Tinnitus Newbie Desperate for Answers, Trying to Determine the Cause — From Cervical Injuries?

Those who overcome the trials that life puts in our way certainly are role models. We all have a world of knowledge/experience out there to help shape our lives.

Conversely, those that claim to know it all are probably not the best instructors. And self-absorbed types (whether or not they fall into the former category) will doubtless not have the time or perspective to offer much assistance (though we can learn from everyone and must not be too quick to discount).

You are incredibly kind, @Greg Sacramento. I will hang around on here to offer what help I can to @IntotheBlue03, and seek what help I can in turn.

Best wishes.

 

@IntotheBlue03, have you heard of these guys?

https://www.caringmedical.com/prolotherapy-news/tinnitus/

Tinnitus- why this symptom is so common in...

 

@Uklawyer, yes sir, I have, they’re actually how I discovered Prolotherapy/PRP and led me to my local Prolotherapy guy Brian Shiple DO who did my Stellate Ganglion Block today. That wasn’t bad by the way, it definitely disabled the panic and allowed me to drive around and be outside for the remainder of the day, however I’m dealing with some brain fog that hasn’t dissipated that’s giving me anxiety (this very much could be related to my previous symptoms though, going through “panic fog” etc all these months).

Here’s to hoping it helps in the coming weeks as well as how it’s reported to continue to produce effects/improvements for months. I can’t say it was earth shattering other than the physiological symptoms of fight or flight are not as present, at least not today. No change in tinnitus.

 

Hopefully you’re saving the day again! Etifoxine is arriving in the mail today and I’m hoping it can help with any potential withdrawals I’m dealing with and anxiety issues in a more sober non habit forming way. Will post here how it goes.

@peter91 mentioned it might have lowered tinnitus for him but that could have been from reduced anxiety.

My anxiety and panic unfortunately have been going to new heights but my tinnitus has not increased or reacted. I don’t know if that’s just because I’m in such a panicked and exhausted state that it is dominating all of my senses/psyche, but this is just as debilitating as tinnitus has been for me for sure.

I noticed that the longer I go between treating with Clonazepam, the worse these attacks get, so either I’m stuck in some type of PTSD or it’s withdrawal. (To be fair I had all of these symptoms before starting benzos, just not as severe). I noticed the brain fog I thought may have been from the SGB has halfway dissipated as I’ve slowly taken .25 mg of Clonazepam through the night along with head pressure and anxiety.

Lastly, happy to report the SGB is doing its job of blocking some physical symptoms for me including chest pains, adrenaline rush, heart palpitations and increased blood pressure etc. Here’s to hoping the Etifoxine will help stabilize me as I continue to try and taper down. I’m also looking into home Neurofeedback and possibly NAD+ IV Therapy, as both should address whatever my true cause is (PTSD, addiction or both).

 

Hello @IntotheBlue03. I hope that Etifoxine has the desired effect of calming the anxiety whilst reassuring you that it will not do you any harm.

For what it's worth, I do not believe that you are going through any withdrawal. It did not sound as though you took Clonazepam very much at all (i.e. months in a row), so I do not see how your body could have built any tolerance to it. I do remember suggesting to try taking it daily, possibly starting at a lower dose if uncomfortable and splitting into 2 periods during the day rather than taking only once per day to help you feel more comfortable with it also. Given that you refer to periods between taking Clonazepam, I am inferring that you have not tried taking it on a regular basis but perhaps I am wrong. All drugs come with possible side effects, but we can only know if they do the job if we take as directed (not by me, but by a medical professional). Correct me if I am wrong, but it appeared as though you felt calmer when taking the Clonazepam.

From a personal perspective, I am unsure how you can measure such debilitating anxiety as increasing on a periodic basis (unless there is an obvious uplift each time). Has something happened? Have you shifted any thinking with regard to to the tinnitus? You have stated that the tinnitus, itself, has not become any worse and, I thought, following the SGB, you were reporting the tinnitus at being at a much improved level - so the opposite in fact. In my case, I became aware that the worsened tinnitus was not getting better after a certain period and this, effectively, shocked me into a state of extreme panic, which overwhelmed me and deprived me of sleep. It was a total shift, which put me on permanent high alert against something that I could not, it appeared, do anything about. I could not measure any discernible increase or decrease in the anxiety. I did notice that, at some point during the day, I let go a little and managed to focus on something else (TinnitusTalk if you can call that something else usually), but when panic firmly took hold once again, it was a constant throughout this initial phase.

You, yourself, have admitted that the symptoms were there prior to Benzo use. Again, side effects are possible, including anxiety, but I would guess that any side effect like increased physical symptoms of anxiety would be relatively easy to spot upon taking the drug. A psychiatrist will tell you this, but (repeating myself), I do not see how it can be withdrawal.

I think that benzos are usually taken in conjunction with antidepressants (unless only taken very occasionally). This is something you have been asking about, but might need to enquire about further. All I can suggest is to go slow and steady: take the Etifoxine, see how you feel. If it helps one day or has no discernible negative effect, take it again the next day. Try for a week and see how you feel. Follow recommended guidelines and if you need to increase the dose (to a safe, suggested level, do so.

I think that more severe anxiety will, logically, require stronger benzos. Either they will help in some way (and should for high anxiety states) or they will not. If they cause any clear side effects, report these and be guided to an alternative.

I do feel that being under the care of a good psychiatrist would help with psychological/emotional side of things.

 

Hey @Uklawyer.

Hopefully the Etifoxine provides some clearheaded relief. I really hope you are right and that this is not withdrawal. But I was on the Grandaxin for 3 weeks at 100 mg daily for the most part. One symptom I’ve noticed is pinpointed pupils that have not changed for days which I’ve read doesn’t really accompany benzo use or withdrawal but does accompany prolonged severe anxiety so hopefully you are right.

You are absolutely correct about your observations. The tinnitus has seemed to shift to the background while my severe panic has dominated the rest of my life. This has confused me as well because the severe anxiety and panic started increasing as of the beginning of last week while I was still taking Grandaxin. I noticed that it was escalating and despite the medication I could not calm down. In addition to this (and to this day) I cannot sit or lie down for the most part as I have a strong urge to move. This led me to believe that maybe the Grandaxin was causing me a symptom similar to akathisia but it is still with me to present day.

After experimenting with a number of natural antianxiety supplements such as CBD, Passionflower, Kava root, Skullcap and Ashwagandha, the only thing that calms the panic down to some extent is Clonazepam (I am slowly taking 0.25-0.50 mg every other day and so far the pattern has been that the following day I feel mostly normal). However, once that half life approaches, the panic, brain fog and anxiety steadily goes back up. I had 2 great days last week and I have to remember that.

I’m doing the best to cover all my bases, and hoping since the brain fog did seem to dissipate somewhat following some Clonazepam after the SGB that the SGB didn’t worsen that. Doing my best to remember that all these symptoms were here in one way or another (including not being able to sit down or lie down for long) prior to SGB and benzo use.

I’m definitely going to continue to work with my psychiatrist and now a psychologist moving forward. Here’s to hoping I can break this cycle and get some relief as it’s really taking its toll at 3 months in now. Thank you for the kind words as I always look forward to them everyday while trapped at home and feeling trapped in my mind.

 

Hi @IntotheBlue03. Akathisia can be treated with at least one drug, so there is a remedy for that, if required. I know someone who got it when trying an antipsychotic. She was pacing an equivalent of over 10 km per day.

I don't know if it is side effect of Grandaxin, but, again, you can judge just how likely this is to be the case.

Estimate appear to vary over the half-life of Clonazepam, but the minimum appears to be c.20 hours. So taking it twice a day would certainly be enough to prevent experiencing any such effects.

If I were to hazard a guess, I would say that you need to calm down your limbic system; do whatever you can to relax. Your tinnitus problem is moving in a positive direction. Take your mind there with it and you will see progress. Don't get hung up about the medication. It will help. If not, you will know very soon. Try the Etifoxine. If it isn't right, retry the Clonazepam or another benzo. See what the psych says about an antidepressant.

You can get past this. Your positive progress shows that you can achieve positive results. That's the reality. Believe it.

Keep us updated.

Best

 

I wanted to catch everyone up on the Neurofeedback I’ve started as it’s been very impressive and I am in tears as I type this. Dr. Starr who is an MD and neuroscientist and wrote the algorithm for MyNeurvas qEEG is the real deal. I’ve worked with him for 2 sessions now.

I never told him much about my tinnitus and haven’t had much detail to tell him about these distressing eye symptoms I’ve been dealing with, nevertheless his qEEG found the following:

1. The location of my tinnitus in the center of my brain
2. Evidence of a TBI
3. Severe PTSD
4. Left eye slight vertical nystagmus which is probably causing my defocus symptoms.

No matter what happens from here I am so relieved that someone was able to validate on a brain scan everything I’ve been experiencing. He thinks I can start making improvements in 5-10 sessions. Here’s to hoping this is where the pain stops.

 

Hey,

Impressive. What does the doctor think you can make improvements in?

There is evidence of a brain injury? Do you know what that could be? Something happened?

 

@IntotheBlue03, sounds like good news. What is the treatment you’re undergoing? What does it consist of? Hope it brings relief.

 

Hey @Uklawyer, so he thinks he can help me with both PTSD and the nystagmus within 5-10 sessions which is a huge relief. I have 20 sessions to use. Apparently nystagmus can be a side effect of a TBI. It can also be a side effect of MS just like tinnitus. Honestly I am just having more and more suspicions of an autoimmune disorder/underlying disease at this point than anything. The TBI really makes me think it’s my upper cervical injuries that I was preparing to treat right before my tinnitus happened. The timing is unbelievably ironic.

I’m seeing a neuro ophthalmologist on Thursday and hopefully between the NAD+ treatments and my Neurofeedback sessions I’ll be able to make it there in one piece. I left the house for a third time today albeit with some anxiety to get some prism glasses for this eye condition but still.

Lastly unfortunately I do not recommend the SGB. I still cannot rule out if it attributed to my eye issues/brain fog etc so I would advise everyone to steer clear unless they were healthy to begin with. I’ve spoken to 2 docs now that administer them that tell me what I’m experiencing could be a rare side effect.

 

Hi @Jerad, I hope you’re doing ok these days. It’s Neurofeedback which basically is a retraining/rewiring of the brain similar to neuroplasticity for tinnitus. I did a qEEG and it revealed that my brain is producing the hyperactive/hyper vigilant brain waves in PTSD while suppressing the calming brain waves. It’s been great for me because it’s done at home remotely and you’re guided over Zoom with the doctor and you’re basically watching videos while cues are sent to your brain through those videos. I even was able to do the qEEG at home. Could be placebo but I have felt slightly calmer after 2 sessions.

Hoping this is the answer I’ve been waiting for after 3 long traumatic months.

 

How's it going, @IntotheBlue03? How is tinnitus? Is the brain fog a little clearer?

 

Hey @Uklawyer, thanks for checking in on me as always I’m still struggling with some PTSD and this debilitating eye condition but my tinnitus is low.

I’ve been let down by conventional medicine as usual so my full faith is in my NeuroDoc and Neurofeedback to hopefully address both problems.

I have had the panic subside about 50% over 5 sessions and made a worthless trip to a Neuro-Ophthalmologist with tests for 2 hours without having a panic attack so I am highly impressed. He has also completely validated my experience without knowing much detail so that’s also been empowering. I don’t know if I have another 3 months in me to deal with this chaos but I am trying. I’m off all benzos at this point for a week and finished NAD+ IV therapy yesterday.

I believe the fog is a combination of anxiety and the disorientation from this eye condition for sure.

Unfortunately, I am coming across other people who have the same symptoms as me post SGB. Highly highly DO NOT recommend it.

 

Hi @IntotheBlue03,

This guy sounds really good. I might have to come and try him for my anxiety problems.

The tinnitus is lower, which is really good. If he can help sort out any trauma and your eye issue, it may, in turn, have an additional beneficial effect on the tinnitus. Do you know what it was that helped the tinnitus, if it was not the nerve block? I am sure the brain fog will clear up. Count yourself lucky: I have had brain fog for about. 20 years (plus other cognitive issues)!

Did the NAD+ IV therapy help? You are supposed to feel a bit funny during the session and then energetic afterwards. I guess that should help with the brain fog.

Best.

 

@IntotheBlue03, to what do you attribute the reduction in your tinnitus?

 

Always thought that @IntotheBlue03's problems (all) were caused by cranio-cervical instability. Alar injury also causes brain fog and sensations when moving head and eyes. All this increased anxiety.

Tinnitus is decreasing as Alar ligaments are healing, thus anxiety is decreasing. qEEG may be also helping with anxiety.

I give her a medal for seeking the treatments that she has received. Not just present treatments, but for past treatments as well.

 

Hey @Uklawyer, yes, I highly recommend him. Not sure if you saw any of my recent statuses but he drove me to tears after giving me his report from my qEEG. He could see the location of tinnitus in my head and why it was so distressing, that I have severe PTSD and a TBI. Most importantly he diagnosed my eye condition from brain waves which was later confirmed by an optometrist to the T. Looking forward to the rest of my treatments with him as he feels he can address every one of those issues over 20 sessions.

He also winced when I told him I had a SGB. Enough said there lol.

I truly think it’s been the LDN at this point that’s helped the most because everything that’s occurring just screams autoimmune disease to me. From what I understand now, the people who have adverse side effects to the SGB are people with an underlying condition. This is just an example but tinnitus can be the first sign of MS especially when it resolves or gets better in a few months. MS can also cause nystagmus. Not certain I have MS but I also have other visual symptoms that have gone on for 2 years that fit either a neurological or autoimmune condition. Then again this could all also be caused by the TBI. Either way, I am definitely not in the noise induced camp at this point.

Sorry to hear about your brain fog. I know you’re not much older than me but I’d recommend NAD. It definitely helped with anxiety and brain fog. From what I understand when you have high anxiety/PTSD, it’s one of the first nutrients that gets depleted in your body AND is needed for neuroplasticity. I’m in the process of trying to see how I can replicate the process (with less bioavailability unfortunately) sublingually.

The only thing to beware of is the treatment can be painful. Some NSAIDs during the session will help though.

 

Hey Ben. I definitely think it was the LDN. I have no doubts now that my tinnitus is autoimmune related as I just continue to have what appears to be autoimmune issues.

 

Hi @Greg Sacramento, this is an absolute honor coming from you! I knew you would chime in regarding the findings of my qEEG. I couldn’t agree with you more. I believe the “TBI” that was found is absolutely my upper cervical instability and driven by such. While I’m on the fence about autoimmune issues (which I know upper cervical instability has a link to), I do know that even some of the visual symptoms I’m experiencing could be caused by this as well.

It’s still so ironic to me that in my pursuit to address my upper cervical that my world came crashing down the same day as that digital motion X-ray.

You are correct in your assessment as always.

I still have quite a few upper cervical PRP treatments to complete and will keep you all posted regarding those results. I hope this thread can serve as a reference for all the alternative treatments I have attempted.

 

Hi @IntotheBlue03. Sounds very interesting. So you have one meeting where he hooks you up and make the diagnoses and then you can do the rest remotely with instructions? I wonder if he has a protocol that others doing this can follow. And I wonder how much this can help with generalised anxiety, panic disorder etc. some people believe the CFS/ME is an autoimmune disease, but I don't believe that it has been proven. Also, it may be a subset of sufferers for whom it is autoimmune. Regardless, I'd still love to kill all of the anxiety. And that may have an impact on the fatigue.

I don't suppose there is any chance you can ask if others can use his protocol or if he has an approved list of people that he has worked with? I'll look it up again.

I might have to try the NAD+ too. But not sure how to get any long-lasting effects.

Sounds like you are making good progress. Hope it continues.

 

Hey @Uklawyer.

The protocol is pretty custom based on your personal needs and brain scan (for example, due to my PTSD we have to customize my treatments quite a bit so that I can make it through them since I cannot sit for long or close my eyes for long) so a clinician (either him or one of his staff) will monitor you through each session over Zoom so I feel like I’m in good hands. In researching Neurofeedback, his program is one of the most trusted in the industry and he actually helped develop the database of brain scans most of the industry utilizes. I’ve felt pretty fortunate to be working directly with the creator of the program as well. Personally I wouldn’t recommend any system where you weren’t being monitored as the protocol can change depending on how you respond to treatment and changing needs throughout the course of treatment. I will definitely ask if he recommends any other system or clinicians when it comes to G.A.D. or CFS/ME for you as he is pretty pricey (I paid $5000 for 20 sessions) and there might be a more affordable option when your symptoms are less extreme. I can only see Neurofeedback being beneficial for anyone looking to improve their brain functionality.

Yes NAD+, while a great therapy, is expensive and short lived where Neurofeedback is more of a longterm benefit for sure. I’d recommend it maybe once a month which is what I might pursue, I did do 5 days as part of a package that I purchased and after over 3 months of severe PTSD I’m sure it was badly needed.

Thank you always for the well wishes and hopefully I can report back with good info.

 

Ok folks, looks like @Greg Sacramento hit the nail on the head again. Unless it’s autoimmune related, or an autoimmune byproduct of my upper cervical instability, looks like it’s upper cervical instability. I went to my ENT (convinced he’s the only good one on the East Coast) and he confirmed that I have PPPD (Persistent Postural Perceptual Dizziness) instead of BVVP. I for one am very frustrated to be dealing with another constant debilitating difficult to treat problem. From what I understand this comes from changes to the brain stem?

Anyway, I found this very helpful article which could be very applicable to my case and I am now kicking myself for moving my upper cervical PRP treatment to April.

While the treatment course I have been prescribed is Zoloft and Lorazepam, I am hoping to avoid both with continued Neurofeedback treatments since I’ve had such a breakthrough with my anxiety (will advise after consulting my Neurofeedback doctor) as he is sure I will have even bigger results in this next week.

Otherwise, I was advised taking Zoloft for the next 6-12 months will be required to resolve this, along with vestibular therapy and CBT which have already proven to be less effective than Neurofeedback. In addition with my tinnitus and anxiety being low, I feel like I’m playing Russian roulette once again with medications like SSRIs and Benzos.

@Uklawyer, feel free to chime in regarding your experience with Lorazepam as I believe it is shorter acting or milder than Clonazepam? After my experience with benzos I am looking to avoid this altogether but I do recall when I was on a very small dose of Clonazepam last week that my dizziness symptoms were reduced so it is tempting if it’s less intoxicating than Clonazepam.

Wish me luck! Any folks who have dealt with PPPD, feel free to chime in.

 

@IntotheBlue03, you are certainly running the gauntlet with the treatments! I had Lorazepam (I appear to be a walking pharmacy) many years ago. I did not use it regularly, but I remember it working pretty quickly. I think it is in the same category as Oxazepam (short-acting benzo), so they work quickly and stay in the system for a shorter period than Valium or Clonazepam. The downside is that you have to be more careful with them because of the shorter half-life.

I cannot tell you how it compares to Clonazepam, since I have not taken Clonazepam, but I would imagine that the above pretty much covers it. If for occasional use, I would think it is fine. If the intention is to take it more regularly, I would think that a longer acting benzo might be a better option. Try it and see how it compares, then you can decide. For me, personally, I think that if tiredness is not so much of an issue, Valium is safer for a longer period, and at a lower dose, you should be ok if not being overly reliant on it. Antidepressants are a separate issue. They take a while to work, so you have to persist, whilst taking care to note any undesirable side effects. I never had such effects with benzos.

Is the tinnitus still lower? If so, great news and take comfort in it - that's an excellent result.

 

I see you were around today. How are you @IntotheBlue03?

 

Hi @Uklawyer, I am doing pretty terrible unfortunately. My vision is still awful (feel like I’m swimming under water) and I now have a focusing problem where I can’t visually focus on anything for more than a few seconds so every day is distressing. On a good note the tinnitus is still low but I’d rather have that back over this vision/focus problem.

I reviewed my 2nd qEEG with my Neurofeedback doctor yesterday and I’ve had improvement in my PTSD but he can clearly see the problems in my vision. According to him there’s a lot of compensation going on in my occipital lobe and it’s attributing to the brain fog I’m experiencing as well as the focusing issues because my visual tract isn’t processing information well. He's told me more in these 2 qEEGs than all the dozens of doctors I’ve seen since my tinnitus started. He sees the TBI as the cause for all of this but feels the remainder of my sessions can help as he’s going to change the protocol to aid in vision processing as opposed to anxiety.

My FCOVD also found evidence of what they call Saccadic intrusions and smooth pursuit problems and these things only seem to occur from underlying diseases like MS or TBI.

Every doctor I’ve seen feels this isn’t MS (fingers crossed) and I will be having a brain MRI soon now that I can hopefully sit through one without the tinnitus to rule that out, but this definitely points to the TBI being caused by that SGB injection I had. What a triple tragedy this has all been. I know of 2 other cases who also have similar brain to eye issues as me who were told they also had a concussion/TBI from recent tests but they didn’t have any trauma aside from the SGB. Class Action lawsuit is on the way.

On another note I will also be starting microdosing of Psilocybin after all. Turns out you can do that without the associated high or trip if the dose is low enough, and I’ve found a reliable source who is going to walk me through all the steps as it seems helpful for resetting the brain if you have a TBI or other underlying diseases even.

So here’s to hoping I’m taking the fast track to neuroplasticity between Neurofeedback and the microdosing.

I hope you are well and I will keep you posted on my results, and if the tinnitus completely resolves with microdosing. Cheers!

 

Hi all,

Continuing to document my case with some new updates. My tinnitus remains a 1 and non reactive. It has completely taken a backseat to the debilitating cognitive and visual symptoms I’m experiencing. I am still on LDN at 4.5 mg.

I am 17 sessions into neurofeedback that has greatly helped reduce my PTSD. This is reflected in updated qEEGs I have done. We have adjusted protocols hoping it may provide some visual relief for me as well for remaining sessions.

I am 1 week into microdosing Psilocybin that definitely has also helped greatly with my anxiety/akathisia symptoms without any adverse side effects. I am confident microdosing is helping because as much as I wanted a thousand products I tried before to even give me a placebo effect for relief, none did.

@Greg Sacramento, good sir, curious about your thoughts regarding my Brain MRI results as a partially Empty Sella was found and I am trying to seek out the right professionals to review my case.

Currently my neurofeedback doctor has been the only helpful HCP in my case in identifying traumatic brain injury from my qEEGs (4 areas affected including occipital). My theory Im curious about now is if my upper cervical injuries/Craniocervical Instability could have caused the TBI in addition to the Empty Sella? From what I understand the combination of the 2 could most certainly be affecting my visual neural pathways and may potentially explain why high dose oral steroids (80+ mg of Prednisone) seemed to provide me relief in the way of reducing inflammation I’m assuming.

In researching this it seems a neuro-radiologist may be helpful in my case to further review my imaging?

@Uklawyer, I’ve noticed a lot of folks commenting on Empty Sella Syndrome attributing to CFS/ME and thought of you. Have you had a brain MRI?

 

Thanks @IntotheBlue03 - that's very interesting: I will have to look into it further.

Great to hear that the tinnitus is at a 1 right now - I hope it fades away. As for your visual issues, I hope that they will resolve in short time also. Keep at it - I am sure that you can get there.

Best wishes.

 

Primary and secondary ESS is most common in adults and women.

25% of adults have ESS and most never find out about it. You just have partial or incomplete ESS - probably less than <25% - otherwise partial wouldn't have been used in MRI report. Really doubt treatment is needed.

Your MRI is outstanding - nice brain. Very smart brain. Also, very active in thought.

Stay clam. Important for vision improvement.

Use correct posture with computer use for improvement of occipital region, alar ligament - upper cervical injuries and cranio-cervical instability.

Continued use of warm moist compresses on entire back of neck.

Hug.

 

Hi my wise friend @Greg Sacramento. I appreciate your insight as always. I do have the results of a CT venogram that I wanted to post here from a Saturday ER visit.

Correct me if I’m wrong but I am concerned about the possible stenosis that is noted in the transverse venous sinuses. While this is anecdotal I’ve come across another young lady actually in my area who has strikingly similar symptoms to me visually and cognitively and her venous stenosis is apparently more severe. She will be having a venous stent placed by a neurosurgeon by the name of Dr. Athos Patsalides in NY who is known for the procedure. I’m hoping I’m not in that camp. I’ve come across a few posts regarding this procedure on Tinnitus Talk as well. I have disregarded my intermittent pulsatile tinnitus because it’s less distressing than my other symptoms but it is very much in play still. In the meantime I am looking to get those upper cervical PRP treatments from C0-C2 as soon as possible and will be using a cervical collar as much as possible. I’ve noticed that all of my symptoms seem worse when I am upright or moving, especially when driving a vehicle. I have no doubt in my mind at this point that any pathology including IIH most likely started with my craniocervical instability.

Also posting my results from my Neurofeedback that documents potential TBI which I again feel stems from my CCI.

Hope this at least served as a interesting read and case study for any poor souls who follow in my footsteps!

Please forgive some of the typos as well. You know how doctors are.