Episode Summary

In this episode, Dr. Lucy McBride sits down with Dr. Shira Doron, Chief Infection Control Officer and Hospital Epidemiologist at Tufts Medical Center, to cut through the confusion surrounding COVID vaccines and public health policy. With the CDC in upheaval and patients calling with urgent questions about protecting their families this winter, they tackle the messy reality of vaccine access, institutional breakdown, and what it all means for your health decisions. Dr. Doron explains why getting clear answers feels impossible right now—and offers practical guidance for navigating the chaos.

Key Concepts

The Regulatory Meltdown

* FDA approved new COVID vaccines but only for high-risk groups, creating access barriers at major pharmacies

* Entire ACIP advisory committee was gutted—all 17 members replaced at once—leaving no clear decision-making authority

* CDC leadership departures and delayed meetings mean the usual vaccine rollout process has completely broken down

* Retail pharmacies like CVS can't administer vaccines without ACIP recommendations, forcing patients to get prescriptions

* The dust may settle by late September, but institutional trust has been severely damaged

The Backstory Nobody's Talking About

* A little known fact: the Biden-era ACIP was already planning to shift away from universal annual vaccines toward risk-based recommendations

* Internal polling of that committee showed 76% support for targeting high-risk groups rather than everyone over six months old

* Current policy direction mirrors what the previous committee intended, but the chaotic process has destroyed confidence

* Medical and scientific community feels betrayed by political interference in normal advisory processes

* Reform was needed, but "slash and burn" approach leaves the country vulnerable to future health crises

Making Sense of Who Should Get Vaccinated

* Dr. Doron suggests talking with your doctor but in general she recommends waiting for the new formulation rather than rushing to get the current vaccine during this summer's wave

* Dr. Doron notes that “high risk” for COVID is broadly defined—and includes sedentary lifestyle, history of smoking, anxiety, ADHD—such that most Americans will qualify for a shot. Plus, self-attestation of risk is likely to continue (rather than requiring medical documentation at pharmacies), and she predicts it will not be difficult to get a shot if you want one (though cannot be sure, and insurance coverage is up in the air)

* Professional medical societies are creating their own guidelines to fill the regulatory void

* Individual risk assessment with your doctor beats one-size-fits-all recommendations

What Vaccines Actually Do (And Don't Do)

* Modest protection against any infection for 2-3 months, more like "wearing a raincoat in a rainstorm" than a force field

* Strong, durable protection against severe disease (due to cellular immunity i.e., T cells) is the real benefit for high-risk individuals

* Limited impact on transmission, so getting vaccinated to protect others isn't particularly effective

* Timing matters: Dr. Doron suggests waiting 6 months to get vaccinated after a COVID infection, 3 months after previous vaccine for most people

* Novavax may offer better side effect profile and longer-lasting protection than mRNA options

Beyond Vaccines: Testing and Treatment

* Paxlovid remains effective for high risk patients when started within 5 days for people at risk of severe disease but is not a standard recommendation for healthy, vaccinated people; we live in a data-free zone on the degree of benefit (if any) for lower risk individuals

* Test for COVID or flu only when results would change your management—mainly for those who might benefit from antivirals

* Home rapid tests can help gauge contagiousness as you recover

* Basic rule: stay home until fever-free for 24 hours without medication

* Early testing and treatment of high-risk household members beats trying to prevent transmission through vaccination

Trust, Messaging, and Moving Forward

* Current chaos represents backlash against heavy-handed pandemic messaging that ignored individual risk differences

* Public health authorities lost credibility by overpromising vaccine effectiveness and dismissing legitimate concerns

* Acknowledging uncertainty and meeting people where they are builds trust better than blanket mandates

* Need institutional reform, not destruction of essential public health infrastructure

Upshot

Dr. McBride and Dr. Doron emphasize that navigating this regulatory chaos requires working closely with your healthcare provider for individualized risk assessment rather than relying on one-size-fits-all guidance. They stress that while patients must advocate for themselves in the current fragmented system, the real solution lies in rebuilding trustworthy public health institutions that prioritize transparent communication and evidence-based recommendations over political interference.

Episode Summary

In this episode, Dr. Lucy McBride tackles the crisis facing American healthcare and provides practical strategies for navigating a broken system. She explores a fundamental disconnect between what patients need and what the current system delivers: while patients require comprehensive, relationship-based healthcare that addresses their whole story, the system provides fragmented, rushed medical care that focuses solely on immediate symptoms.

Key Concepts

The Systemic Breakdown of Primary Care

* Root causes: Pressures from insurance companies and large hospital systems force doctors to see high patient volumes in brief increments, creating unsustainable working conditions and suboptimal care

* Consequences: Primary care has evolved from comprehensive problem-solving into rapid referrals and prescription writing, leaving doctors feeling burned out and unable to provide the care they trained to give

* Scale of crisis: Millions of Americans currently lack access to a primary care provider, with shortages expected to worsen significantly in coming years

* Financial reality: Only 5% of U.S. healthcare spending goes toward primary care, while the vast majority addresses damage control rather than prevention

* Professional exodus: Primary care physicians are leaving medicine due to burnout, time constraints, and inability to practice the comprehensive care they were trained to provide

Medical Care vs. Healthcare: Understanding the Critical Distinction

* Medical care defined: Problem-specific, episodic, transactional treatment focused on immediate symptoms (what urgent care and emergency rooms provide)

* Healthcare defined: Patient-centered, relationship-based care involving shared decision-making, understanding of individual health risks and goals, and comprehensive whole-person treatment

* The integration challenge: True healthcare requires connecting physical symptoms with biographical data, social determinants of health, and emotional well-being

* Relationship foundation: Healthcare depends on trust, rapport, and a provider's understanding of the patient's complete story and context

* Access inequality: While medical care is available through urgent care and ERs, comprehensive healthcare is increasingly accessible only to those who can afford it

Primary Care Options in the Current System

* Insurance-based care: Traditional approach using provider networks, though often limited by short appointment times and restricted access

* Federally Qualified Health Centers (FQHCs): Community-based centers providing comprehensive care regardless of ability to pay, often with shorter wait times (findahealthcenter.hrsa.gov)

* Direct Primary Care (DPC): Membership-based model allowing doctors smaller patient panels and longer appointment times to provide more comprehensive care, though not universally accessible due to cost

* Nurse practitioners and physician assistants: Can provide excellent primary care when well-trained and aware of their knowledge limitations

* Telehealth services: Options like One Medical and MD Live meet specific needs but have limitations in providing comprehensive relationship-based care

How to Evaluate & Select a Primary Care Provider

* Access assessment: Inquire about wait times for routine appointments, same-day sick visits, and between-visit communication methods

* Care philosophy evaluation: Understand appointment lengths, approach to preventive and whole-person care, mental health integration, and specialist coordination methods

* Logistical considerations: Verify insurance acceptance, understand membership details for DPC practices, and clarify after-hours coverage and prescription refill processes

* Red flags to avoid: Providers who lack time for building relationships, demonstrate defensive behavior when questioned, or fail to provide adequate access when needed

* Fit assessment: Recognize that doctor-patient relationships require mutual trust and respect; switching providers when the relationship isn't working is acceptable and necessary

Self-Advocacy Strategies & Appointment Preparation

* Priority setting: Prepare the most urgent issues for each appointment, understanding that comprehensive care may require multiple visits

* Rapport building techniques: Acknowledge providers' time constraints, share personal details to establish connection, and express understanding of systemic pressures while maintaining care standards

* Documentation responsibility: Keep personal medical records since electronic health records are fragmented across different healthcare systems and make sure they are updated with medications, dosages, allergies, family history, vaccination records, and specialist information

* Follow-up planning: Schedule subsequent appointments proactively rather than waiting for problems to arise, ensuring continuity of care

The Future of Healthcare Technology and Innovation

* Electronic health record limitations: Current systems serve primarily as billing tools rather than patient-centered care coordination platforms, with each healthcare system maintaining separate, incompatible records

* Technology's potential: AI and digital innovation (if done well) could create centralized, real-time health records shared across all providers, improving care coordination and reducing redundancy

* Innovation priorities: Successful healthcare technology must elevate—not eliminate—the patient-doctor relationship. Tech entrepreneurs who understand this principle are most likely to achieve meaningful reform

* Patient empowerment through data: Individuals must maintain their own comprehensive health records until systems improve, including all provider visits, medication changes, and test results

* Systemic reform needs: Long-term solutions require centering primary care in the healthcare system, ensuring universal access to medical homes, and prioritizing prevention over damage control

The Upshot

Dr. McBride encourages everyone to advocate fiercely for comprehensive relationship-based care rather than settling for episodic medical transactions. She emphasizes that while individual self-advocacy is essential for navigating current realities, true reform requires investing in primary care and ensuring universal access to medical homes that address the whole person.

Episode Summary

In this episode, Dr. Lucy McBride welcomes cognitive neuroscientist Dr. Julie Fratantoni to discuss practical strategies for protecting and improving cognition. There’s a fundamental disconnect between modern lifestyle patterns and optimal brain health: while our culture celebrates multitasking, passive consumption, and constant stimulation, the neuroscience reveals that our brains thrive on focused attention, active engagement, and purposeful challenge.

Key Concepts

Active vs. Passive Engagement with Information & Technology

* Dr. Fratantoni discusses recent research showing passive AI use creates "cognitive debt" by bypassing memory encoding and reducing creativity

* Study found 15 of 18 participants who used ChatGPT couldn't recall a single sentence from essays they'd just written with AI assistance

* Using your brain first before incorporating tools requires engaging through critical thinking and connecting new knowledge to existing information

* Always close down and repeat back what you learned, either aloud or in writing, to consolidate information

Emotion Regulation & Stress Recovery

* Dr. Fratantoni advocates for stress “recovery" rather than stress management, focusing on bouncing back to keep the prefrontal cortex online

* The “physiological sigh” involves one full inhale, pause, extra sip of air, then full exhale through mouth to activate parasympathetic nervous system

* Reappraisal strategies include reframing anxiety as excitement or considering alternative explanations for ambiguous social situations

* Studies show reappraisal reduces amygdala activity, increases prefrontal cortex activity, and improves heart rate variability and telomere length

* Breathing patterns directly affect blood oxygen/carbon dioxide ratios, modulating norepinephrine production and focus levels

Focus & Attention Training in a Distracted World

* Modern digital environments work against natural attention patterns, requiring strategies to rebuild focus capacity

* Multitasking is actually rapid task-switching that increases brain stress and reduces performance

* Simple tally systems to track interruptions build consciousness of attention patterns and reduce their frequency through awareness

* Start with 5-10 minutes of focused work without distractions, then incrementally build this "focus muscle" over time

* Memory formation requires both attention and encoding time, so constant busyness prevents proper memory consolidation

“Hormesis” & Finding the Right Level of Challenge

* Dr. Frattantoni introduces hormesis for cognitive health—moderate stress benefits the brain while extremes become detrimental

* Research with 12,000+ people found low to moderate stress induces cognitive benefits that promote resilience

* The right challenge level varies by individual interests, capabilities, and circumstances, requiring self-assessment over universal prescriptions

* Examples include learning languages, dance classes, martial arts, or hobbies requiring ongoing skill development

* Neither overwhelming stress nor complete lack of challenge serves cognitive health

Flexible Thinking & Perspective-Taking

* This executive function involves shifting between viewpoints, adapting to circumstances, and maintaining curiosity about others' experiences

* Cognitive flexibility functions like physical flexibility—enough structure to be sturdy but adaptable enough to avoid breakage

* Taking different perspectives activates multiple brain regions and reduces inflammation in healthcare interactions

* Learning to disagree while maintaining emotional regulation and curiosity strengthens multiple cognitive systems simultaneously

* Having difficult conversations while disagreeing represents one of the most challenging tasks for the brain

Purpose and Meaning as Cognitive Protection

* Longitudinal research shows having life purpose provides significant protection against cognitive decline

* Study of 11,000+ older adults found purpose protective against cognitive decline regardless of other health variables

* Purpose doesn't require grand accomplishments—can be simple as tending gardens or contributing to community

* Dr. Fratantoni suggests a two-minute "personal manifesto" exercise to clarify core values and life direction

The Upshot

Dr. McBride and Dr. Fratantoni make the case that conscious attention to cognitive health isn't just personally beneficial—it's essential for redefining how we age and challenging the assumption that cognitive decline is inevitable.

Episode Summary

In this episode, Dr. Lucy McBride welcomes Dr. Sunita Puri for an intimate conversation about death, dying, and what it means to have a "good death." Dr. Puri, author of the critically acclaimed memoir "That Good Night: Life and Medicine in the 11th Hour," shares her expertise on palliative care while addressing the critical gap in how modern medicine approaches end-of-life conversations. The discussion explores the historical context of dying well, the problematic medicalization of death in contemporary healthcare, and practical guidance for both patients and families navigating end-of-life decisions. Dr. McBride brings a personal dimension to the conversation, sharing how Dr. Puri supported her through the sudden loss of her brother the previous year, illustrating the profound impact of compassionate end-of-life care.

Key Concepts

Redefining "Good Death" Beyond Idealized Visions

* The concept of "good death" has historical roots dating back to medieval Europe's "Ars Moriendi" (The Art of Dying) and ancient Buddhist and Hindu contemplations of impermanence

* Modern expectations often center on dying at home surrounded by loved ones, but this idealized vision can create unnecessary guilt and stress for families

* Financial and practical constraints make home death unrealistic for many families, as hospice doesn't provide 24-hour caregivers

* Good deaths are possible in hospitals, ICUs, and nursing homes when focused on dignity, comfort, and honoring the patient's values

* Flexibility and acceptance of circumstances, rather than rigid adherence to a "perfect" death plan, leads to better outcomes for patients and families

The Crisis of Medicalized Dying in Modern Healthcare

* The 1960s explosion of medical technology (iron lungs, CPR, ventilators) shifted medicine toward extending life at all costs, regardless of quality

* Healthcare systems default to aggressive interventions without adequate discussion of alternatives or patient values

* The "conveyor belt of technology" operates independently of what patients actually want or what would serve their best interests

* Medical training fails to prepare doctors for honest end-of-life conversations, leading to inherited patterns of avoidance and euphemism

* The gap between cure-focused medicine and compassionate end-of-life care leaves patients and families without adequate support for decision-making

Transforming Medical Communication Through Radical Honesty

* Traditional medical communication often provides facts without explaining their significance or implications for the patient's life

* Effective palliative care requires moving beyond "checklist" approaches (Do you want CPR? Feeding tube?) to understanding what gives the patient's life meaning

* Dr. Puri's approach involves explaining that "reversing a death is not the same as restoring a life," helping patients understand the reality of interventions like CPR

* Doctors must learn to sit with discomfort, witness suffering, and acknowledge uncertainty rather than defaulting to medical interventions

* Authentic communication requires doctors to examine their own reactions and fears about death, as "95% of doctoring is an inside job"

Practical Framework for Advance Care Planning

* Individuals should reflect on deaths they've witnessed, considering what seemed acceptable or unacceptable about those experiences

* Choosing a surrogate decision-maker requires careful consideration beyond automatic family hierarchies - sometimes friends understand one's values better than spouses or children

* The MOLST (Medical Orders for Life-Sustaining Treatment) form provides a concrete starting point for documenting wishes and should be displayed prominently for emergency responders

* Advance directives should be revisited after major health events, hospitalizations, or significant life changes rather than treated as one-time documents

* Effective planning requires honest conversations with primary care doctors, not just legal documentation, and patients should specifically request these discussions

Embracing Uncertainty and Impermanence as Spiritual Practice

* Buddhist and Hindu concepts of impermanence offer frameworks for accepting life's inevitable changes, including death

* Learning to "sit with uncertainty" becomes essential for both patients and healthcare providers in end-of-life situations

* Death anxiety can be addressed through traditional therapy, medications, and emerging research on psychedelics such psilocybin

* The practice of observing impermanence in everyday life (seasonal changes, relationship evolution) builds capacity for accepting larger uncertainties

* Healthcare providers must model comfort with uncertainty rather than promising false certainty or avoiding difficult conversations

Mercy and Dignity as Core Medical Values

* The concept of "mercy" encompasses both aggressive curative care when appropriate and allowing natural death when intervention would cause suffering

* Modern medicine must balance technological capabilities with recognition of human dignity and individual values

* The phrasing "allow natural death" reframes end-of-life care as supporting a natural process rather than withholding treatment

* Psychedelic-assisted therapy shows promising results for death anxiety in terminal patients, offering profound spiritual experiences that reduce fear

* Healthcare encounters become acts of love when providers center patient values and offer their authentic presence during vulnerable moments

About Dr. Sunita Puri

Dr. Sunita Puri is an Associate Professor of Medicine at the University of California, Irvine School of Medicine, where she serves as Director of the Inpatient Palliative Care Service. A Rhodes Scholar and Yale University graduate, she is the author of the critically acclaimed memoir "That Good Night: Life and Medicine in the Eleventh Hour," which examines her journey into palliative medicine and quest to help patients and families redefine what it means to live and die well. Her writing has appeared in publications including the New Yorker, Atlantic, New York Times, and Wall Street Journal. A sought-after international speaker, she has delivered lectures around the world on compassionate end-of-life care. In 2019, the Guardian created a mini-documentary about her work that has been viewed over 3.5 million times. You can follow her on Instagram and Twitter, and you can hear her previous conversation with Dr. Lucy McBride here.

Episode Summary

In this conversation, Dr. Lucy McBride speaks with author and journalist Debbie Weil about the surprising truths of aging. Weil, who writes the [B]old Age newsletter on Substack, shares insights from her journey of self-discovery in her 70s, challenging common narratives about aging as inevitably terrible. The conversation explores the unexpected freedoms that come with age and the importance of vulnerability in building community—plus the broken healthcare system's impact on trust, and practical health topics including GLP-1 medications. Both women discuss how authentic storytelling creates meaningful connections and how aging can be a time of continued growth rather than just loss.

Key Concepts

The Surprising Gift of Self-Discovery in Aging

* Weil describes discovering that aging involves getting to know your essential self better, rather than losing yourself

* Contrary to anti-aging messaging that suggests everything goes downhill, she found increased self-acceptance and authenticity

* The process involves recognizing you're fundamentally the same person while becoming more comfortable with who you are

* This self-knowledge becomes a foundation for making better decisions about health, relationships, and life choices

Freedom from Others' Opinions and Social Expectations

* Many older adults experience liberation from constantly seeking approval or worrying about others' judgments

* Weil notes the common refrain among older women: "I don't give a s**t anymore" about trivial social pressures

* This freedom manifests in practical ways: not wearing makeup if you don't want to, saying no to obligations that don't serve you

* The shift allows for more authentic relationships and choices aligned with personal values rather than external expectations

The Power of Vulnerability in Building Community

* Weil's most popular writing pieces are those where she shares personal struggles and physical challenges

* Vulnerability creates connection by allowing readers to feel seen and understood in their own experiences

* Both women discuss how sharing imperfections and uncertainties makes them more relatable and trustworthy as voices in health and aging

Healthcare System Failures and the Crisis of Trust

* Dr. McBride explains that only a small percentage of healthcare spending goes to primary care, with the vast majority focused on disease management and hospitalizations

* The average patient has just seven minutes with their doctor, creating transactional rather than relationship-based care

* This broken system has given rise to the wellness industry, which attempts to fill gaps but cannot replace proper medical care

* Trust in healthcare providers requires authentic listening, understanding of individual circumstances, and collaborative decision-making

GLP-1 Medications: Sophisticated Weight Management Tools

* Dr. McBride describes GLP-1 medications (like Ozempic) as the most sophisticated medical technology in her lifetime for weight management

* These medications work through multiple mechanisms: improving insulin efficiency, suppressing appetite, reducing "food noise," and slowing digestion

* Contrary to popular belief, not everyone who stops the medication regains all weight, especially when properly tapered with medical supervision

* The medications can help people break cycles of food restriction and emotional eating, leading to healthier long-term eating patterns

Creating Authentic Communities Through Shared Stories

* Both women have built engaged communities by sharing personal experiences rather than just dispensing advice

* Weil is launching a "No Guilt [B]old Women Book Club" featuring memoirs by older women writers

* The power of storytelling lies in helping people feel less alone in their experiences of aging, health challenges, and life transitions

* Writing and sharing stories becomes a way to process personal experiences while creating connection with others facing similar challenges

Episode Summary

In this conversation, host Dr. Lucy McBride sits down with Shannon Watts, founder of Moms Demand Action and author of NYT bestselling book, Fired Up, to explore how women can break free from societal pressures and pursue their authentic desires. Watts shares insights from her 11 years leading the largest grassroots gun safety organization and her interviews with 70 women for her new book. The discussion covers the psychological barriers that prevent women from "living on fire," the inevitable blowback that comes with stepping outside traditional roles, and the transformative power of female community. Both women examine how age can become a superpower for authenticity, the importance of redefining success beyond traditional metrics, and practical strategies for identifying and pursuing one's values, abilities, and desires.

Key Concepts

The "Living on Fire" Formula: Values + Abilities + Desires

* Living on fire is a metaphor for combining your core values, unique abilities, and authentic desires in meaningful action

* Most women are taught to fulfill obligations rather than desires, creating a fundamental barrier to authentic living

* The formula requires ongoing practice - sometimes it leads to big changes, sometimes small ones, but all matter equally

* Women often underestimate their abilities and need exercises to catalog their skills and seek outside perspective on their strengths

* Values evolve throughout life stages - Watts' values of protecting family and community when starting Moms Demand Action at 41 have shifted now that she's an empty nester

Blowback: The Primary Barrier to Women's Authentic Expression

* Fear of blowback (criticism, social disapproval) emerged as the number one limiting factor for women across all demographics

* Women are socialized to be people-pleasers, making criticism particularly painful and likely to trigger retreat behaviors

* Three strategies for managing blowback: evaluate the source, reframe the temporary nature of uncomfortable feelings, and remember you're modeling courage for others

* Blowback is predictable but not personal - it's a systemic response to women challenging traditional roles

* Learning to endure difficult emotions without numbing behaviors (alcohol, social media, isolation) builds resilience and agency

The “Deathbed Regret” Paradox: Motherhood vs. Authentic Living

* While the most common deathbed regret globally is "not living authentically," mothers in the study feared their regret would be "pursuing desires at the expense of children"

* This internalized guilt prevents women from recognizing that pursuing their own fulfillment actually benefits their children

* Children need to see mothers as whole people with interests beyond parenting to avoid unhealthy pressure and learn healthy life modeling

* Experts consistently affirm that children benefit when mothers pursue meaningful work and interests outside the family

* The fear reflects deep societal conditioning around women's roles and self-sacrifice expectations

Community and Female Friendship as Essential Infrastructure

* Watts discovered at 50 that despite leading a large women's organization, she lacked close personal friendships

* Female friendship requires intentional cultivation and vulnerability - it doesn't happen automatically in midlife

* The "five people you can call at 3 AM" test revealed how many accomplished women lack deep support networks

* Women's collaborative approach differs fundamentally from male competitive patterns, creating opportunities for mutual elevation

* Building authentic community requires moving beyond scarcity mindset and embracing the belief that supporting other women strengthens everyone

Avoiding "False Fires": Redefining Success and Fulfillment

* False fires include the commodification of purpose (turning every passion into profit), chasing ephemeral happiness, and equating busyness with fulfillment

* Society pressures women to monetize their interests rather than allowing pure pleasure and personal satisfaction

* The pursuit of perfection and the fear of public failure keep women from taking necessary risks

* True success means pursuing fulfillment over external validation, allowing for pleasure without productivity requirements

* Understanding the difference between temporary emotions and lasting values helps distinguish authentic desires from societal expectations

Age as Superpower: Wisdom, Self-Awareness, and Fearlessness

* Women over 50 develop crucial abilities: wisdom, self-awareness, and reduced concern about others' opinions

* The Serenity Prayer concept - knowing what you can and cannot control - becomes more accessible with age and experience

* Acceptance becomes a superpower when women learn to focus energy on areas where they have agency

* Later-life authenticity allows women to challenge the narrative that their productive years end when children leave home

* Generation X is rewriting rules around aging, menopause, and post-maternal identity, creating new possibilities for older women

The Upshot

This conversation illuminates a fundamental tension in women's lives: the conflict between societal expectations to prioritize others' needs and the human necessity of pursuing authentic desires. Watts and McBride make the case that women's liberation isn't just personally beneficial - it's essential for modeling healthy adulthood to the next generation and addressing society's most pressing challenges.

Episode Summary

In this conversation, Dr. Lucy McBride hosts Dr. Mary Claire Haver, the renowned board-certified OBGYN from Galveston, Texas. Dr. Haver, author of the bestselling book The New Menopause, discusses the current menopause moment, the complexities of hormone replacement therapy, and why women have been deprived of essential information about their hormonal health for decades. The conversation covers everything from the misinterpretation of the Women's Health Initiative study to practical prescribing guidelines for estrogen, progesterone, and testosterone. Both doctors emphasize that menopause care requires a nuanced, individualized approach that treats the patient, not just the symptoms or lab values.

Key Concepts

The Current "Menopause Moment"

* Social media as catalyst: Dr. Haver explains that social media has become a powerful platform where women share their menopause experiences, creating unprecedented awareness and demand for better care

* Generational shift: Gen X women are refusing to "quietly suffer" through symptoms like vaginal atrophy, bone deterioration, and cognitive decline

* Health span focus: Patients are increasingly concerned with quality of life and preventing the trajectory of decline they witnessed in their mothers and grandmothers

* Caregiver burden awareness: Women are motivated by not wanting to burden their children with preventable chronic illnesses and disabilities

The Women's Health Initiative Legacy and Medical Education Gaps

* Flawed interpretation: The 2002 Women's Health Initiative study wasn't inherently flawed, but its interpretation and media coverage created decades of fear around hormone replacement therapy

* Medical school inadequacy: Both doctors received minimal menopause education—Dr. Haver recalls just one hour in medical school with outdated information

* "Bikini medicine" concept: Dr. Haver describes OB-GYN as focusing primarily on "breast, uterus, vagina" rather than comprehensive women's health

* Guideline conflicts: Current conflicting guidelines between ACOG and the North American Menopause Society create confusion for practitioners

* Systemic healthcare bias: The medical system struggles to address symptoms that can't be measured in blood tests or imaging

Hormone Replacement Therapy: Estrogen Formulations and Prescribing

* Oral vs. transdermal delivery: Oral estrogen carries a small increased risk of blood clots (7 in 10,000) due to first-pass liver metabolism, while transdermal forms (patches, gels, sprays) avoid this risk entirely

* Cardiovascular benefits: Oral estrogen may offer slightly better cardiovascular protection and LDL reduction due to liver metabolism

* Bone protection thresholds: Different estrogen levels provide different benefits—some stop bone degradation while higher levels can actually build bone

* Individual absorption variability: Patients absorb hormones differently, requiring personalized dosing and monitoring

* Cost considerations: Generic patches are often the most affordable option, while newer formulations like gels and rings can be expensive

Progesterone: Beyond Endometrial Protection

* Mandatory for uterus owners: Women with a uterus must take progesterone with estrogen to prevent endometrial overgrowth and cancer risk

* Sleep and anxiety benefits: Progesterone converts to allopregnenolone, which binds to GABA receptors and provides sedative effects

* Multiple delivery options: IUDs can provide local progesterone for endometrial protection while oral progesterone can be added for sleep benefits

* Individual tolerance: Some women experience paradoxical stimulation or next-day grogginess from progesterone

* Newer options: Duavee combines conjugated estrogen with bazedoxifene, a SERM that blocks estrogen receptors in breast and uterine tissue

Testosterone: The Overlooked Hormone

* Age-related decline: Testosterone levels begin declining at age 30 in women, reaching about 50% of peak levels by age 50

* FDA approval gap: Despite multiple medical societies supporting testosterone for low libido treatment, the FDA has not approved any testosterone products specifically for women

* Evidence for libido: Strong evidence supports testosterone use for hypoactive sexual desire disorder in women

* Potential broader benefits: While not definitively proven, observational data suggests women with higher natural testosterone levels have better bone density, muscle strength, and lower frailty scores

* Dosing challenges: Women must use compounded or modified men's formulations due to lack of FDA-approved options

The Zone of Chaos: Understanding Perimenopause

* Clinical diagnosis: Perimenopause is diagnosed based on symptoms and patient history, not blood tests, due to wildly fluctuating hormone levels

* 7-10 year process: The transition from regular cycles to menopause typically takes 7-10 years as egg supply dwindles

* Unpredictable patterns: Unlike the predictable monthly cycle of reproductive years, perimenopause involves erratic hormone fluctuations

* Multiple system effects: Estrogen affects every body system—brain, bones, heart, vagina, mood—making perimenopause symptoms diverse and complex

* Treatment complexity: Managing perimenopause often requires different approaches than treating postmenopausal women, including considerations about contraception needs

The Upshot

This conversation illuminates why menopause care represents one of medicine's most significant gaps in women's health. The combination of inadequate medical education, misinterpreted research, conflicting guidelines, and time-constrained healthcare visits has left millions of women without access to evidence-based treatment. Dr. Haver's work, along with other menopause advocates, is helping to change this narrative by emphasizing that menopause is not just about hot flashes—it's about optimizing health span and preventing the cascade of age-related diseases that disproportionately affect women after menopause.

The key takeaway is that menopause care requires a toolkit approach where hormone replacement therapy is one important tool among many, including nutrition, exercise, stress management, and sleep optimization.

For women who missed the opportunity for hormone therapy during their menopause transition, it's never too late to focus on building better health through lifestyle interventions and appropriate medical care. The goal isn't just living longer—it's about maintaining vitality, independence, and quality of life throughout the aging process.

Most importantly, this conversation underscores the need for women to become educated advocates for their own health, to seek out menopause-knowledgeable providers, and to make decisions based on current evidence rather than outdated fears. As Dr. Haver emphasizes, women armed with good information make great decisions for themselves.

Episode Summary

In this comprehensive discussion, Dr. Lucy McBride interviews urologist and sexual medicine expert Dr. Rachel Rubin about the critical but often overlooked aspects of sexual health, hormone replacement therapy, and genitourinary syndrome of menopause. Dr. Rubin shares her holistic approach to patient care, explaining why sexual health should be treated like any other organ system and providing evidence-based solutions for common issues affecting both women and men. The conversation covers the biology of hormones, the safety and efficacy of various treatments, and the urgent need for better education among healthcare providers about these vital health topics.

Key Topics Discussed

The Importance of Comprehensive Sexual Health Care

* Drs. Rubin and McBride emphasize treating sexual health as a vital sign, just like checking blood pressure or cholesterol

* They advocate for creating nonjudgmental spaces where patients feel comfortable discussing intimate concerns

* The conversation highlights how taking time with patients and asking the right questions can transform care

* Dr. Rubin notes that sexual health problems are more common than diabetes, heart disease, or osteoporosis

The Bio-psycho-social Approach to Low Libido

* Low libido affects approximately 40% of women, but only 10% are bothered enough to seek treatment

* Treatment requires addressing both biological factors (hormones, medications) and psychosocial factors (therapy, education, relationship dynamics)

* Antidepressants, while often necessary, can significantly impact sexual function for both men and women

* The approach must be individualized, meeting patients where they are and addressing their specific goals

Testosterone: The Forgotten Hormone for Women

* Ovaries produce significantly more testosterone than estrogen—about 10 times more when measured in equivalent units

* Testosterone decline begins in a woman's 30s, contributing to low libido, urinary symptoms, and loss of muscle mass

* Despite extensive safety data, no FDA-approved testosterone exists for women due to regulatory barriers and moved goalposts

* Transdermal testosterone gel can be life-changing for women and for men, often taking 3-6 months to show full effects

Hormone Replacement Therapy: Safety and Efficacy

* Transdermal estrogen (patches, gels, rings) is superior to oral estrogen for sexual function due to lower impact on sex hormone binding globulin

* The Women's Health Initiative actually showed estrogen decreased breast cancer risk—it was never the problem

* For the majority of women, the benefits of HRT outweigh the risks of HRT—if, that is, HRT is started within the first 10 years after a woman’s last menstrual period

* The combination of estrogen, progesterone, and testosterone often provides optimal results for menopausal symptoms

Vaginal Estrogen: A Life-Saving Treatment

* Low-dose vaginal estrogen reduces UTI risk by more than 50% and prevents hospitalizations and sepsis

* The treatment costs only $13 per tube and lasts 2-3 months, potentially saving Medicare $6-22 billion annually

* Proper application requires using a full gram of cream rubbed into vaginal walls, not just a pea-sized amount

* The American Urological Association recently released guidelines confirming vaginal estrogen's safety and efficacy

Building a Healthcare "Pit Crew" for Sexual Health

* Patients may need multiple specialists: sex therapists, menopause doctors, physical therapists, and sexual medicine experts

* Dr. Rubin focuses on four key areas: libido, arousal, orgasm, and pain

* The field of sexual medicine is rapidly evolving with new research, treatments, and educational opportunities

* Healthcare providers need continuing education to stay current with evidence-based sexual health treatments

Key Takeaways

Dr. Rubin's advocacy work has led to significant policy changes, including new guidelines from the American Urological Association that explicitly state vaginal hormones are safe and effective. Her mission extends beyond individual patient care to systemic change through research, education, and mentorship. The conversation underscores that sexual health problems are treatable medical conditions, not inevitable parts of aging, and that patients deserve knowledgeable, compassionate care that addresses all aspects of their wellbeing.

The discussion emphasizes that while the field of sexual medicine has made tremendous advances, there's still significant work to be done in training healthcare providers and changing cultural attitudes about sexual health. Dr. Rubin's approach demonstrates that with proper education and tools, any clinician can effectively address these common but often overlooked health concerns.

You can find Dr. Rubin at www.rachelrubinmd.com!

Episode Summary

In this episode, Dr. Lucy McBride addresses the most common gastrointestinal complaints she encounters in her primary care practice. She emphasizes that most GI issues aren't mysterious and often have simple solutions when approached systematically. The conversation covers five main digestive problems—IBS, GERD, bloating and gas, constipation, and colon cancer prevention—while highlighting the important connection between emotional health and digestive symptoms. Dr. McBride advocates for a holistic approach that considers everything patients consume, their stress levels, and lifestyle factors, rather than relying solely on lab tests for common complaints.

Key Concepts

IRRITABLE BOWEL SYNDROME (IBS): IT'S REAL AND IT'S MANAGEABLE

* IBS is a functional disorder where the colon becomes spastic and irritable, causing alternating diarrhea and constipation, bloating, gas, and abdominal discomfort - it's not dangerous but can be very distressing

* Common trigger foods include alcohol, caffeine, sugar, dairy, and gluten, plus FODMAP foods (short-chain fermentable carbohydrates like beans and certain fruits and vegetables)

* The gut is literally the "home of many of our emotions" - stress, anxiety, and emotional distress often show up as digestive symptoms, which is why travel causes constipation and anxiety can trigger diarrhea

* Treatment involves systematically identifying your personal trigger foods, managing stress through exercise or therapy, and addressing underlying emotional health rather than just taking tests

GERD: WAY MORE THAN JUST HEARTBURN

* GERD happens when stomach acid travels upward into the esophagus instead of downward - it can cause chronic cough, sore throat, sinus symptoms, and morning nausea, not just chest burning

* Common culprits include NSAIDs (Advil, ibuprofen), acidic foods and drinks (wine, coffee, vinegar, tomatoes, citrus), certain medications, and emotional stress that increases acid production

* Simple fixes include reducing acidic foods, elevating the head of your bed with wedge pillows, eating earlier in the evening, and reviewing your medication list with your doctor

* Dr. McBride recommends the book "Dropping Acid" as a practical guide to reducing dietary triggers

Bloating and Gas: The Usual Suspects

* Primary triggers include sugar-free gum and sweeteners, NSAIDs, too much fiber (yes, you can have too much of a good thing), eating too quickly, and not moving your body enough

* Many gas-producing foods are FODMAPs, but don't eliminate everything on the list at once - pin it to your refrigerator and notice correlations between what you eat and your symptoms

* Your gut needs movement to function properly - if your body isn't moving, your gut sits there "too quiet" and needs motion to get things going

* Focus on gradual identification of your personal triggers rather than wholesale dietary restrictions that leave you feeling restricted

CONSTIPATION: FIBER IS YOUR FRIEND (PLUS A FEW OTHER HELPERS)

* The most common cause is simply not getting enough dietary fiber from fruits, vegetables, leafy greens, and whole grains - "fiber, fiber, fiber, fiber, fiber"

* GLP-1 medications like Ozempic, Mounjaro, and Wegovy commonly cause constipation as a known side effect

* Dr. McBride's go-to recommendations include Colace (docusate) as a safe stool softener, magnesium supplements (400-500mg) for muscle relaxation, and Swiss Kriss - however hers is not a substitute for advice from your personal physician

* Don't forget the basics: regular exercise, adequate hydration, and stress management all support healthy bowel motility

COLON CANCER SCREENING: THE GOALPOST HAS MOVED

* Screening colonoscopy is now recommended starting at age 45 (down from 50), or earlier if you have a family history of colon cancer, especially in first-degree relatives

* Colonoscopy is both diagnostic and therapeutic - it can detect cancers and polyps while removing polyps during the procedure to prevent future cancer

* Cologuard stool tests are "pretty amazing" technology but aren't as sensitive as colonoscopy and can't remove polyps if found

* Red flags requiring immediate medical attention include rectal bleeding, persistent changes in bowel habits lasting weeks or months, unintentional weight loss, and severe abdominal pain

THE GUT-MIND CONNECTION: YOUR EMOTIONS LIVE IN YOUR STOMACH

* Stress, anxiety, and emotional distress commonly express themselves through digestive symptoms - some patients use their gut as a "check engine light" for when they need better self-care

* Address mental health through therapy, exercise, journaling, and stress management alongside dietary changes for the most effective treatment

Upshot

Common digestive complaints often have straightforward solutions that don't require extensive testing or complex interventions. The key lies in taking a systematic inventory of everything consumed, recognizing the profound connection between emotional health and gut function, and addressing lifestyle factors like movement and hydration and behaviors around eating. She advocates for patients to become detective-like in tracking their symptoms and triggers, while also ensuring appropriate medical evaluation to rule out serious conditions.

Episode Summary

In this live (unedited!) discussion, Dr. Lucy McBride sits down with Adam Cifu, MD to examine the evolving COVID landscape in 2025. This conversation explores recent FDA and CDC guidance, the challenges of medical decision-making under uncertainty, and the broader implications for how Americans navigate health information in an era of politicized science. Both physicians emphasize the importance of humility, nuanced thinking, and the irreplaceable value of the patient-doctor relationship in making complex health decisions.

Key Concepts

The New COVID Vaccine Landscape

* The FDA's recent recommendations target specific populations: those over 65 and those under 65 with underlying conditions should receive COVID vaccines

* The guidance represents a shift toward more targeted, evidence-based recommendations rather than universal vaccination

* Initial proposals to remove COVID vaccines from pediatric schedules and discourage use in pregnant women were later moderated by CDC intervention

* Both physicians noted the transparency of the new approach, which clearly states what studies would be needed to expand recommendations

Risk Assessment and Trade-offs in Medicine

* Every health decision involves trade-offs; there are risks of taking action and risks of not taking action

* COVID vaccines are safe but, like all medical interventions, carry small risks that must be weighed against benefits

* The benefit-to-risk ratio varies significantly based on individual factors like age, health status, and previous COVID exposure

The Limits of Scientific Certainty

* Current COVID vaccine recommendations operate in a "data-free zone" compared to earlier pandemic guidance

* Unlike established treatments where physicians know precise benefit numbers, COVID vaccine efficacy in 2025 populations remains unclear

* The absence of updated clinical trials in highly vaccinated/previously infected populations creates uncertainty for practitioners

* Both physicians acknowledged frequently having to say "I don't know" when patients ask about COVID interventions

Long COVID: Perspective and Reality

* Post-viral syndromes have existed throughout medical history; COVID's uniqueness lies in the scale of infections, not necessarily the phenomenon itself

* With widespread immunity from vaccination and previous infections, new cases of debilitating long COVID appear to be rare

* Fear of long COVID may now cause more harm than actual long COVID infections

* The term "long COVID" has become a catch-all for various post-illness symptoms that may have different underlying causes

Medical Misinformation and Trust

* The current era represents a "snake oil salesman renaissance" where certainty sells better than nuanced advice

* Algorithms reward confident messengers over those who acknowledge uncertainty

* The most valuable medical advice for healthy people is often "boring basics": exercise, sleep, nutrition, avoiding smoking

* Longevity and optimization influencers often oversell marginal interventions while ignoring fundamental health practices

The Irreplaceable Value of Primary Care

* Individual medical decisions require understanding the whole person, not just population-level data

* The fragmentation of healthcare means that specialists don’t always see the whole person—they can’t—and too many Americans lack a medical home

* Primary care relationships built over time allow for the most important conversations about values, goals, and everyday health decisions

* Both physicians advocate for expanding access to primary care as the foundation of good healthcare

Key Takeaway

As the COVID pandemic transitions to an endemic phase, the conversation highlights medicine's fundamental challenge: making decisions under uncertainty while maintaining trust with patients. Dr. McBride and Dr. Cifu argue that the path forward requires embracing humility about what we don't know, focusing on proven fundamentals of health, and preserving the sacred relationship between patients and their primary care providers. Rather than seeking certainty in an uncertain world, Americans need physicians who can acknowledge limitations while providing thoughtful, individualized guidance based on the best available evidence and understanding of each person's unique circumstances and values.