you as an American and a tourist. When you go as a physician to help people, they don’t view you as that. They view you as just a human being who’s there to help another human being. There’s so much more open and appreciative and they open their homes to you and it’s just a different kind of experience.”
• “The funny anecdote about that is that it was so much a part of my life that it was in my wedding vows with my wife. She said in front of the entire wedding crowd that was there at our wedding that one of the reasons she was marrying me was that she was guaranteed lattes for life.”
• “One thing I will tell you that is preventable are infections from manicures and I see more of those than I wish I did. It happens all too often and there’s the cuticle at the base of your nail and a lot of manicurists will really get in there and dig under the cuticle with various instruments.”
• “It’s a tiny miniaturized fiberoptic camera that we can put into the joint through just a tiny little puncture. The diameter of the camera that I use for most of my arthroscopy is only 2.3 millimeters in diameter, so it’s really about the size of a pencil led. We can put that little fiber optic scope inside the joint and aim it wherever we want to look at those structures and it projects up on a big flat TV screen, just like a video game.”
• “Technology has both impacted medicine and medicine has also impacted technology. There are a lot of developments in technology that have come from medicine. But one of the ways that I think we haven’t been able to keep up as well as many other sectors is in information technology and how we distribute information to patients. Because we’re doctors, we’re not IT professionals.”
• “I do think that when Doctorpedia hopefully becomes more widely available and people are searching for it more freely, that people looking at carpal tunnel syndrome will find it to be an outstanding resource. I think that we really took a lot of care in making the videos. I know that I was very conscious of trying to really give people the information that I would want all of my patients to have and they’re very comprehensive. They’re very thorough, but I think they’re pretty easy to understand for the average patient.”
• “Fitness has always been a big part of my life. I enjoy athletics. I’ve been a cyclist for over 40 years and I continue to bike almost daily when I have the time. My average is probably five days a week. I either get outside on a bike or we have an indoor bike at home. I like to surf, I like to ski, I like to run and hike.”

Relevant Links

• Doctorpedia Spotlight Interview
• Doctorpedia’s Tech Channel
• Carpal Tunnel Website

Episode Transcript

Daniel Lobell: (00:02)
Hi, this is the Doctorpedia podcast. I’m on the line with Dr. Kyle Bickel. How are you?

Dr. Kyle Bickel: (00:14)
I’m good. Thank you, Daniel. How are you?

Daniel Lobell: (00:16)
I’m doing well. It’s an honor to have you on the show. Thanks for agreeing to do it.

Dr. Kyle Bickel: (00:20)
My pleasure.

Daniel Lobell: (00:21)
I’d like to jump right into it by getting to the beginning early stages. When I’m talking to a doctor, I want to find out what inspired you to get into medicine in the first place. How old were you when you decided you wanted to be a doctor and was there a moment in your life that made that decision clear for you?

Dr. Kyle Bickel: (00:40)
That’s a great question. It was a series of decisions for me in that my grandfather and my father were both doctors. If I remember correctly, the decision was made for me before I was born and they informed me about it sometime later. I had a natural interest in the sciences. I took a lot of science classes both at school and some extracurricular classes in the summer and was really interested in science and fascinated by it, as you know, I think most kids are. I went along that pathway and then like a lot of teenagers, I rebelled and decided I didn’t want anything to do with it. When I went off to college and declared my major as a freshman, I had also been really active and interested in art from a young age and had drawn and done some sculpture and some other things and really enjoyed artistry. And so I declared my major as fine art.

Daniel Lobell: (01:48)
You declared it – it’s one of the few things, by the way, that they make you declare – is your major.

Dr. Kyle Bickel: (01:53)
Yeah, right. Exactly.

Daniel Lobell: (01:53)
It’s such a powerful thing. A declaration, you know? I declare my major is art! [Laughs].

Dr. Kyle Bickel: (01:59)
[Laughs] Yeah. Unfortunately although I declared it, I did not necessarily bring along with that enough talent to be secure that I would be able to make it as an artist and support myself in a career. I still enjoy it and I still dabble in it. I definitely appreciate it. But it became apparent after a couple of years of going down the starving artist student pathway that I would probably always be starving as an artist and that it was a very, very difficult and insecure way to make a living. And so after a couple of years of that, I decided to go back to my default position, which was to apply to medical school. So I changed my major.

Daniel Lobell: (02:42)
Did you have to undeclare the art major? “I undeclare!”

Dr. Kyle Bickel: (02:47)
[Laughs] No, I think, I think we need to declare a new one, they automatically undeclare it for you. So I switched and spent the last two years of my undergraduate pursuing the sciences and getting all of my prerequisites for med school. And then I was fortunate to get involved in medicine before I got to medical school by working in a laboratory at UCLA doing immunology research and that really stoked the fires for me. There were certain creative elements in that, believe it or not, and so it kind of satisfied my creativity–

Daniel Lobell: (03:20)
–Well, let’s slow down for one second. You said immune – is that immunizations? Is that what that is for a guy like me who doesn’t know?

Dr. Kyle Bickel: (03:32)
Right. So immunology is a field of science that deals with the immune system, which most of us have heard about. So it’s antigens and antibodies, it’s your body defending itself against foreign invaders. And so the field is immunology. Immunizations are part of that field.

Daniel Lobell: (03:51)
You said it was really creative, so I’m curious as to what elements of it satiated your creativity?

Dr. Kyle Bickel: (03:59)
Sure. Like most jobs I started at the bottom and it was pretty menial. I was actually looking into a microscope for several hours at a time, counting little dots in wells in plastic trays to see what the antibodies that were being put in those wells were doing, cause the cells – whether they killed them (and therefore they were the antibody directed at those cells) or not. And it was literally counting dots in a tiny well under a microscope. So that was not terribly creative. But I stayed at the lab for long enough that they promoted me to actually doing bench work and it was in the 1980’s–

Daniel Lobell: (04:39)
–What is bench work?

Dr. Kyle Bickel: (04:39)
It’s actually doing experimentation under a hood where you have ventilation. We were working with blood products from animals and also humans, so it had to be ventilated. We had to have masks and gloves and eye protection because of contamination issues. But it was basically scientific research and the part of the research that I was involved in was in actually creating new antibodies in order to try to kill tumor cells to treat cancer in cancer patients. So it was fascinating and it was obviously very relevant. Yeah.

Daniel Lobell: (05:22)
That is cool. That’s like if you hit one, you hit it big. You’re like, “I got the antibody! This is the one everybody’s been waiting for.” Right?

Dr. Kyle Bickel: (05:28)
[Laughs].

Daniel Lobell: (05:28)
Like, “phone up big cancer, we’ve got this on lock! The kid’s got it!”

Dr. Kyle Bickel: (05:35)
It certainly felt that way at the time, but like a lot of early experimentation, the implementation phase was a lot harder than we were expecting it to be. There are now antibodies that are produced by that technique. It’s called monoclonal antibody production and some of the best in the world – the most effective drugs in the world – are actually made by that process. We were in the lab (one of the few labs at that time) that was on the ground level of developing that technology. So it was very exciting as an undergrad to be involved in that, and it got me very excited about medicine.

Daniel Lobell: (06:15)
Yeah, that’s very cool. Okay, go on with the story. I’m on the edge of my seat.

Dr. Kyle Bickel: (06:23)
[Laughs] Well, it’s a long story. Where would you like to go with it?

Daniel Lobell: (06:28)
Well, at some point you wind up specializing in hands, correct?

Dr. Kyle Bickel: (06:33)
I did. Yeah. That was a long evolutionary process.

Daniel Lobell: (06:38)
Now I wonder if there was some impetus from your days as a sculptor to protect the hand, the artist in you?

Dr. Kyle Bickel: (06:47)
Yeah, very good question. It wasn’t necessarily in terms of thinking about protecting the hand, but I went into medical school with a very open mind. I was really fascinated by all of it and just decided that I would go through the process of medical education and really let my gut tell me where I wanted to end up. So I was able to rule out certain specialties pretty early on and kept others in mind and then winnowed the field – one by one – as I got more and more exposed to what the practice of those specialties would actually be. And eventually I settled on reconstructive surgery. So I finished medical school and applied for residencies in reconstructive surgery. And it was during my residency that I got exposed to hand surgery and that was sort of the final step in that evolution. I just realized that this was really everything I was looking for in a specialty.

Daniel Lobell: (07:50)
Can you put your finger on why? (No pun intended.)

Dr. Kyle Bickel: (07:58)
[Laughs] Are you sure about that? I really believe that had to do with the specialty’s unique ability to combine the right brain/left brain attributes that I have and that I wanted to be able to continue to use. Some people are much more analytical and more scientific and other people are much more creative and visual. I’ve always been someone who likes to have one foot in each of those different areas.

Daniel Lobell: (08:34)
Or one hand.

Dr. Kyle Bickel: (08:34)
Yeah, exactly. Hand surgery really allows that to be manifest in a very real way because there’s an enormous amount of creativity involved. If you can imagine a mangled hand, a person who had their hand and their forearm mangled in a piece of heavy machinery and patients are brought to you and your job is to take that mangled extremity and to somehow find a way to reconstruct it so that it as closely as possible resembles a normal functioning hand.

Daniel Lobell: (09:04)
Sculpture!

Dr. Kyle Bickel: (09:05)
Yeah, there’s a lot of sculpture. It’s very visual, it’s very manual but as well it requires a lot of discipline and a lot of understanding and experience and a lot of science. And so it was a great opportunity for me to combine the things that I like the most and it still is.

Daniel Lobell: (09:23)
How often do you have to sit your patients down and say to them, “you know, it’s not looking good. Let me show you some hooks.” [Laughs]

Dr. Kyle Bickel: (09:36)
[Laughs] I’ll tell you a funny anecdote. It’s one of those macabre, sort of dark medical humor stories. But it’s funny if you just keep it in mind and don’t get too squeamish about it. So I was a resident and it was exactly that situation. We had a young boy who was brought to us with injuries from a very powerful firework. He was playing around with his friends and they had much stronger than I guess we used to call them M-80s, which was a pretty strong firework. This was stronger than that. And the thing blew up in his hands and he was brought to us with essentially just remnants of fingers and angling from each hand. And we set about going to the operating room, but in the course of talking to his parents before we brought him back, it became apparent that he was a very promising musician. He had studied his whole life in music. He played numerous instruments, he wrote music and he was headed for a career in music as a musician. And so we are in the operating room for hours. I was with my attending who was kind of guiding me and I was still studying and I was young and impressionable and I was really shaken up by what had happened to this poor kid. And it became apparent that there was absolutely no way that this guy was going to play the piano or the guitar or any other instruments. And I said, “what are we going to tell his parents?” And he said, “oh, that’s easy. Just go out and tell them there’s good news and there’s bad news.” And I thought, “what in the world are you talking about?” And he said, “you tell him the good news is your son’s going to play in the orchestra again. And the bad news is he’s going to play the triangle.”

Daniel Lobell: (11:23)
[Laughs] Oh, man. But those moments must be very tough for you as a doctor when you really can’t do anything for them, right?

Dr. Kyle Bickel: (11:36)
It is. There aren’t many instances and we don’t like to look at it as “we can’t do anything for them” because there’s always something that we can do. And the other anecdote that I’ll tell you is really more of a homily that that we all learn in reconstructive surgery and that is “to someone who has nothing, even a very little bit is a lot.” And so you have to do the best with what you have. If you’re dealing with remnants of digits, then you try to make them functional in any way, shape or form. We can borrow parts from elsewhere. We can take toes, for instance, and transplant them to the hand to make them function as fingers and there are always options.

Daniel Lobell: (12:19)
Really? People have toe hands?

Dr. Kyle Bickel: (12:22)
They do. More than you think.

Daniel Lobell: (12:24)
I’m going to start paying close attention. When I start shaking people’s hands, if I have foot fungus on my hand at the end of it, I’m calling you up.

Dr. Kyle Bickel: (12:33)
[Laughs] Yeah

Daniel Lobell: (12:35)
I can’t believe it. I wonder how many people I’ve ever met who actually have toe hands.

Dr. Kyle Bickel: (12:41)
Well, I suspect you may have met one at least, or even perhaps more than that. If you look carefully, unfortunately they don’t often looking exactly like a finger. The best cosmetic results we get from that operation are with thumbs, believe it or not, because the big toe pretty closely resembles a thumb and we can make very functional and often pretty cosmetically appealing thumbs out of big toe.

Daniel Lobell: (13:09)
But then the person has no big toe. Right?

Dr. Kyle Bickel: (13:13)
Right. So as I said, it’s making the most of what you have and if you had to make a choice – do I want a thumb or do I want a big toe? I think it’s safe to say that the majority of us would prefer to have a thumb.

Daniel Lobell: (13:27)
Are there no dead people with big toes that you guys have access to or would that not work?

Dr. Kyle Bickel: (13:34)
There are, and that that gets back to my research in immunology. Transplantation is something that most people have heard of – liver transplants and lung transplants and kidneys – and those have been performed for 40 or 50 years now with great success. The problem is that in order to take apart from a dead person – unless that person just happens to be your identical twin – they’re not genetically identical to you and your immune system will recognize the part that’s transplanted into your body as foreign and your antibodies will start to attack it and they will eventually destroy that part. So in order to make transplants from cadavers successful, we have to treat the recipient – the patient who gets the transplant – with very powerful immunosuppressive drugs so that they can’t form the antibodies necessary to attack that part. That’s great for the transplant, but it’s not always so great for the patient because they still need a functioning immune system to fight off the cold or flu or chicken pox or all the things that we’re subjected to exposure from in our daily lives. And so those drugs have significant potential complications and risks associated with them. So there’s always been a risk/benefit analysis that has to be made. If you’re going to die without a new liver, then it’s worth it to be immunosuppressed for the rest of your life and be very careful about wearing masks and washing your hands and not being exposed to sick people and hoping for the best. When you’re dealing with a finger, it’s not a life-threatening problem. People can live just fine without a finger or even a hand or an arm. It was previously felt that the risk was not worth it for that. But as immunology has progressed, the drugs that are available now are more specific for certain parts of the immune system, so you can partially suppress their immunity so that they don’t attack the transplanted part but not wipe out their immunity altogether. And that opened up the possibility of doing transplants for things like fingers and hands. And in the last 10 years there have been numerous hand transplants which have been pretty well publicized in the broader news community and people are aware that hand transplants are certainly a possibility. It’s a pretty drastic possibility, but for people who don’t have hands, they’re often willing to take that chance.

Daniel Lobell: (16:11)
What about robo-hands? Is that something that we’re seeing yet?

Dr. Kyle Bickel: (16:16)
Yeah, sure. That’s the other line of research which is in robotics and the real breakthrough that has happened in that field in the last 15 or 20 years is that the prosthetics that people used to use since essentially the civil war and before were largely mechanical. So they would be strapped to your arm, for instance, and there would be straps around the person’s shoulder and back so that if they wanted to activate the claw or the fingers, they would elevate their shoulder and that muscle and that would pull on a strap and then it was operated by levers and pulleys to move the fingers – not very effective and very cumbersome and very slow. It would be great if you could just think like we all do, “I want to move my thumb, I want to pinch, I want to turn my car key” and all of a sudden it happens. That’s how we all operate on a daily basis. In order for that to happen with a prosthetic, there has to be some way to create an interface between your brain and your nervous system and the prosthetic, some kind of electrical connection. And lo and behold, that’s actually been worked out and we now have prosthetics that are actually controlled by the person’s nervous system. They think, “I want to move my finger” and the finger moves because there’s actually an interface, a little chip that can connect nerves in their spinal cord with the electronics in the prosthetics. So that’s also something that’s happened in the last 10 or 15 years. It’s obviously very exciting and it eliminates the need for those medications for transplantation.

Daniel Lobell: (18:04)
Wow.

Dr. Kyle Bickel: (18:04)
So there are a lot of great developments that are still being worked out and as with many things in medicine, there’s a pretty bright horizon with new developments to come.

Daniel Lobell: (18:15)
That’s incredible. That’s so cool. I would imagine if you can use your brain as the interface now to move body parts, that there’s no limit on what you could do. You could have hands that are even more functional than our hands put on.

Dr. Kyle Bickel: (18:30)
Right? Absolutely. Although, as I think we all recognize the human body is a pretty miraculous machine and it’s been pretty hard to duplicate and to make it better than it was before.

Daniel Lobell: (18:45)
But what about if the tips of your fingers were flashlights? [Laughs]

Dr. Kyle Bickel: (18:50)
[Laughs] Well, there’s a whole field now that’s a pseudo medical field – I don’t know if you’ve read about it – but there are these people who are really interested in piercings and tattoos and now they have implantable magnets and little electronic devices that these people are getting put into their fingertips and in their arms and on their scalps and they can literally have a magnet in their finger so that they swipe it in front of an automatic door and the door opens. They don’t have to enter a code or use a key and they can pick up magnetic objects, etc. So there are a lot of possibilities out there and it’s just a matter of what’s feasible and what’s practical. And that varies a lot from person to person. What you and I think is far out and crazy, some people think is a fascinating idea.

Daniel Lobell: (19:42)
Or if you snapped your fingers and your index finger worked as a lighter. I don’t know if that’s the healthiest. [Laughs]

Dr. Kyle Bickel: (19:52)
[Laughs] Well it would come in very handy at rock concerts.

Daniel Lobell: (19:55)
Right. Okay. So I’m going to shift gears for a minute. I know that you’ve been very active for over 25 years in charitable medical missions in developing countries. You’ve provided medical and surgical treatment to populations and helped educate health professionals in countries that wouldn’t have it otherwise. Right?

Dr. Kyle Bickel: (20:15)
Yes, I have.

Daniel Lobell: (20:16)
I was wondering if you had any particularly fascinating or rewarding experiences that you could share with us? A story from doing that.

Dr. Kyle Bickel: (20:26)
Boy, there are so many and it almost seems redundant to talk about rewarding experiences from those trips because honestly every trip I’ve been on has been in and of itself a rewarding experience more than you really anticipate going into it. They are Herculean challenges in many ways because we’re bringing our own equipment and going into very remote areas, often with very few resources and trying to do state of the art work. It’s exhausting. It’s daunting. Some of the places that we work are half a world away and they take 36 hours of three or four different plane trips just to get there and you land and you’re exhausted. In the case of La Paz, Bolivia, which is one of the cities that I’ve worked in, you can’t breathe either because it’s 13,000 feet above sea level and you get off the plane with no chance to acclimate and you hit the ground running. The first thing you do is you have a clinic the day you get there and 400 people show up and you have to evaluate them and screen them and talk to them and counsel them and then set up your surgery schedule and the next day you’re operating for sometimes 12-14 hours. So, they’re daunting but you come away from it – no matter how hard it is, no matter how physically demanding or challenging it is – feeling like it was one of the best things you ever did because there are so few opportunities in life to give that much to people so freely. They never asked for anything. They’re incredibly grateful. There’s no money that exchanges hands. There’s no insurance company as a middleman, you know, all of the things that we have to deal with here in the modern world that sometimes take away from some of the gratification in what we do. And so it’s really a very pure form of caring for people and I really enjoy that about it.

Daniel Lobell: (22:24)
Well, I commend you for doing it. If you ever want to take a comedian along to make them laugh, I’m down. I’m used to no money being exchanged. [Laughs]

Dr. Kyle Bickel: (22:35)
[Laughs] We could definitely use one here and there, there’s no doubt about it. But I will tell you that one of the most rewarding things about it is that you get to interact with people in a very different way than you do when you travel somewhere as a tourist and I’ve certainly done my fair share of travel for my own edification. My wife and I like to travel and so you go somewhere and you’re a tourist and you try to be polite and you try to be understanding and to adapt to their culture. But they still view you as an American and a tourist. When you go as a physician to help people, they don’t view you as that. They view you as just a human being who’s there to help another human being. There’s so much more open and appreciative and they open their homes to you and it’s just a different kind of experience, a different way to experience people from other cultures that I don’t know if there are a lot of other ways to get at.

Daniel Lobell: (23:37)
Yeah. Really cool. What an interesting window you have into humanity through that. Now Jeremy here at Doctorpedia mentioned to me that you’re a bit of a coffee connoisseur.

Dr. Kyle Bickel: (23:49)
[Laughs]

Daniel Lobell: (23:49)
Which I thought was funny, considering that you work on hands and coffee can make them jitter.

Dr. Kyle Bickel: (23:56)
Yeah.

Daniel Lobell: (23:56)
Having too much coffee before a surgery, I don’t know if I would want that doctor. I was wondering about if you could expand on this – what makes you a coffee connoisseur? What got you into it? Can you share some details with us?

Dr. Kyle Bickel: (24:14)
Well, I think he might be overstating the connoisseur part a little bit. I appreciate his confidence in my skills–

Daniel Lobell: (24:18)
–[Laughs] Correction – he goes to Dunkin’ Donuts every morning. No, I’m kidding.

Dr. Kyle Bickel: (24:25)
Right, exactly. So I think it just gets to my artistic background. I really do appreciate form and function and perfection and things. I was never a coffee drinker. I didn’t grow up drinking it. I’ve tried to live a pretty healthy lifestyle and you know, I have my vices like all of us do, but they are fewer and farther between than some people’s and coffee to me just never really was very appealing. And then I did some of my training 30 years ago in Europe and I was in Switzerland and France and Italy and there, coffee is a part of their culture. They take breaks from surgery just to go have a cup of espresso every day. And I got exposed to espresso and I loved it. It was a little bit more of a ritual, it wasn’t just putting some Folgers into a cup and pouring hot water over it. It was centuries-old history and it was a part of their culture and I really grew to love it. And so when I came back to the United States, I started looking around at espresso, and this was before the days of Starbucks. There was no such thing. And you really had to kind of look pretty hard to find good espresso in the United States. There were some artisanal coffee houses in some cities like Berkeley up here in Northern California, but it certainly wasn’t on every street corner. And so I gravitated toward that and then thought, “wow, it’d be really great to be able to make my own wonderful espresso and lattes”. And so I started to look into what that would entail, it was finding a really great espresso machine and that can be pretty expensive. So I kind of put that on hold. And then I had a second job aside from medicine for five years – I’ve been a lifelong bicyclist and I was fortunate enough to get connected with the founder and CEO of a very, very successful bicycle company that happens to be based here in the Bay area and I was hired on as a product designer and a medical tester for the bike industry, for this one company. And one of my fellow workers at this company was a coffee maniac. This guy knew everything about espresso. He and I started trading ideas and thoughts and we traveled together to some foreign countries with this company to do some presentations and we would go to find the best espresso in Amsterdam or in Paris or in Australia. And when I got back from that trip, I said I was going to do it, I’m just going to jump in. And so I purchased a handmade Italian espresso machine, and then it just became a matter of trying to find the best beans to make the best possible espresso. After I got the machine, my wife sent me to a class for my birthday one year to learn how to do latte art. Believe it or not, there are classes where you can learn how to do beautiful designs with milk and espresso and make latte art. So that kind of got me started on the road to trying to perfect the perfect latte.

Daniel Lobell: (27:40)
I don’t think Jeremy was exaggerating. [Laughs] I think he was right on with that.

Dr. Kyle Bickel: (27:46)
If you want after the podcast, I’ll send you some pictures of some of my best creations. [Laughs]

Daniel Lobell: (27:51)
I would love that. Yeah, I’d love to see them.

Dr. Kyle Bickel: (27:53)
The funny anecdote about that is that it was so much a part of my life that it was in my wedding vows with my wife. She said in front of the entire wedding crowd that was there at our wedding that one of the reasons she was marrying me was that she was guaranteed lattes for life.

Daniel Lobell: (28:17)
[Laughs] Yeah.

Dr. Kyle Bickel: (28:17)
[Laughs] So she’s held me to it and every morning she gets a latte, come rain or shine and no matter how tired I am, I make her a latte every morning when I wake up.

Daniel Lobell: (28:23)
Hey, that’s a good deal.

Dr. Kyle Bickel: (28:24)
Yeah, it is a good deal. I get a lot out of it, too.

Daniel Lobell: (28:24)
Any advice for hand health in general? Because I know that you have more experience with hands than the average person. Is there anything that we should just be doing to try and keep our hands healthy?

Dr. Kyle Bickel: (28:42)
Boy, that’s a great question. It’s a little difficult because most of what I see is sort of induced upon people not through any fault of their own. So it’s not that they weren’t taking care of their hands. It’s that they were doing what they love to do and they got injured or they were born with a hand defect or they have a genetic predisposition to develop that arthritis in their hands. There’s not much that you can do to prevent any of those things. And so in thinking about that, you want to keep your hands clean, obviously. One thing I will tell you that is preventable are infections from manicures and I see more of those than I wish I did. It happens all too often and there’s the cuticle at the base of your nail and a lot of manicurists will really get in there and dig under the cuticle with various instruments. Those instruments are sometimes not as clean as they should be and also it’s a matter of the fact that we have bacteria on our skin that we all carry around with us and it belongs there, but it belongs on the outside of our body. When people start jamming things under the cuticles and draw blood, they can actually introduce bacteria from our skin under the skin into the bloodstream and it can cause infections. So you know, being careful about hygiene, keeping your hands clean, avoiding contamination or things like that – I think is helpful. Keeping your hands warm and cold environments. I became something of an expert in frostbite when I practiced, the first five years of my practice was in Baltimore, Maryland. And one of the years I was there just happened to coincide with one of the coldest winters they had ever had on record and there were wind chills for a few weeks in a row 50 below zero. It was unheard of cold wind chills and people were coming in night after night after night with frostbite and losing fingers and toes. And so keeping your hands protected from the extremes of cold temperatures is certainly helpful. And then flexibility is important. So as we age and when we develop arthritis, which is sort of inevitable – if you live an active life, your joints start to wear out – you want to really maintain flexibility and avoid stiffness. So just keeping the fingers moving and keeping them flexible is really helpful.

Daniel Lobell: (31:08)
I wonder if piano players wind up with less arthritis problems than the rest of us.

Dr. Kyle Bickel: (31:15)
I think they may end up with less stiffness from arthritis. I think that they have the same genetic risks that all of us have. If their parents had arthritis, then there’s a good chance they’re going to get it too. I think that the general population is not particularly aware of just how strong a role genetics plays in the development of arthritis.

Daniel Lobell: (31:38)
And there’s nothing we can do about that, I suppose. Right?

Dr. Kyle Bickel: (31:41)
Not yet.

Daniel Lobell: (31:42)
Not yet – I like your optimism.

Dr. Kyle Bickel: (31:42)
There’s a very active body of research in genetic manipulation and maybe someday we’ll be able to delete the bad ones and replace them with good ones. A little bit of a scary thought.

Daniel Lobell: (31:57)
I’m going to shift gears for a second. I know that you use some of the most cutting edge technologies at The Hand Center, including minimally invasive and arthroscopic surgical techniques.

Dr. Kyle Bickel: (32:08)
Yes, we do.

Daniel Lobell: (32:08)
Can you please explain how these facilitate a better patient experience?

Dr. Kyle Bickel: (32:15)
Oh sure. I’d be happy to. Minimally invasive surgery is an expanding field in many specialties. When I trained in surgery back in the 1980s and 1990s, surgery involved cutting somebody open. If somebody needed their gallbladder out, we had to go through the muscles and under the liver and take out the gallbladder and it left them with a five or six or seven inch long scar under their rib cage. And also all of the internal scarring and disruption that happened as we went in to get the gallbladder out and then came back out and had to put everything back together. So the word we use in medicine is morbidity, meaning the negative side effects of our treatment. And so there was a lot of morbidity associated with surgery and people were certainly aware of that. So the development of minimally invasive techniques came about as an effort to try to minimize the morbidity of surgery. How can we get in there and take that gallbladder out? How can we get in and fix somebody’s ligament inside their wrist – this tiny little ligament – without having to disassemble the entire wrist joint and everything above it and then put it all back together just to go in and put in a couple of stitches in a torn ligament? And the answer to that has been arthroscopy. The two root words from arthroscopy are “arthro”, which means joint, and “oscopy” is basically a scope. And that’s exactly what it is. It’s a tiny miniaturized fiberoptic camera that we can put into the joint through just a tiny little puncture. The diameter of the camera that I use for most of my arthroscopy is only 2.3 millimeters in diameter, so it’s really about the size of a pencil led. We can put that little fiber optic scope inside the joint and aim it wherever we want to look at those structures and it projects up on a big flat TV screen, just like a video game. And then through other little punctures I can insert instruments – I can insert suture instruments, I can insert little biting forceps to nibble away tissue that doesn’t belong there, etc. We can do a lot of really important work through very, very tiny incisions and we don’t have to take anything apart and put anything back together to get in and get out in order to do that work. How that benefits patients is it dramatically decreases the morbidity, the negative effects they’re going to experience of the surgery itself. None of those tissues are disrupted. None of them have to heal. They don’t have a visible scar when everything is said and done and they’re fully healed and therefore they tend to recover faster and with less pain because there’s not been as much invasion of their tissues in performing the surgery.

Daniel Lobell: (35:18)
Fantastic. Do you think we’ll get to a point where we go from minimally invasive surgery to noninvasive at all? Somehow is there a way to get in there without breaking any skin?

Dr. Kyle Bickel: (35:32)
Yeah, I mean there is already noninvasive treatment. If you think about radiation therapy for cancer, there’s no incision that’s made and the beam is directed at the tumor cells and the depth of the beam is calibrated and then people are zapped and it treats the tumor. The other modality is ultrasounds, we used to have to go in from the outside to fish out – and sometimes we still do if they’re large – but we used to have to fish out all of our kidney stones if people had kidney stones obstructing their urinary flow and they’re very painful. And now there’s something called lithotripsy, which is ultrasound shockwaves that are applied that will basically polarize the kidney stone and just break it up into dust so that it can be passed without pain.

Daniel Lobell: (36:29)
Wow.

Dr. Kyle Bickel: (36:30)
And that’s done without any incision whatsoever. It’s an external source of ultrasound waves. So there are some modalities where there’s no invasion of the skin at all.

Daniel Lobell: (36:39)
And are they going to be able, do you think, to bring some of those modalities to hand surgery?

Dr. Kyle Bickel: (36:46)
Good question. It’s hard for me to envision how that would happen. But you know, that’s the beauty of progress is a lot of times the things that we take for granted now were things that our predecessors could not even have dreamed up.

Daniel Lobell: (37:03)
Yeah. And as we move forward with technology, this gives me a great segue into my next question. We are going more and more to the Internet, which brings us to Doctorpedia. And my question to you of how we here at Doctorpedia can best assist the online health space with regards to your line of medicine.

Dr. Kyle Bickel: (37:27)
Well, I don’t think it’s unique to my line of medicine. I think that medicine in general has done a great job in many respects of incorporating technology. We use computers in everything we do in the operating room and the hospital, even the way we take people’s temperatures now – we don’t stick a thermometer under their thumb, we just hold a little sensor up to their forehead. It’s really been pervasive. Technology has both impacted medicine and medicine has also impacted technology. There are a lot of developments in technology that have come from medicine. But one of the ways that I think we haven’t been able to keep up as well as many other sectors is in information technology and how we distribute information to patients. Because we’re doctors, we’re not IT professionals. We’re used to talking to patients. So there has been some resistance, I think, in the broader medical community to relinquishing our control of that discussion to the Internet. But having said that, I don’t think that patients feel the same way. They often feel that the traditional way of practicing medicine is cumbersome, it’s time consuming. There are young people out there who don’t want to leave their desks, period. They don’t cook food, they just order it online. They don’t have to go pick it up. Somebody delivers it to them. They want drones to drop their packages on the front doorstep so they don’t have to go out off of their property. There is an entirely new way of thinking of technology and convenience and I think that a lot of our younger patients especially expect that from their medical interactions as well. I think Doctorpedia can service that aspect of the medical interface quite well. But even more than that, I think that the downside that a lot of us have seen in the technology that is being put out there – information technology about medicine – is that it’s not very well curated. It comes from sources that aren’t often well vetted. They’re not truly experts and some of them are just vehicles for advertising and they’re not really distributing very valid and very useful information to patients. I think that if we look at Doctorpedia and the mission of Doctorpedia, it’s actually to serve as a resource for expert medical information from actual experts directed at patients in a way that they can receive it readily, they can understand it, and they can use it to their benefit. I think it’s a fantastic resource for that – in every specialty.

Daniel Lobell: (40:34)
Yes, I agree with you on that. I know that you have some videos up on Doctorpedia about carpal tunnel syndrome.

Dr. Kyle Bickel: (40:41)
I do.

Daniel Lobell: (40:41)
Has your public profile impacted your relationship with your patients and has it instilled more confidence in them in your work?

Dr. Kyle Bickel: (40:53)
Not that I’m aware of – I think that hopefully that will happen. As you know, Doctorpedia is still largely in the development phase and I don’t think that a lot of people know about it yet. We’re working hard to change that. And I have not taken those videos – I haven’t taken ownership of them and distributed them to my patients or put them out there under my name, something I have thought about doing but haven’t done so yet. But I do think that when Doctorpedia hopefully becomes more widely available and people are searching for it more freely, that people looking at carpal tunnel syndrome will find it to be an outstanding resource. I think that we really took a lot of care in making the videos. I know that I was very conscious of trying to really give people the information that I would want all of my patients to have and they’re very comprehensive. They’re very thorough, but I think they’re pretty easy to understand for the average patient.

Daniel Lobell: (41:52)
Yeah. Is it a big problem, carpal tunnel syndrome, still?

Dr. Kyle Bickel: (41:58)
It’s a huge problem, yeah. People have a lot of misconceptions about it. One misconception is that the only people who get carpal tunnel syndrome are people who keyboard all day long and nothing could be farther from the truth. It’s actually the most common peripheral compressive neuropathy we see in the body. It’s more common than compression of nerves in the foot or the leg or the neck. It’s the most common compressive neuropathy that there is. So there are literally millions of people around the world with carpal tunnel syndrome and the causes are numerous. It’s not just related to work activities and keyboarding.

Daniel Lobell: (42:41)
Is there any piece of advice – general advice – you can give the public on how to prevent it?

Dr. Kyle Bickel: (42:50)
Yeah, I think for those cases that are directly related to activity, paying attention to the things that your body is telling you is really important. The symptoms of carpal tunnel syndrome – without trying to recapitulate the videos and give people a tutorial on it, but just to briefly encapsulate it – it’s a nerve compression and the primary symptom that people have is numbness and tingling, sometimes associated with pain in their fingers. Anybody, I think, who is starting to experience numbness and tingling in the fingers that is repetitive – they keep getting it every time they go to bed at night or they wake up with it in the middle of the night or they get it after keyboarding for an hour or they go and work in their garden for two hours and their hand falls asleep – not to just ignore it because that’s usually a sign of the development of carpal tunnel syndrome. The best time to treat it effectively and to experience complete 100% correction of the problem is to treat it early. If people ignore it for too long because it’s a nerve compression, it can actually physically damage the nerve and then the potential for restoring function is much less if the nerve has already been damaged. So it’s better to treat it if it’s early and if the changes to the nerve are mild or moderate before they become severe. So don’t ignore it.

Daniel Lobell: (44:14)
Alright, good advice. I want to sort of go back for a second. You’ve been very active in teaching and lecturing and in your research, what do you think has been the most fundamental outcome of the research that you’ve done?

Dr. Kyle Bickel: (44:34)
A lot of the research that I’ve done lately has been more clinically-based research, looking at effective treatments for different problems. We try not to just practice anecdotal medicine. What I mean by that is, “well, this is how I do it because that’s the way I was taught to do it,” or “this is how I do it because I’ve always done it that way and so that’s just what I’m going to keep doing.” We try to more and more rely on data as we do in all aspects of life to inform us about what the best way to approach things might be. And so I’ve really tried hard to incorporate current data in my presentations to other physicians about how to treat different problems. Complex fractures or complicated nonunions of fractures, etc. To teach people that looking at the outcomes should really help to inform our decisions about how to treat things.

Daniel Lobell: (45:35)
Yeah. There’s so much data out there, how do you know which data to look at?

Dr. Kyle Bickel: (45:43)
Yeah. There’s a body of analysis of evidence and there’s high level evidence and there’s “crappy” evidence, for lack of a better term. There are criteria that we use to differentiate high level evidence from purely anecdotal reporting. Anecdotal reporting is “here are three cases of this condition that I treated this way. This is how they ended up.” Not really very scientific, no control groups, no statistical analysis, etc. Comparison is here’s this same problem and here’s an analysis of 500 patients with that problem. Half of them were randomized to placebo or to other treatment processes, the other half to this particular process that we’re looking at. And then we treated them and then we followed them and we analyzed the outcomes in terms of the results. How did it effect their pain? How did it affect their motion? How did it affect their ability to return to their occupation? And then that is subjected to statistical analysis so that we can actually look at numerical data. That’s a high level study. So when we read the medical literature, we don’t just read it and take it verbatim as the truth. We read it with a jaundiced eye and say, well, “was this high level evidence? Was this a properly controlled study or not?”

Daniel Lobell: (47:12)
Right. Well, Dr. Bickel, you’ve done so much great work and we really appreciate all that you’ve put out there and continue to put out there and I would encourage people to check out your videos on Doctorpedia. I always wind down the interview with the same question and that is: what you do to stay healthy?

Dr. Kyle Bickel: (47:31)
Good question. Fitness has always been a big part of my life. I enjoy athletics. I’ve been a cyclist for over 40 years and I continue to bike almost daily when I have the time. My average is probably five days a week. I either get outside on a bike or we have an indoor bike at home. I like to surf, I like to ski, I like to run and hike. Fitness I think is important. Nutrition is really important. I try more and more as I’m getting older to be really conscious of what I put in my body and to try not to do things that are going to hurt me and sleep. All of the key core recommendations that we give everybody about a healthy lifestyle is eat well, exercise, and get plenty of sleep.

Daniel Lobell: (48:24)
Yeah.

Dr. Kyle Bickel: (48:24)
And then the rest of it, I think, is mental. Trying to keep a positive attitude and to be optimistic about life – I think that has an enormous impact on people’s overall health. And that’s something I try to practice as well – to be conscious.

Daniel Lobell: (48:38)
Well, your optimism has shown through in this interview and I appreciate it. Thank you so much for doing the show.

Dr. Kyle Bickel: (48:44)
Thanks, Daniel.

Daniel Lobell: (48:44)
Yeah, my pleasure.

Dr. Kyle Bickel: (48:45)
I appreciate it.

Daniel Lobell: (48:47)
Thank you.