By Lucy McBride MD
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The podcast currently has 68 episodes available.
Life transitions are sprinkled with possibility. They invite adventure and hope. They can also force us to look inward, to reevaluate our life choices. They can beget sadness and regret, a mourning over the passage of time.
There’s nothing like kids getting older to remind us how it goes so fast.
Mary Louise Kelly writes out these very issues in her memoir It. Goes. So. Fast. It is a heartfelt chronicle of her eldest child’s final year at home, the death of her father, and other curve-balls in her life that forced her to reckon with her evolving roles as a parent, mother, daughter and wife. On this very special episode of Beyond the Prescription, Mary Louise describes the emotional and physical manifestations of grief, the bittersweet moment of sending a child to college, and the heartbreak of losing a parent and ending a marriage.
It turns out that even a woman who “has it all” isn’t immune to feelings of regret and sadness over the passage of time. Mary Louise’s authentic voice provides reassurance and hope that we are all caregivers at heart, doing the best we can with the time we are given.
ICYMI 👉
* 4 Steps Toward Reclaiming Your Health
* It’s Okay to Not Be Okay
* How to Care For Your Body with Kindness & Respect
A note to paid subscribers: Join me for our next Zoom hangout on Tuesday, Feb 6 at 8:30 pm ET. The topic: Reclaiming Your Health in 2024. Bring your questions! Click here to register. 🎉
In a special video episode of today’s newsletter, my friend Shira Doron, MD, and I discuss the state of COVID—new variants, testing, treatment, boosters, and long COVID.
Shira is the Hospital Epidemiologist at Tufts Medical Center, an infectious diseases doctor, and Professor of Medicine at Tufts School of Medicine. She is a nationally recognized expert in antimicrobial stewardship and infection control. During the COVID-19 pandemic, she played a key role in helping the general public separate fact from fiction.
I hope you take a listen above!
In addition, here is Dr. Doron’s take on the current state of COVID & respiratory viruses in the U.S.:
Respiratory viral season is upon us. It’s likely that you know several people who are sick right now. These days, it can be hard to figure out how worried to be. Is this a “normal” flu season? Is COVID-19 “surging”? The media is paying more attention to respiratory infections than they did before the pandemic, and the headlines are often designed to garner clicks, which is to say they are sensationalist. Let’s cut through the hype.
Here are a few things to know:
Current state
There are many respiratory viruses circulating right now, most of which are always more prevalent in the winter. You cannot tell the difference between them without a test. Health authorities track a metric called “ILI” which stands for “influenza-like illness.” This metric encompasses all of the respiratory viruses including but not limited to COVID-19, influenza (“flu”) and COVID-19. Right now, where you live determines how much ILI you are seeing.
source: CDC.gov
Trends show that ILI peaked in the last week of 2023 and is coming down. The peak this season was lower than the year before, and comparable to the year before the pandemic, despite the fact that we have a new virus in the mix. In other words, this is a “normal” respiratory virus season in terms of severity.
This is an ad-free, reader-supported newsletter. Consider supporting this work with a paid subscription!
Testing and treatment
Health authorities still recommend that everyone test themselves for COVID-19 even if they have mild symptoms. That’s because everyone is still advised to stay home for 5 days if they have COVID-19 infection (plus another 5 days of mask wearing). Testing is especially important for people with risk factors for progression to severe disease (such as those over 65 years of age, who have multiple medical problems, are immunosuppressed, or are pregnant), because there are highly effective antivirals like Paxlovid for those who qualify. You should be aware that, while the accuracy of home tests hasn’t changed, widespread population immunity means that the levels of virus in your nose might not reach the detectable threshold until later in your illness, as late as day 4, so keep testing.
If you haven’t gotten the latest round of free tests from the government (announced November 20, 2023), they can be obtained at https://special.usps.com/testkits.
Testing for influenza is indicated if you are within 48 hours of symptom onset and have risk factors for severe disease. Antivirals for influenza can shorten the duration of symptoms. Talk to your doctor if you think you have the flu, which is characterized by sudden onset fever, body aches, fatigue and cough.
It is rarely necessary to test for other respiratory viruses, including RSV, because there are no available treatments for them.
Prevention
Updated annual vaccines are available for COVID-19 and influenza. For the first time, we now have immunizations for RSV too.
COVID-19 vaccines
No longer to be referred to as a “booster,” the 2023-2024 annual vaccine was reformulated to target more recently circulating strains of the virus. Everyone age 5 and older who is not moderately to severely immunocompromised is recommended to receive one annual dose. While vaccination is recommended for all individuals over the age of 6 months, those at highest risk stand to benefit the most. There are three options: the Pfizer vaccine, the Moderna vaccine, and the Novavax vaccine which is a good option for people who need or want an alternative to the mRNA vaccines.
RSV immunizations
Almost overnight, an entire arsenal of preventative strategies have been approved for RSV. They are:
* The Pfizer and GSK vaccines for adults over age 60—public health authorities recommend that people in this category discuss with their doctor whether the RSV vaccine is right for them.
* The Pfizer vaccine for pregnant women—all women should receive this vaccine if they are between weeks 32 and 36 before the end of January. This will protect their newborn baby from RSV infection. Fortunately, the RSV season is almost over for the year.
* The monoclonal antibody, Nirsevimab, for newborns—this preventative treatment has been in very short supply. Talk to your pediatrician if your baby’s mother did not receive the RSV vaccine during pregnancy.
Influenza
Annual flu vaccination is recommended for everyone over the age of 6 months. Patients age 65 and older should receive a high-dose, recombinant or adjuvanted vaccine for greater potency. People with egg allergy may now receive any vaccine (egg-based or non-egg-based) that is otherwise appropriate for their age and health status without the need to be vaccinated in a medical setting.
Other preventative measures
If you are high-risk or risk-averse, you may want to avoid crowded indoor spaces where the risk of respiratory virus transmission is higher. You can protect yourself with a well-fitting high-quality mask.
Maintaining your general health will go a long way to helping you successfully weather a respiratory infection, as it is inevitable that everyone will catch one at some point. Remember to eat well, get plenty of sleep, exercise, manage your stress, and optimize your underlying medical conditions like diabetes and high blood pressure.
-Shira Doron, MD
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You can also listen to this episode on Spotify!
The new weight loss drugs such as Ozempic are stunningly effective at helping patients lose weight and improve their metabolic health. Their existence also seems to have intensified polarizing rhetoric around weight, health and BMI.
On one end of the ideological spectrum, there is the “Healthy at Every Size” (HAES) movement that aims to decouple weight from worthiness—and argues that doctors who recommend weight loss to their patients with obesity do more harm by enabling body shaming without evidence to support the benefits of weight loss on health. On the other end of the spectrum is the camp that believes obesity is a result of poor health and life choices—and that patients with obesity should simply eat better and exercise more rather than succumb to the pharmaceutical industry’s latest fad.
Emily Osteris a Professor at Brown University, a best-selling author, and a leading voice in health economics. In her wildly popular newsletter, ParentData , she tackles pressing health issues of the day, helping people frame risk in order to make everyday decisions. Dr. Oster joins Dr. McBride on this week’s episode of Beyond the Prescription to discuss the data on BMI and health, and how to empower readers and listeners with nuanced information to be healthy, inside and out.
They review the data on the health benefits of exercise, independent of weight loss; the arbitrariness of BMI cut-offs; and the importance of focusing on health habits over a specific target weight. They agree that doctors do harm when they narrowly define health as a number on a scale—and the metabolic health involves addressing the medical, nutritional, behavioral or social-emotional elements of people’s health. As Dr. McBride says, “Sometimes that includes weight loss medication. Sometimes it’s a prescription to stop dieting and start eating lunch.”
The transcript of our conversation is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond the Prescription. Today we have an amazing guest joining us, my friend Dr. Emily Oster. Emily is a renowned economist, a bestselling author, and a professor at Brown University. Emily is one of the leading voices in health economics. Her superpower is applying data to some of society's thorniest health questions, including why people don't always make rational health decisions.
[00:01:30] In her wildly popular newsletter called Parent Data, Emily tackles pressing issues about pregnancy and parenting, helping decisions. I grabbed Emily today because I wanted to talk with her about her recent piece on body weight and health: What is the relationship between BMI and health? She pulled together a lot of data, and because weight is something I talk about with my patients every day, I thought I'd grab her for a chat. Emily, thank you so much for joining me today.
[00:02:03] Emily Oster: Thank you so much for having me. It is a delight as always to see you. It's such a treat.
[00:02:09] LM: Emily, you are no stranger to controversy. In fact, I was with you in the proverbial bunker during COVID, hiding from the haters who didn't like that you and I were trying to help message about risk. We were trying to help people better calibrate their degree of anxiety around COVID to their level of actual risk.
[00:02:31] By the way, I stand by everything I said and wrote. I hope you do too. And it was so fun to work with you then as it is now. So when I think about sensitive subjects, I think also about weight. And so, why did you want to write about weight? Is it just that you like putting your finger in the electrical socket? Or, did you have something to say?
[00:02:49] EO: So I've actually written about weight a bunch of times. So it is a topic that I work on in my academic work. So as a professor in economics, the work that I do is about health economics and statistical methods. And I actually work a lot on diet and dietary choices and why people make the dietary choices they do.
[00:03:07] And so it's not specifically about weight, but it really is about food. And so this is a kind of source of data that I think about a lot. And as a result, I've written about a lot in many different ways. And every time I come at this and I've come at it from all of the angles. So I wrote a piece once called what's the best diet?
[00:03:31] And it was just like the diet that you can stick to which is a sort of standard finding. But the frame was, you know, a lot of people are interested in diet. And when I write that, many people are very angry. They're sort of like, no diet works, we should never talk about dieting, is kind of what comes back.
[00:03:48] I did an interview with Virginia Sol Smith, who I really like, and we don't always agree but is just one of my favorite people to talk to. She always makes me think about her book Fat Talk, which is very much in the other direction, sort of very much in the space of, we should definitely not be talking about BMI, we should throw away our scales, all foods are neutral.
[00:04:10] And when I published that interview, I got it from the other side. I got the, you know, how could you possibly say this, cake and apple are not the same, like this is, this is insane. And I've written about Ozempic, so just anything, I mean, you know this—anytime you write about it in this space, there's really, really strong feelings from both sides.
[00:04:26] So this piece was trying, as I always do, more or less, sometimes more successfully than others, is to try to thread the needle and say, look, let’s look at the data and see between the view of BMI is completely meaningless and correlated with nothing, and the view that your BMI is completely deterministic of your health and that is the only information we should use.
[00:04:49] Where is the truth? And how can we use the data to get to that?
[00:04:52] LM: It is such a crucial question because everybody who's paying attention reads the headlines and understands from their doctor even that weight and weight management is good for your health. We have diet culture seeping into our pores. I mean, it's sort of in the air we breathe, everything you look at on the covers of magazines, on Instagram, and in doctor's offices is about weight, or it feels like it's about weight.
[00:05:20] I see people all the time who have avoided coming to see me, even if I've known them for decades, because they thought they would feel better about themselves, and I would feel more proud of them if they had just lost weight before they came in. And as I say to patients all the time, weight is one piece of a larger puzzle.
[00:05:36] It is not a reflection of your value, your worth. And it certainly doesn't tell us everything about your health. So I'd love to hear about your findings about the relationship between BMI and actual health.
[00:05:50] EO: In my mind, the most, the sort of most important thing to note here is that something can be correlated and can have some explanatory power and not be all of the explanatory power. So one version of this question is to say, on average, if your weight is higher, are you more likely to have other health conditions?
[00:06:13] And I should say, that's actually different from the question of whether weight causes other health conditions. But purely taking this from like a correlational standpoint, if you saw one piece of data about someone, you saw their BMI, would you learn anything about their health? And the answer is, yes. On average, there is a relationship, particularly at the upper end of BMI, between increasing BMI and worse health.
[00:06:41] And in particular, worse metabolic health. So things like, there's a strong correlation between high weight and diabetes. That's just true in the data. Now, those relationships... are there, but they're actually not as big, I think, as many people think. And that's sort of the other thing that comes out of this.
[00:06:58] And that, that has two parts. So one is actually, even to the extent that there's a positive relationship there, it doesn't show up until you start getting to sort of higher levels of BMI. So sometimes we talk, we talk about overweight being 25 BMI versus 24. Actually, the health differences between people with a BMI in the 25 to 30 versus 20 to 25, if anything, probably favor the 25 to 30, but you're certainly not seeing much in that range.
[00:07:30] As you get into a BMI of 35-40 you do see some of those, some of those correlations. But it's also true that in almost any health outcome you look at there is variation within a group and that's the thing I was sort of trying to illustrate in the piece is you look at something like diabetes or the distribution of blood pressure, like the distribution of blood pressure, it's shifted up for people who are higher BMI, but there's a lot of overlaps.
[00:07:56] Plenty of people with high blood pressure whose BMI is 19 and plenty of people with low blood pressure whose BMI is 38. And so that's the sense in which like this number Tells you maybe a little bit, but really not that much.
[00:08:12] LM: let's talk about what BMI is. BMI, I mean, you define it for us here, Emily.
[00:08:17] EO: BMI is a weight in kilograms divided by your height in meters squared. It's just a number.
[00:08:22] LM: So what you pointed out so beautifully in your piece is that medicine does this weird thing where we say that a normal BMI, body mass index, is between 20 and 24.9, and overweight is 25-29. 9
[00:08:37] EO: You guys love a sharp cutoff. It's your, it's your favorite. You love it.
[00:08:42] LM: I don't, but fine. The medical establishment loves these arbitrary cutoffs. There's nothing magical or particularly different between somebody who has a BMI of 24.9 and 25 and moreover, there are so many different elements that go into this whole person's health. That to call it a diagnosis point X and not a diagnosis at X minus .1 is ridiculous. So, you know, herein lies why we're here to talk about pulling back the curtain on what this actually means.
[00:09:18] EO: Right. And, and so I should say, like, you might wonder why have any cutoffs in this at all? I think the answer to that is that when people are describing, not even doctors, when population health scientists are describing characteristics of populations, it can sometimes be useful to define categories.
[00:09:40] So, you see this in weight, you also see it in something like low birth weight is another good example which has some cut-offs, right? So when we talk about baby weight, there's a number, 2,500 grams. And if a baby is below 2,500 grams, they're classified as low birth weight, and if they're above 2,500 grams, they're not.
[00:09:56] There's nothing special about 2,500 grams, obviously, but it’s helpful when we sort of describe a population. You want to say, does this, you know, is the low birth weight share in this population bigger than this population? We want to have a common language. And so saying, like, that's the cutoff we're going to use, so we have some number to compare, is helpful, it can be helpful. The same thing happens here. You want to describe characteristics of a population. I think the problem, and it actually shows up in the birth weight also, but the problem comes when we start, we take that, which is just away to use a number to make some descriptive statements about some population.
[00:10:35] When we take that number and we decide it's meaningful. It's like a somehow a meaningful number that we would, that would tell us something if you were on either side of it. Of course it's not. And when you're using it for populations, for individuals and populations on which it was not based, I mean, this is a much deeper issue, but when we talk about BMI in particular, this is something, these are sort of cutoffs that were developed with reference to like a white European population, they may have very different meanings and relationships with health for different populations off of which they are not based. So there's a sort of whole other can of worms there.
[00:11:14] LM: Totally. It's, I mean, to make an analogy briefly that you and I are familiar with is, you know, COVID risk, right? It's not that a 65-year-old, every 65 year old is at so much higher risk for outcomes. Then every 64-year-old, but there is truth to the fact that older people tend to get sicker on a population level when I'm talking to a patient who has just turned 65 and who is generally very healthy and active. I'm not going to counsel them in the same way. I'm going to talk to a 64 year old who's technically not at higher risk, who has myriad health problems. So population level data is one thing and then individual risk calibration and counseling.
[00:11:58] EO: Yeah, and I think the piece of this that my senses provoke so much anxiety and discomfort in people is that it is true that, and I don't think you do this, but it is, I think, an experience people either have or fear having in their doctors. They'll be weighed, their BMI will be calculated, and then they'll be told, you know, well, you just, you edged up above, you know, 20, now you're 25.1, and like this is how we're going to define you, and that becomes such an important, like, number in the conversation, and so salient, and the words, I mean, the words we use, overweight versus normal weight, obese, those take on an attention and a meaning, and they didn't just label them BMI category one, BMI category two, which, Maybe would have been more helpful.
[00:12:46] You're really using words that suggest that there's a way to be, which is normal, and then other ways to be. And that, that's, it's just not helpful. It's not, I don't think it's a helpful part of counseling. It starts people off on, on a bad, on a bad foot.
[00:13:00] LM: Yeah, I mean, I think people, for better or worse, look at doctors as authority figures and people who, whose judgment matters. And if you have a doctor who is doing a little tsk, tsk, tsk, ooh, you're getting up there, that has real power in many ways. And so I think that has real power and can do real harm.
[00:13:20] Which is not to say that doctors shouldn't be honest about the data in that patient's situation and what they could do and help to arm them with tools and information to be healthier. It's to say that shame is not appropriate or meaningful in any space, not to mention
[00:13:37] EO: Yeah, and I think the other, the other piece that I sort of spent some time on in, in this, and is actually quite closely related to stuff I work on, is that it's actually, It's very hard for most people to lose weight. Like, we know, I mean, we can sort of put Ozempic, Wegovy aside, but for people just changing diet, changing habits, consistent long term weight loss happens for a very small share of the population.
[00:14:04] And so, when we sort of start with the advice, you should lose weight, which people get, you know, in these situations, often that's just not possible. So it's like giving people a set of advice that they just... They're just going to fail on and then giving it as if, well, if only you could have this kind of willpower, if only you could achieve this, like that would be so important.
[00:14:24] I think the whole dynamic ends up in a place where you're giving people advice they can't follow based on a number that may or may not be that meaningful and isn't very nuanced, and you can easily see why that generates frustration, sadness, discomfort, lack of productive conversation with your doctor.
[00:14:43] And then by the way, turns off your ability to have a productive conversation because now we're like in defensive. Now you're like, well, you know, screw you, don't tell me what to do. What do you know?
[00:14:54] LM: Right? If we learned nothing else during the pandemic, that trust is precious. And when you don't have trust between the doctor or patient, and there's a moralization of human behavior, we're just at a standstill. And so how do you see the data that you've pulled together in this piece and before this piece helping people, individuals who are reading your stuff and then going to the doctor's office, understand better what their weight.
[00:15:21] EO: The piece I pulled out at the end that I thought was really meaningful was, in this piece I'm actually pulling data from the NHANES, the National Health and Nutrition Examination Survey, which is a very big survey of, of people, it weighs them, it measures them, collects a lot of biomarkers, which is why we can say all this stuff about, about health.
[00:15:39] They also collect information about their exercise. And so if you look at people, if you sort of take a, a second, uh, almost a second metric of health and you ask like, okay, does this person do like some, some moderate amount of exercise a week and it's like some cutoff and you look at that relationship.
[00:15:57] One of the things I show in the piece is that doing more exercise is correlated with better metabolic outcomes, better kind of health outcomes in various ways. And it's quit informative on top of BMI, and so people who are doing sort of exercise who have a BMI of like 40 actually have sort of similar metabolic health to people who like aren't doing any exercise and have a BMI that we would consider, you know, normal or, or thin.
[00:16:26] And so I think for me that has sort of two pieces of it. One is that it just again emphasizes like this is one other thing you could like if you said like you can only learn two things about people It's like well, how much more could I add with a second thing? Well, actually like quite a lot the characteristic knowing somebody's BMI and whether they have exercised rigorously or moderately in the last week that tells you a lot more about their health than knowing their BMI alone You could add on top of that smoking… it's just one simple illustration of like how much more you could learn if you ask some more questions The other thing, and here I'm going to reveal what my husband is always saying, it's just like, just because you like to exercise, fine.
[00:17:08] But like, actually, I think we should tell people to exercise. I think that we spend too much time telling people to lose weight with their diet, which is something we know is really difficult, and I think we should spend more time telling people, like, you should go take a walk after, like, try to walk for ten minutes every day.
[00:17:27] You know, actually, it's not saying, like, you need to go run a marathon. But just some aerobic exercise. I think we have a lot of evidence from a lot of different places that that's associated with better health. And I think if we started telling people that and talking about that, we would then get to the questions like, well, how can we make it possible for everyone to do that?
[00:17:45] How can we make there be safe places for people to do that? How can we increase access to sports? How can we be in a position where everybody is welcome to... to go running no matter what, you know, their race or body size or anything? And I think that's, you know, for me, that's something that's pretty, that's pretty important. And I think we're kind of missing with this focus on food.
[00:18:08] LM: I totally agree. And what I love about the NHANES data is what you earlier said, which is that there's an incredibly tight correlation between the amount of exercise and health outcomes, even more than BMI and health outcomes. So when I'm talking to a patient who wants to lose weight or, you know, Needs to lose weight, perhaps I often tell them, let's not think about the number.
[00:18:35] In fact, I commonly say, let's not think about the number. That's not our end point. And, and I'm not saying that to be politically correct, to pussyfoot around hard conversations is because the number on the scale is immaterial. When we were talking about this whole person, we are the complex sum of these integrated parts.
[00:18:57] And you can, as you said have a BMI of 40, which is technically obese. But if you are exercising on a regular basis, first of all, your mood is better, your sleep is going to be more efficient, your blood sugar control is going to be better, your blood pressure is going to be better, most likely. And so, I focus, with my patients, less on the number and more on the behaviors.
[00:19:21] The relationship with food, not just what you're eating. The cadence of how you're eating. Sometimes you don't need a fancy diet, you just need to have lunch. I just wrote a piece about that. Lunch is an underrated food group, like eat lunch. Honestly, that is huge. Sometimes we don't need to, you know, go to the doctor and be told that our weight is technically higher than it should be.
[00:19:43] We need to be given materials and information on the benefits of exercise. Not just on our weight, but on our mental health, our metabolic health, our cognition, and not just... Are you told to exercise, but to help people figure out where to put it and how to incorporate it in their everyday life. Because as you know, telling someone to exercise is one thing, helping them figure out what to do is another.
[00:20:10] So I think you're absolutely right, Emily. We need to treat people, not just as a set of metrics and data, but as people. And as you know, from your research, human behavior is complicated. We do things that don't serve us all day long. Even doctors do, which is again, ridiculous, why I would shame anybody for a behavior that's part of the human nature.
[00:20:30] So to do a lot of shooting with patients or to say you should do this is less productive than to say like, how do you think you could incorporate a little more movement because of the data on the benefits of regular movement into your whole health?
[00:20:44] EO: I actually think, you know, when we do this kind of counseling and when people hear this counseling and they hear, they sort of hear the phrase diet and exercise, like you should improve your diet and exercise. They think of that as improve your diet and exercise so you'll weigh less. And that's the link we should sever.
[00:20:59] It would be, I think there's a place to say, improve your, let's think about are there changes you could make to your diet that would make you feel better? Are there ways for you that you could incorporate exercise, which by the way, like 10 minutes of walking slightly faster than you would otherwise, that's exercise.
[00:21:16] That's an exercise activity, so just like making it clear that these things are possible. But also without saying, and if you did that then the number will look better on the, no, if you did that maybe some of these elements of health, metabolic health, maybe some of this would improve, your sleep might improve, your mood might improve, that's what we're aiming for. We're not aiming for some number.
[00:21:37] LM: That's right. And by the way, when you're sleeping better and your mood is better and your dopamine hormone axis is being triggered by the lights of being outside and feeling more fit and getting the endorphins going that is good for our metabolic, metabolic health too. But I also want to be clear that I don't shy away from talking about a number when it is relevant.
[00:22:00] So if somebody has bilateral knee osteoarthritis, bone on bone, and their BMI is 40, and they're resistant to, you know, getting a knee replacement, we have to talk about weight. So it would be irresponsible for me to say, oh, weight loss isn't going to matter to this gravity-dependent set of joints. And so that is where it gets really hard, but it is where I actually like for me it's my like superpower is never to have judgment about it because by the way when you have bone-on-bone arthritis in your knees As a result of age and genetics and weight all together you can’t exercise and You gain weight more easily.
[00:22:43] And so this is what happens. So there's no shame about it. It's just, let's figure out what to do. But we have to talk about the number, not just the number, but we have to talk about what weight might make sense to that offset pressure on the knee.
[00:22:56] EO: Yeah, I mean, that's such an interesting, like, it's, this conversation is so hard because it takes, like, it's so hard to have that conversation. And I bet you are really good at this, but I think for me, it's very hard to have that conversation without it feeling like shame because of the, as opposed to just saying, look, there are a bunch of things, like, there is a physical reason why this, this number matters, not because this number has to do with whether you're a good person or not a good person or have willpower or whatever, it's just like, this is putting pressure on your knees.
[00:23:23] LM: Well, and that's why I'd really like to reinvent the healthcare system to have doctors incentivized to have more time with their patients to understand their story and to build trust and rapport and for patients to feel comfortable and then to train doctors on sensitivity on these subjects. Which, by the way, doctors went into medicine, the field of medicine to do that, but it's just people don't have time and then people don't trust and then there's diet culture and then it's just lose weight, exercise more, see you next year.
[00:23:50] EO: This is totally off topic. I mean, it's a little bit off topic, but, but one of the things that's been pretty effective in, you know, obstetrics is these group prenatal care. People have exactly this sort of same complaint about, like, there isn't enough time to talk about all the issues that have come up, da, da, da.
[00:24:05] And so they do these things where it's like six people, but you get two hours, you know, and we do, like, there's this sort of examination component that happens, like, that's short for each person, but then we all, they, people all talk together, and it turns out to actually be, some good evidence on the relationship between that and preterm birth, particularly for black women.
[00:24:20] So I wonder if there's like, I almost think there's like a parallel care model, where it's like, we have a group of people here for counseling about, you know, whatever it is, improving their heart disease metrics or something.
[00:24:33] LM: Yeah, stay tuned for some courses I'm going to be offering in 2024. One of my little kind of mantras is that health is about more than BMI. It is about having awareness of our health ecosystem, which includes ur story, it includes our data, it includes understanding our genetics, and then sort of a laddering up to acceptance of the things we can't control.
[00:25:01] Maybe we are predestined to have a higher-than-ideal body mass index because of our genetics. And we have to accept that. We have to accept that we are predisposed to diabetes. And then agency over the things we can control. So, arming yourself with tools and information to carve out space in your life to work on the things you have control over, which are a lot.
[00:25:26] But if you're stuck in the acceptance bucket where you're not accepting hard parts of your genetics or your story that you can't control and you're then listening to a lot of kind of wellness gurus who are telling you that, you know, thin is better or whatever, even just all this messaging. And then you're spending a lot of brain space trying to accept things you really need, or trying to control things you can't control, that's where people run into trouble, and that's where shame is born, and that's where people, frankly, binge on things like food and alcohol, and that's where we land in trouble. And so if we could just help people understand they're not alone, they're human, and that we all have our challenges. One of them, for a lot of Americans, is weight.
[00:26:12] And that they're not alone, and that there are things they can do to be a lot better off. So... What was the takeaway from this piece you wrote? Like, what was the reaction? Because, as you said, like, there's sort of two camps. It's like health at every size, there's a movement, which I agree with in many ways, except that there are certain medical realities we have to acknowledge.
[00:26:32] And then there's the sort of, weight is genetic, and there's nothing you can do about it. And, I mean, there's just, there's just these false dichotomies.
[00:26:39] EO: So I think like with most things, most people are in the center. And so this kind of like, I think that many people found this interesting. You know, I'm not sure everybody thinks about this data quite the same way, and sort of seeing some graphs about it, it made some people think. A bunch of the comments were like, yes, like I started exercising, and I felt like this is very validating, because like, that, you know, that totally changed, but then my weight didn't change, but still I feel better, and I was trying to understand that.
[00:27:08] So there was like some good stuff there. And then I did get, certainly, some people who said, you know, talking about BMI at all is very fatphobic and I am, like, I will say, like, I'm a relatively thin person and so I think, you know, I don't know, I guess that's part of, part of it. And then certainly there were people on the other side who said, you know, this whole thing is like, you know, anybody who's overweight is just, you know, is just lazy and I don't agree with that at all. But some of those people fought with each other and, you know, that's what comments are for.
[00:27:39] LM: That's what's comments are for. And that is why Emily Oster is here. Emily is here to help us get to these story issues, and ask the questions that... People are wrestling with every day, like, can you have a glass of wine when you're pregnant? Can you have bluebean cheese when you're pregnant? Can you jettison some of the shame about parenting and the parenting industrial complex?
[00:28:01] And thank God for you because I think you're doing so much good, Emily, and you're reassuring people based on evidence. You're not reassuring people for the sake of reassuring them for you to look good. You're reassuring them because you have the data to show. How to calibrate risk to, or sort of how to calibrate anxiety to the actual
[00:28:21] EO: Yeah, I mean, I see a lot of what I try to do is sort of help people see what those risks are and make the choices that work for them, which [are] going to reflect our own risk tolerances and preferences and, and what's important to us.
[00:28:33] LM: Yeah. I mean, at the end of the day, as we talked about during COVID quite a lot, it's about framing risk. It's not about telling people how to feel or telling people how to choose. It's about framing risk. And then it's like, you do you, and that's fine. And if you do something that's not healthy for you, that is fine too. As long as you're armed with the data, then that, that, that is, that is great. Emily, thanks for joining me. And by the way, how can people sign up for parent data?
[00:28:56] EO: So, parentdata.org, you can find me there, we have a newsletter that goes out, we have an enormous volume of writing for pregnant people and parents and, and some things for people who are not parents, and we have like a little search AI, so parentdata.org is the best place, or you can find me on Instagram at profemilyaster.
[00:29:20] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
You can also listen to this episode on Spotify!
Dr Devika Bhushan is a pediatrician and public health leader who has lived with bipolar disorder for the last 13 years. She has served on Stanford’s faculty and trained at Harvard Medical School and Johns Hopkins. She's a firm believer that life’s trials and tribulations not only improve our self-awareness, they help us flourish.
While serving as California’s Acting Surgeon General last year, Dr. Bhushan publicly revealed her diagnosis in an effort to reduce stigma and spread hope for people suffering with mental illness:
I believe that our struggles can be the source of our superpowers. They can show us our capacity for vulnerability and strength, and that we can endure and overcome hard things.
Through her popular newsletter, Ask Dr Devika B, she is growing a community to help break down the stigma associated with mental illness. As she says, "Stigma festers in the dark and scatters in the light.”
On this episode of Beyond the Prescription, Dr. Bhushan shares her advice for mental wellbeing. The two doctors also discuss the complex roots of emotional distress; the shame around mental health diagnoses; and the possibility of post-traumatic growth.
Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight. We are the integrated sum of complex parts. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.
[00:01:02] Today I'm joined by the amazing Dr. Devika Bhushan. Devika is a pediatrician and public health leader who has lived with bipolar disorder for the last 13 years. Devika served as California's acting Surgeon General in 2022, where she focused on initiatives around equity, resilience, and innovation. She's a firm believer that our trials and tribulations can help us flourish, and she's learned this through her own experience living with mental illness. Today we will talk about what it's like to face a mental health diagnosis and the individually oriented lessons she's learned along the way. Devika, thank you so much for joining me today.
[00:01:42] Dr. Devika Bhushan: It's so great to be here with you, Lucy. Thanks for having me.
[00:01:46] LM: So in your op ed for the LA Times last year, you wrote some pretty powerful words. You said, I believe that our struggles can be the source of our superpowers. They can show us our capacity for vulnerability and strength, and that we can endure and overcome hard things. Can you expand on that a little bit? What do you mean by our struggles being our superpowers?
[00:02:11] DB: So my toddler, his name is Rumi. And so it's very apt. I'm going to borrow a quote from Rumi. The wound is the place where the light enters us, and this also hearkens on this Japanese tradition whereby when a ceramic bowl breaks rather than throwing it away, they will actually patch it back together with gold.
[00:02:37] And so at the end of that break, what you're left with is a stronger bowl, a more unique bowl, and a more beautiful bowl. And I firmly believe that when you have a chance to walk through a really difficult time in your life, whether that's because of mental illness, whether it's physical health, whether it is an early experience of adversity, whatever it might be, I firmly believe that once you have emerged through that, and walked through it and come out the other side, you become much more self aware, number one. You know exactly where you're able to stretch and flex and accommodate and where you're going to break. Right. And so that knowledge when you acquire it is something that will never leave you and will always make you a better whatever you decide to do after that.
[00:03:29] So, for instance, like for me, I know that. I can endure a lot. But one thing that my brain, and anybody with bipolar disorder's brain, might not be able to tolerate is actually a lot of circadian rhythm shifts. So, for instance, when I was in residency training, I didn't really internalize this. The fact that I should, from the get go, be really careful about day night switches, about 28 hour calls.
[00:03:53] And I learned the hard way that those experiences led me to have mood episodes that required me to be out for three months, two months and really struggle to find an equilibrium again. And so that's number one, right? Like you learn exactly what you're capable of and what you cannot do, where your boundaries need to be as a person.
[00:04:13] Number two, I think you learn that there are superpowers that come from enduring really difficult things. So for me, one of those is that I'm a really deep empath and I really understand other people's struggles and vulnerabilities in a way that I don't think I would have if I hadn't had such deep and dark experiences of my own.
[00:04:36] And so when, you know, when I was a practicing pediatrician sitting with patients, sitting with families, walking through very challenging things, I could connect with how they were feeling and sometimes give them lessons from my own experiences when those were relevant in a way that really helped me be a better pediatrician. And I similarly found that when team members of mine, when I was the leader of a team, when folks would go through stuff in their own personal lives that was difficult, and impacted their work because we're all human beings first, and whatever's happening for us at home or outside of the work context does show up for us at work, I was able to connect again with what they were going through and help them make the space for whatever that was in a way that maybe a leader who hadn't had their own struggles wouldn't have been able to do. So I think on both of those levels, people don't always, acknowledge or talk about the ways in which struggles lead to superpowers.
[00:05:39] But that's a firm sort of belief of mine. And when I'm, for instance, interviewing podcast guests of my own on my podcast called spread the light with Dr. David Gabby, also published in my substack. One of the questions I always ask people is, “So how do you feel like this experience led to your unique strengths or superpowers?”
[00:06:00] And people always love reframing their experiences and distilling those strengths down for people. And I'll tell you, when I published my LA Times op ed, which you quoted from, that was the line that people most resonated with. And that was a line where people specifically said to me sometimes, “You know what? I never thought about my chronic PTSD or my... OCD or my borderline personality disorder as giving rise to these superpowers that I have. But you are so right. That's exactly how I experienced this. So I think it's a very empowering frame and it's an important one,
[00:06:35] LM: I think you're right. And I think mental health is having this moment, rightly so in the popular vocabulary, right? We've been talking about the mental health toll of the pandemic. We've been talking about the, the grief, the loss, the trauma people have experienced. And I think it's fantastic that we're finally identifying mental health as part of whole health.
[00:06:59] I think sometimes though people are confused about what mental health means or what it is. And I think sometimes we think that mental health means that you're happy or mental health means that you're content, mental health means you're not anxious And so I'm very clear with my patients and with my own kids and hopefully with myself as well, that mental health is really about that laddering up from self awareness that you described to acceptance of the things We can't control like we cannot control, for example, genetic predisposition towards bipolar disorder or breast cancer or what have you, and then leaning into the agency that we have and so mental health to me is really about self awareness.
[00:07:45] It's about sort of an understanding of where we can flex, where we have that extra Reserve and then where we need to hold a boundary. And so I think it's important to recognize what health, what mental health is. It's about having the resilience, the self awareness to weather the storms that inevitably come our way.
[00:08:06] It's not about being happy all the time. Happiness is great. We're not against happiness. We're all for happiness. I'm believer in contentedness, but I think it's those tools and that we have to get sometimes the hard way that are the most kind of beautiful and that the things we don't often count in our kind of resume of life skills.
[00:08:25] And I also want to say that Rumi is an old soul. Clearly he understands that even at two years old, when we break is when we repair as well… can shed some wisdom on our resilience. So let's talk about kids for a minute. So in your role as the acting Surgeon General in California, you did quite a lot of work on adverse childhood experiences or ACEs.
[00:08:49] And many people who are listening understand that there's an abundant amount of literature about the effect of adverse childhood experiences or ACEs on social, emotional, mental, and physical health issues later in life. So some of those are my patients, people who have had some sort of childhood experience of neglect, abuse, trauma, that shows up in their bodies in the form of hypertension, an anxiety disorder, binge eating. Our stories live in our bodies. And I commonly try to help patients with various physical problems by looking back at what happened, what's behind the curtain that we can then kind of connect to their current physical state. And it's often the case that a patient who's struggling with binge eating disorder and diabetes gets better when we put them on metformin and we get them in trauma therapy to work on kind of pulling the curtain back on what happened.
[00:09:48] And helping them understand that hypervigilance that was organized around a traumatic childhood experience shows up later in life. And that's, I mean, that's the most kind of fun part of my job, if you will. So adverse childhood experiences show up as social, emotional, mental, and physical health problems in patients later in life. And so I'd love to hear about your work on adverse childhood experiences and do you agree with me that they show up in our bodies, that our stories live in our bodies?
[00:10:18] DB: That is such a beautiful way to put that. And I could not agree more. Our experiences, whether positive or negative, end up living in our bodies, and they end up living in our bodies at a cellular level, at a organismal or organ level, um, systems level, and even for all, for the whole body, right, the whole system.
[00:10:39] And what we recognized around ACEs, so all of the folks listening, are probably well acquainted with this term, but these are essentially 10 experiences that are really difficult before you turn 18 years. So child abuse, neglect, growing up in a household where maybe somebody had an untreated mental illness, intimate partner violence between adults in the home, things of this nature.
[00:11:02] And basically what happens is that you're exposed over and over again to a threat and a stressor that is extreme. And so your threat response system and your stress response systems end up being activated and have trouble getting regulated and have trouble turning back off. And what happens is that can change the way that your brain develops, your hormonal cascades, your immune system, even your genes and the parts of your genes that regulate cellular aging.
[00:11:34] So those are called telomeres for those who are aware of this term and familiar with it. And so, you know, when you look at a population level, there is this dose response relationship between the number of ACEs you've had and all sorts of health outcomes, anything from cancer to heart disease to, of course, mental and behavioral health disorders.
[00:11:53] There's about 60 or more health conditions that you're at risk for. But equally, we know that being really intentional about turning off the stress response and using that, just as you mentioned, as part of the treatment plan for a patient who's coming in with a history of trauma and let's say diabetes or heart disease. If you are not intentionally looking at that toxic stress response that's in the background that has been with them potentially for years since their childhood and you're not specifically intervening on that toxic stress response, then you're leaving part of the physiology on the table.
[00:12:32] So the ACEs Aware initiative, which we launched at the end of 2019, just before some of the biggest traumatic events of our lives were to unfold during the pandemic, the plan there was to really help health care workers of all kinds understand toxic stress physiology. And so, you know, there's a lot of talk about ACE screening, whether, you know, universal ACE screening is worth it on an individual level.
[00:12:59] We know all of this stuff is true at the population level, that ACEs will put you at risk for these health conditions, that sometimes the link gets lost. So the point of ACEs Aware Initiative is not, in fact, to say, do you have ACEs or do you not have ACEs? It is actually to say, hey, are you coming in with health conditions and symptoms today that are rooted in a toxic stress response? And if so, if you're at risk for a toxic stress response, how can we specifically cater your healthcare to be more individualized, and to not only give you the metformin for your diabetes, but also to help you understand that trauma therapy, as you mentioned, or anti inflammatory nutrition, or certain exercise habits, sleep habits, connection, etc., that there are these other evidence based behavioral strategies that we have in our toolkits as healthcare providers, as individuals that we can start to use to specifically turn off the toxic stress response as a way of treating somebody.
[00:14:02] And so that, that message of hope is, I think, really important because we often talk about ACEs as posing risk for health, but we don't spend equal time sometimes talking about the fact that we do have these evidence based tools for enacting resilience if you do have toxic stress. In other words, toxic stress is preventable. And once it's in place, it's very treatable. And so that was the overall mission that we were working on at the ACEs Aware Initiative.
[00:14:31] LM: I love it. And then on top of it, there is the opportunity to make meaning and to find out where you can flex and where you need boundaries based on the self awareness from the work you might need to do on your toxic stress. So, let's talk about your childhood. Do you look back, Devika, on your childhood and see threads of your bipolar illness that predated the actual diagnosis? And, you know, to the extent you want to share that, I mean, how do you make sense of things that may have happened to you, good and bad, and the evolution of your mental health story?
[00:15:10] DB: It's a really important question. As we know, most people who have mental health symptoms, it's most common to start to have the first symptoms when you are in your teenage years or in your early 20s. And for me, my very first symptoms happened when I was in medical school. I didn't have any kind of sign of mental health instability or any kind of mental health symptom when I was growing up. I did have a very unusual childhood in some ways. So I spent… my first 21 years about a third in three different countries. So the first one was India, which is where my family is from originally and where my majority of my family actually still lives.
[00:15:52] So we started there. I was seven when I left India, and then we came to the US for a few years where my parents were grad students here. Very stressful set of circumstances financially and otherwise. And then we went to the Philippines for my parents’ jobs, which were in health and development. And we didn't know anyone in the Philippines when we first arrived, and we were supposed to have spent three years just trying it on for size.
[00:16:18] And my parents ended up spending over 20 years there. So it was a big part of our lives and big part of their careers. And so, within each one of those countries, even there was a lot of moves. So by the time I was in fifth grade, I was 11, but I had been to seven schools in three countries. So there was a lot of changes and a lot of transitions and a lot of figuring out who I was culturally, you know, where I belonged.
[00:16:45] There were these kind of deep existential questions taking place, although I will say my four person family, so it's my sister and I and two parents are a very close knit unit, and so that unit kept us grounded and it made us feel like we were in home, wherever we were and you know, that, that made all the difference because I think I felt very grounded growing up despite the fact that things were changing on us so often.
[00:17:14] And I felt like a lot of folks who have multiple cultural influences, multiple languages. I grew up speaking Hindi, then had to learn English and. You know, uh, the whole, uh, getting made fun of for my accent in the U S and trying to get rid of that accent overnight, you know, all of those different pieces of like, am I Indian? Am I American? Do I have influences from the Philippines, but I'm not quite Filipino, even though I've spent so many years here, there's all of that stuff growing up, but I will say kind of back to your question, nothing that really would qualify as a mental health symptom, just sort of common experiences around moves and cultural identity that I think anyone would have with a similar set of circumstances.
[00:17:59] And it wasn't until I hit medical school, as I was saying, I was 23 and my first symptoms were of the depressive variety. And I didn't have a family history of bipolar disorder. I didn't have a personal history of either hypomania or mania. And so it looked for all the world, like garden variety, unipolar depression, right?
[00:18:19] And I was treated with antidepressants, which ended up over the course of three years, not working and making my brain worse, which is typical when a brain is on the bipolar spectrum. So often what'll happen is you'll induce sort of the little bit of activation that's not recognized. It's actually hypomania in retrospect, but might just look like anxiety on top of the depression, right?
[00:18:42] And that's essentially what happened to me. I had about three years where I was on the wrong meds. And I tried 20 different meds, you know, in that span of time. And luckily, you know, three years in, I was on three different activating meds and had a frank manic episode. And that really saved my life because it allowed people to understand that I was somebody who had a bipolar spectrum disorder rather than a unipolar depression with anxiety on top of it, which was the working hypothesis.
[00:19:12] And that led me to have the right condition diagnosed and also the right treatments then in place, which, which really, really truly saved my life.
[00:19:21] LM: I want to interrupt you to say, well, I don't want to interrupt you, but I would, I want to say thank you for sharing that because I think there are a lot of people, I don't know the number. I don't think we know the number of people who are suffering with bipolar disorder, who are called. Depression and anxiety, right?
[00:19:39] I mean, depression and anxiety are extremely common conditions. You know, certainly if people have enough depression, they can be anxious about it. If people have enough anxiety, they can get depressed. But I do think there is a subset of people who are inappropriately treated who actually are on that spectrum and they didn't have that manic moment or the doctor to understand that's what that was.
[00:20:02] And then they get further medicated and then sort of down a pathway that isn't appropriate for their diagnosis. So, I mean, did you have trouble recognizing sort of activation, the activation driven by the antidepressant that was then maybe the beginnings of your, of mania? Or did your doctor, like, did it go for a long time without being recognized? Or how did you make sense of those initial failures of the antidepressants?
[00:20:30] DB: It was much more clear in retrospect, you know, we had these three years where I did not feel like myself and I wasn't, you know, depressed for all of that time. At some points I was, you know, hypomanic where I might have been euphoric, right? And just tripping too quickly in terms of the energy and the thought processes.
[00:20:49] Or I had periods where I was hypomanic, but in a sort of dysthymic state of mind, meaning I was just activated and energetic, but I was irritable and angry and anxious. And it wasn't really recognized. Now in retrospect, it's very clear that, okay, all of that was hypomania. But at the time, when you're dealing with, you know, a 23 or 24 or 25 year old, because I crossed all of those numbers as we were seeking treatment, it just felt like, okay, this person is not responding to treatment.
[00:21:24] And as a patient, you feel very vilified because the statistics will tell us that most people with bipolar 2 disorder end up having symptoms that are mistreated for an average 11 years from the first time they're symptomatic to the time that they get the right treatment in place. And I was lucky that mine was only three years, but I will tell you, they were the hardest three years of my life, like, I was considering dropping out of med school, I didn't think I could hack it, I thought it was something about medicine, potentially, that was kind of triggering these symptoms that I'd never faced before, I was also pretty convinced that, like, the person that I thought I was pre symptoms, was completely gone, inaccessible, lost.
[00:22:11] Like, I would never find that person again. That I was just somehow stuck in this place of unwellness. And I think that's something that most people who have ever had any mental health symptoms can really relate to. Like, in the midst of it, you feel like you are never gonna be well again. And whoever you once were is no longer a person that you can access. I think that is the hardest part when I look back at that period of my life of true terror that I was never going to be myself again.
[00:22:39] LM: There's so many things I want to react to that with. First and foremost is deep gratitude for saying that because I think as I talk to patients with mental health issues, as I talk to family members with mental health issues, as I've talked to my myself when I've been struggling with mental health myself, there is this hijacking of our own brains that happens where you [become convinced that you're never going to feel good again.
[00:23:03] You're never going to feel okay. You're never going to be that person that you thought you were. And it's terrifying. And I think to see someone like you, Devika, who is, I mean, beautiful, healthy, accomplished mother and physician, it just gives people hope that this is not a death sentence. That it truly is a hijacking of your brain that is not a permanent condition and that you can get better.
[00:23:32] I think it's important for people to realize that if they are getting treated for depression or anxiety and they're not getting better, not getting better. You need to ask the question, is there something else going on? I mean, 11 years is too long for people to get a diagnosis. Bipolar 2 is not a zebra.
[00:23:47] I don't know the stats on the commonality of it. I don't know because I don't think we probably have accurate statistics at all. I mean, because it takes 11 years to get the diagnosis, but I know from my own experience seeing patients, I will commonly make a referral to a psychiatrist when I, for example, have tried my patient on Lexapro for what seems like unipolar depression and they're not better, or they have a little bit of an uptick in their energy, irritability, and then we ask the question.
[00:24:12] Because for people who are listening, a diagnosis of bipolar one or two, which are a bit different, we can talk about that, opens the door to another set of medications for treatment. This is one of the things I worry about with online, kind of drive through kind of mental health startups. I mean, I think it's great that people are getting better access, but I worry that we are bucketing people into depression, anxiety, depression, anxiety, when sure there's a lot of depression. There's a lot of anxiety, but first of all, do we need to medicalize all of it? I'm not sure. And secondly, are we making the right diagnosis in the first place?
[00:24:46] Such important points. You know, I think just stepping back, like, from the data, you're absolutely right. There's a whole variety of studies that have been done with differing prevalence rates of bipolar 1 and bipolar 2, depending on sort of what is counted. And it's very common within the bipolar spectrum for you to receive let's say one kind of diagnosis. I was initially diagnosed as bipolar not otherwise specified, which is sort of a soft call it's like somewhere in the on the spectrum. We don't exactly know where and then as people's lives go on you end up realizing like okay You've now had a manic episode off of antidepressants let's say, and now you qualify for bipolar one rather than bipolar two, so there's a lot of shifting along the spectrum and that makes it hard to assess and get true prevalence rates. there's a meta analysis that came out now about 10 years ago, and they said that 2.
[00:25:32] There's a meta analysis that came out now about 10 years ago, and they said that 2.6 percent of the population will meet criteria for bipolar one or two at any given time. But that's not counting the other parts of the spectrum, which we now know is also a sizable portion. But, you know, with depression, when people come in for a first time depressive episode, one in three of them. will end up being on the bipolar spectrum.
[00:25:59] And so if primary care doctors know this, if, you know, other kinds of healthcare providers know this, then we can start to turn the tide on that statistic of 11 years for bipolar 2, and it's shorter for bipolar 1 because it's much more obvious when someone has a manic episode, whereas hypomania can be a little bit more, it can cloak itself as anxiety as you said, and other symptoms that are harder to diagnose.
[00:26:23] LM: So what prompted you to be public about this? I mean, it's a pretty big move. I mean, there's a lot of stigma around mental illness, even though it is having a moment. There's a lot of misunderstanding about what bipolar is. I mean, I think people throw that word around a lot. Like, Oh, she's so moody and crazy.
[00:26:40] She's so bipolar as a derogatory term. You know, we used to call it manic depression. I think patients associate bipolar disorder with someone who's driving a stolen Ferrari a hundred miles an hour down the highway. And then someone who's standing on a ledge about to jump. And there's so much more nuance there.
[00:26:58] There's people in our lives. These are people who are functioning, who are parents, community members, people we know. I think it's, it's very brave of you to come forward as you and I were talking about before we started recording, particularly in a public role, like you had as the acting surgeon general in California, I mean, you're out there. So I'm just going to ask you, what is it that prompted you to go public? And what has that been like?
[00:27:25] DB: I was serving in the role of acting surgeon general in a moment in time when everybody was struggling with something, right? We had been in the pandemic for two years plus at that point. And we all, at that moment, knew somebody who was truly struggling, or we were that person ourselves. And so I felt like it was a really important moment to publicly own my story on a couple of different levels.
[00:27:53] One, to help everyone realize, like, you can walk through a really difficult period of your life and think that you can never bounce back from that, but actually walk through it and then, on the other end, be able to fulfill your own dreams, right, personally, professionally. At a point in my life, I thought I'm never going to have a career.
[00:28:16] I'm never going to be a parent. I'm never going to be a stable partner. But to recognize that even a really stigmatized mental health diagnosis like bipolar disorder, and it does carry a very loaded set of stereotypes with it, that even that, you know, you can look back at your hardest moments and say, those were in my past.
[00:28:36] And... The last 10 years or more, I've been well for the majority of them and now, you know, having figured out what it is that keeps me well, both behaviorally and medication wise, I can hope to be well for the rest of my life and I think that it's an important message because unfortunately, for instance, all of the people I know who are living well with bipolar disorder, there's a very small fraction of them who feel comfortable sharing that truth with their coworkers, with their with the people in their lives beyond just a few.
[00:29:11] And so, if we all live in secret, once we've figured out how to live well with this disorder, then we have a very skewed sample of who it is that has bipolar disorder and what that can look like. So number one, I wanted people to know that when you've got the right treatments and the other systems in place to stay well, you can do the things that you want to do in your life.
[00:29:28] And then number two, I wanted to reach those people who were truly still in their hardest phases who are struggling to know that there is hope for a better tomorrow. That with the right treatments once more things can turn around very dramatically. And to have hope that can happen. And the way that it all came about, and I'll just say one quick other thing, which was NAMI California was having their annual conference and they invited me to keynote it and it felt like that would be the most authentic moment in which to share this journey. And I… same day also shared it in the LA times and online on social media. And I'm really glad that I did because in the wake of that, hundreds of people reached out to me with their stories of, I have been struggling and this meant so much to me where my son is in the hospital and I have hope now that he might be coming out and he'll be back to himself.
[00:30:29] You know, it just, it really opened. the door to understanding that we all have this commonality. We all have known struggle or known someone who has struggled very intimately. And then also it helped me understand that I had a way of connecting to this community and join in on a few different advocacy projects, which have been really meaningful.
[00:30:53] LM: I think that's incredible, and I think you're living proof that there is a better tomorrow, and that with treatment, that’s not just medicine, it's behavioral, it's environmental, you can have hope.
[00:31:06] DB: Yes.
[00:31:07] LM: What do you think, Devika, is the most important element of your wellness? It sounds like you take medication, it sounds like you prioritize sleep, it sounds like you try to eat healthy and have boundaries. I mean, if you had like a pie chart for you, and this is going to be different for different people, but what occupies the biggest slice of pie? Is it the medicine? Is it the sleep? Is it self awareness? I mean, could you break it down a little bit?
[00:31:35] DB: Yeah. There's a lot of elements of that pie. I think a big chunk of it, more than 25 percent is going to be connection and community, right? So the people that I rely on a daily basis to, to understand me, to support me, to have fun with me, to, you know, laugh with me. Those people keep me well in, in so many small and big ways, right?
[00:31:58] And then the other pieces are the daily habits, the making sure I'm getting enough sleep. At night, I wear blue light blockers. These are orange glasses that supposedly filter out the majority of blue wavelength light, nightlight, or nighttime. And so sleep is a big part of my life. I really try to do a lot to protect it. I'll tell you one other thing. My husband tends to wake up if my son is awake in the middle of the night or early in the morning. And so that's one strategy that we've sort of got in place to help protect my sleep, which is really meaningful.
[00:32:38] Food, you know, eating a variety of foods. I tend to have sort of a Mediterranean diet over the course of, you know, the day and really, find that important. Exercise… protecting my energy. So, you know, big events, for instance, where I'm spending a lot of time talking about myself, my journey in a conversation like this, it, it tends to be really meaningful and important and also deplete my energy.
[00:33:07] And so I have to be really mindful of how I structure my weeks. So if I know I'm having a conversation like this, I'm going to try not to schedule too many other things in the next week or so. Right. And that gives me some time to sort of rest, decompressed, refill that cup, that energy cup and, and sort of be present and able to do what I need to do in the rest of my life.
[00:33:31] And so just being really aware of what's happening for me mood wise, energy wise. Am I feeling that tension in my shoulders? Like, what can I do differently? Like if I have any red flag symptoms, like let's say I'm starting to feel a little bit on edge or irritable with folks.
[00:33:46] One of my tells is I tend to respond too quickly and with too many messages on WhatsApp. And remember, my family lives sort of abroad, and so that's a big mechanism of contact. But if I'm doing that, that is often a tell that I'm starting to feel a little bit elevated. And just knowing what it is that I need to come bring to bear in those moments to try to reverse where I'm going mood wise and come back into sort of my baseline mode.
[00:34:14] So it's a lot of kind of those maintenance mode things that we spoke about, but also recognizing red flag symptoms and then having a toolkit in place to intervene, whether that's up or down. And that looks different for different people.
[00:34:28] LM: I mean, that is such good self awareness. I particularly like what you said about the energy allocation. You have this busy life, you're a pediatrician, you're a public health leader, you're writing, you're speaking. You're parenting, you're learning from your own two year old. I think women are, I mean, we are just, I think beyond capable and we're interested in so many different things, but I think, you know, that resonates a lot with me too, is this sort of notion of an energy budget.
[00:35:00] Yes, we can do it all, but like, like with everything, there are trade offs, right? So I think that it's important that you're aware enough about yourself and your tank, where you are, of energy to sort of allocate it appropriately. And I wonder if you find like certain relationships you've had to sort of change or if you, or if there are boundaries that you've had to set.
[00:35:22] I know that as I have gotten older, I just turned 50. That I'm a real empath. I love being around people. I also know when my energy is being drained either by a certain situation or a certain set of people. And it's not their fault. It's just, that's just the way my mind and body work together. And so I'm sort of more aware of who, what, where I can tend to over-expend energy and then when I need to pull back. I wonder if boundaries and relationships are something you think about yourself.
[00:35:51] DB: A lot actually. And you know, it's one of those things that we as women are socialized to be very other oriented, to worry about other people's feelings, sometimes at the cost of our own health and wellbeing. And it's a lesson that I think I learned in my late thirties—I’m 37 now—to really honor my needs, my emotional needs, and sort of to know that with certain relationships. That there do have to be some boundaries in place and at the beginning when I first learned about this concept, you know in therapy, I thought, that's kind of I don't know how that's gonna work in an Indian family. Like we're so close. It's a very communal situation even when we're many miles apart.
[00:36:38] There's this like very open expectation that you will be there and vice versa in lots of ways and the concept of a boundary felt culturally potentially inappropriate and what I realized was that I'm putting this boundary in place not to shut this person out of my life, right? Not to have this relationship wither and die, but actually to have a better relationship, where I'm not resentful of them… of something that they are asking of me that I'm not able to do. I realize like it's been such a powerful, game changing thing because I have closer relationships with those same people now because I'm aware of my own emotional needs and triggers and sort of what those boundaries really need to be.
[00:37:24] Sometimes it's something simple like When I see them, I'm going to see them for this amount of time, and there won't be a chance for, you know, necessarily that build up. But it's been, yeah, it's been huge for me, as I imagine for you too, and for many of us who are listening.
[00:37:39] LM: I mean, I think a lot of what you're talking about pertains to the human condition in general. I mean, I think certainly when you have bipolar illness and certainly when you figure out your kit of coping tools, that's essential. I also think for most of us, we need to be careful about our sleep, our exercise, our relationships saying no, kind of recognizing our internal sort of thoughts and feelings and who drains us and who energizes us and meeting our needs, especially as a physician, as a mother, I'm socialized and trained to be empathetic and I am, I think, intrinsically empathetic, maybe not all the time, but I think I am.
[00:38:20] It is hard. It feels culturally inappropriate in my own family and as a physician, as a woman, to say no and to say, I'm so sorry, I can't do that. But I've also learned, like you, that I'm a better mother, sister, daughter, person when I am meeting my own needs, which is not selfish. It's the way I need to be healthy.
[00:38:42] And, you know, sometimes you get it wrong, right? Sometimes you get it, like, sometimes you get it wrong. Sometimes you say no because that's what it felt right. And then you realize, oh, wow, that was actually... at my own expense, but I think that's something that we as women need to practice and I think it is part of a mental health coping kit is to recognize that our needs matter and then to try to practice establishing boundaries and saying no, and you know, we all know that feeling of when you're talking to somebody, whether it's a loved one or a patient or, and they're asking you to do something that doesn't feel quite right.
[00:39:14] And you're thinking no, but then you end up saying yes, and then you're resentful and you can get angry and it's not their fault. We need to own that power and own that ability to say no.
[00:39:24] DB: Absolutely. You know, I'm reading a friend's book right now… Real Self-Care by Pooja Lakshmin. Yes. So I just finished the part about boundaries and two really insightful things that she has in there. One, don't over explain a boundary when you're giving it to somebody because then it seems like you're asking for permission, right?
[00:39:45] And then number two, to your point, allow there to be a pause between the ask of you, and your response. And in that pause, you will figure out does this feel like the right thing to do? Does this feel like a yes but, or you know, a yes and situation? Or do I have more questions? Do I need to negotiate a different situation, right? Or do I need to say no? And you won't know that if you very quickly respond “yes” which is our gut instinct as women again, and taking that pause is where the boundary can actually emerge meaningfully.
[00:40:19] LM: I think that's right. So what I'm hearing from you, Devika, is that your wellness is external. It's about sort of environmental, everything from your nightshades to your medications, to your therapy, to an internal kind of, checking in with yourself on your energy, on your relationships. It's about connection.
[00:40:42] It's about feeling loved. It's about, it sounds like it's about feeling safe. And I mean, I think those are essential parts of health for all of us and it doesn't have to be fancy or expensive. We don't have to buy fancy leggings and show up with a personal trainer and have exotic supplements and be on a yoga retreat in Bali.
[00:41:04] Although, you know, invite me with you if you're going to go, I think it really is about an internal sense of what we need, what we deserve and what, and how we relate to other people that is at the root of our mental health. So I want to just close by reading one more quote which I love from your LA times.
[00:41:23] You said “by sharing my story, I hope to dispel stigma and internalize shame and to help anyone struggling, know that they are not alone. If you feel comfortable, consider shining a light on your story. Stigma festers in the dark and scatters in the light.” So, for anyone who's listening, who feels like writing, or talking to their friend, or their dog, or just their journal, about their story, I think it's important that we acknowledge that we all have vulnerabilities, we all have grief, we all have loss, we all have fears.
[00:41:56] Some of us have mental illness, some of us have... You know, real relationship struggles. And I think that when we talk about them, we can then start to figure out the path forward. And so I just want to say, thank you so much, Devika, for sharing your story, for being such a role model and for teaching us the ways in which you stay well.
[00:42:13] DB: Thank you so much, Lucy, for having me here and for the wonderful work that you do in your sub stack for the whole community. Really appreciate you.
[00:42:28] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
You can also listen to this episode on Spotify!
It’s hard enough for adults to navigate anxiety, lack of privacy, and social relationships in the digital era. How can we expect young people to do it?
On this episode of Beyond the Prescription, media expert Dr. Devorah Heitner presents practical strategies for parenting in an era of perpetual connectivity.
She offers a refreshing perspective in her bestselling new book, Growing Up In Public: Coming of Age in a Digital World. Instead of panicking about social media’s role in young people’s lives, she argues that parents should accept that it’s here to stay and focus on the benefits of technology. Instead of blaming social media’s role for the uptick in adolescent anxiety, she argues to uncover and address the root causes of young people’s distress.
She offers practical advice to help kids set boundaries, maintain digital hygiene, and learn how to make mistakes—even while everyone is watching.
Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter. At lucymcbride.substack.com, and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond The Prescription. Today on the podcast, I'm speaking with Dr. Devorah Heitner, who is a bestselling author, speaker, and expert on raising kids in the digital world. In her various capacities, Dr. Heitner offers practical advice that's backed by science and research. She's providing tools that people can use to start conversations with their loved ones about how to use technology in our lives in a healthy way.
[00:01:25] Her most recent book, out in September, 2023 is titled Growing Up In Public: Coming of Age in a Digital World. It's an essential read for parents. In short, Dr. Heitner thinks we're worrying about the wrong things. We see the panic inducing headlines, yet social media can be an excellent way to help learn about our kids and help them learn about the world we live in today.
[00:01:48] Devorah, thank you so much for joining me today.
[00:01:51] Dr. Devorah Heitner: Thank you.
[00:01:53] LM: So, I talk about inputs with my patients every day. I talk about things that we put into our bodies and brains, like alcohol, caffeine, food, of course. And then I talk about screens, because screens are something we ingest. They're ubiquitous. And it's not just about how much screen time we consume, it's about our relationship, sort of like relationship with food or alcohol.
[00:02:17] What I love about your work is not only are you exploring people's relationships with screens, you're taking a somewhat counterintuitive stance that there's a lot of research out there to suggest that screens are destroying a generation of of youth. That it is the cause for the emotional and mental health despair.
[00:02:38] So, there's a lot of data to suggest that screens are the biggest evil for our kids, that they are the reason that kids are experiencing emotional and mental health problems, but you take a different viewpoint. You take the view that screens are indeed ubiquitous, but they also can be used as a tool. They can be used as a tool to help us shepherd kids through this complicated part of their lives. So talk to me about how you see screens as a boon, as a way to help parents understand their kids. And not just as something we need to be terrified of.
[00:03:20] DH: Yeah, I think we've been really pushed this idea that screens are the big bad that are really tanking kids’ mental health has been really pushed on us and we ignore a lot of other factors and also like, what are the screens bringing our kids? So as you said, it's not just about the quantity, the minutes.
[00:03:36] The minutes are important, too. We want to live in balance with screens and be able to do other things. But we also want to think about the quality of the experience. If your kid is a creator and is making things online, for example, or collaborating with other kids, or has started a business, or is composing music, or is writing a really interesting blog, or fan fiction, and getting a lot of creative juice and community out of that, it could be a really positive thing in your kid’s life.
[00:04:04] So we first want to look at: what is the quality of experience? What is your kid engaging with? Are they finding community there? Are they connecting with people in a positive way? Is it leading them to other interests? And sometimes, especially in the last few years, when so much of our novelty has come from YouTube or Netflix, and we maybe have forgotten about other kinds of novelty. As parents, we may want to look at our kids screen based interests as a clue. Like, oh, they're watching this kind of content on TikTok. What else might be interesting? My kids are very into strategy games on the computer, but we've also gotten into risk and some other deep strategy board games.
[00:04:41] And part of that was like recognizing these multi layer, multi hour games, you know, with strategy and complexity are really interesting. What can we do as a family that might also be related to that? And then we also want to think about the ways kids are connecting with other humans and how this is supporting their friendships. So there's a lot that's going on socially here and we worry about the negative pieces, but we should also look at the positive ways our kids are finding affinity with other kids. Our kids are finding community and finding people who share the same interests.
[00:05:12] LM: I hear you loud and clear. I think headlines that scream: watch out parents. Your kids have a separate life that you don't know about and it's only nefarious and screens are doing harm and only harm are sensationalist and really put sort of fear in the driver's seat of our roles as parents.
[00:05:32] I do think there's a lot to be worried about. I mean, kids are looking at images that you and I never had access to as children. And I think that kids can certainly get lost in a screen addiction. Just like you can be addicted to marijuana or alcohol, you can get addicted to screens. You can develop a relationship with screens such that you're using it to “medicate social anxiety” or fear of failure or you can be bullied online.
[00:06:02] Of course, I think we all know about the harms. The way I practice medicine as a physician is that I try to be a realist. I recognize that alcohol is ubiquitous in our society. I'm not going to be able to take it away from everybody, nor should I. We have to reckon with these phenomena. We can't just mop up risk and make it zero.
[00:06:21] We have to reckon with the realities of our everyday life and screens are not going anywhere. Screens are, if anything, becoming more and more woven into the fabric of our society. So I think what's important as you're saying is to recognize that there are opportunities here. There are ways that we can use screens as a sort of window into our kids lives.
[00:06:46] And that policing them may do harm in and of itself. I mean, what do you make of this idea of restricting kids access to screens until they're 18? I think there's a new law in Utah, for example.
[00:07:00] DH: I think the Utah law is a particularly harmful example. Like I do think when school districts and other folks are trying to push back on the big companies and say, “hey, when we report bullying, we should get a response right away.” Or when we report that our kid started an account under age 13 when they're supposed to be 13 and you don't take it down or you're not doing anything to even pretend to try to age verify and any eight year old can start an Instagram account if they can do the math to change their birth date, then I think it's important to say, yeah, we do want to push back on these companies. So I'm excited to see some states and school districts pushing back on the big companies. Utah's saying, let's put this all on parents. Like parents don't have enough going on and parents should be in charge of their kids social media up to 18.
[00:07:44] I think that's a problem for a lot of reasons. One reason is that not every kid is lucky to have enlightened, wonderful parents. So, what if I'm a gay kid in Utah and my parents don't know and if they find out, I'm going to become unhoused? It's not safe for me to post on social media if my parents have access to my social media up to 18.
[00:08:04] I think 18 is particularly glaring in a state where kids can work at 16 and drive at 16. I think to say that driving and working a job are, are less responsible than posting on social media is a problem. I think when we look nationally at what's going on, where there are states saying we want kids to be able to work dangerous agriculture jobs with pesticides and work in meatpacking plants at 14, but they shouldn't be able to post on TikTok till they're 18.
[00:08:30] I think we're a little messed up as a society if we're saying that, because if we actually wanna protect kids, yes, I think none of us want our children to see pornography, for example. We don't want our children to see extreme violence, but the companies need to take down some of that content when it's getting reported.
[00:08:47] But putting that on parents and saying parents need to be checking their kids' messages and reading their kids' posts up to 18. I went to college when I was 16. I moved away from my house and went to college. I'm not saying that was necessarily the best thing in the world, but that's what I did.
[00:09:04] And to sort of say that, and many kids start college at 17 because that's when they finish high school. So to say that a college freshman in Utah, their mom should still be reading their direct messages is just a little extreme. And I think we really need to get out of that idea of big brother and think about we need to teach kids to swim, putting the electric fence around the pool is not helpful and kids entire focus will just be saying that they don't live in that state or that they're going to change their age in some way when they sign up and many parents will not be in a position to make that not happen. And again, it also assumes that every kid has a well meaning thoughtful parent on their side.
[00:09:39] So there are tremendous problems with that. What if a kid needs to use social media to report abuse in their home?
[00:09:44] LM: So do you think that the headlines about the harms of social media on kids and adolescents mental health are overblown? Or what's sort of your take, in general, on that sort of frenzy,
[00:09:54] DH I think they are overblown because it's an easy thing to blame, but some of the problems that we're seeing in kids, we have to look at the pandemic. We have to look at school shootings. We also, when we see more kids reporting mental health issues, we have to look at access to mental health care as a plus.
[00:10:09] When I was growing up in the early 90s, and there was a smoking lounge in my high school, and many peers were using substances to self medicate. Very few kids would have self identified as depressed or anxious because they didn't necessarily have that language. I would argue that there are kids who are learning the language of mental health from places like TikTok or Discord and are using that language to describe the way they feel, but I don't know that those problems are new to this generation of adolescents. But I think we're seeing increased access to both language around mental health, and hopefully in many communities, actual mental health care. The thing I would worry about is I don't want kids to get their mental health support from TikTok and Discord. It's one thing to identify, like, maybe I have an issue, and learn about it, or have a YouTuber who talks about ADHD and say “oh, I think maybe I should get neuropsych testing.”
[00:10:56] What we don't want to do is self diagnose from YouTube or TikTok, and I'm sure you see that as a physician all the time. Like, that, Is concerning, but the fact that more kids are self identifying with mental health issues, I think is partly that we as a society have shifted to destigmatize that conversation and I actually think social media is part of that in a positive way for kids. But it sounds scary to adults to hear like this many kids say that they're depressed or anxious, but it's not that kids in the past were not depressed and anxious. I think they were self medicating in the smoking lounge at their high school.
[00:11:28] I think adults were turning a blind eye to drug use and other things and alcohol use. So I think we're in a really different place as a society where we're looking harder at adolescents. And there are many reasons adolescents are feeling anxiety. For example, if your kid is looking at their social feed or at the news and information about school shootings, that's distressing, but taking away Instagram doesn't take that distress away. They're going to get that news another way. Their phone may be, in fact, the source of where they're getting that stressful information, but that doesn't mean that if we just take away the phone, they're not going to be worried about it anymore.
[00:12:07] So I think it's really important that we look at, is this a vehicle for getting access to stressful information? When we see the apps themselves encouraging things that are stressful, like the apps themselves may be a problem when they encourage us to location share and we can see that our friends are out without us. And that is a problem that I blame more on social media, versus, you know, that's not just getting information. That's kind of random. That's like, hey, this app is really encouraged us to do this very human thing, which is to want to know where the people we care about are, which is very human. But it's kind of trading on that brain what we want to do.
[00:12:41] And it also trades on parental anxiety when parents put Life360 on their kids devices to track their kids all over town. But that may also not be great for our relationships. There may be ways where that undermines trust and undermines relationships. So I think there are times where what we in the tech world call affordances, but it's basically like what the apps let us do become a problem. And that's where I think we should be looking at do we want to change our own behavior or do we want to make some feel really empowered in relation to an app? Like, yeah, I want to use Snapchat, but I'm going to turn off Snap Maps. I don't want that feature. Or I'm going to turn off location sharing on another device, or I'm not going to use Life360 unless someone actually has disappeared and I haven't heard from them way past curfew.
[00:13:20] I'm not just going to use it to see if my kid might have relationships or errands to do that. I don't know about right now to kind of resist, in other words, the possibility of what apps let us do and make choices about how we're going to use tech that might be healthier for us mentally. So to come back to the headlines, I really don't think we should panic about the ways kids are using social, we need to also just look at our own kids. Like if you have a kid who's predominantly using discord to connect with their three best friends to play a game every day after school, then my worry is, are they getting their homework done? Are they getting enough sleep? But I'm not worried that social media is making them depressed because it's clearly functional for them.
[00:14:02] LM: Right? I think as parents, the screen landscape can make us feel very out of control. Kids in their adolescence are naturally kind of differentiating themselves from their parents and they are behind closed doors a lot of the day and we don't always know what they're looking at. But that's always been the case. And that's part of growing up. That's part of developing our identity is being around our peers. And sometimes that's online. So what do you say to a parent who has, for example, an adolescent who's kind of less accessible verbally, who's spending a lot of time on screens, who you may be worried that they're spending too much time on screens.
[00:14:44] How do you even begin to sort of query whether or not you're doing a good enough job as a parent vis a vis this child and their screens? They don't want to talk about it and they don't want to share with you what they're doing online and you feel completely anxious. And then you look at the headlines and you think, Oh my God, I'm the worst person alive. What do you say to that parent?
[00:15:02] DH Well, it depends on the kid and what your specific worries are, but I do think you could have especially a younger kid who's newer on some apps, like walk you through some of the things they're doing. Like, “hey, can you show me some of the things you love?” You know, like my 14 year old will absolutely show me, you know, things that he thinks are funny from YouTube sometimes and like just getting a sense of like, oh, I can see you're diving into some political satire here.
[00:15:24] I see you're diving into some remixes of the culture and things that you're interested in and movies that you like over here and just getting a sense of like, what is the content? You can decide if the bedroom is a place for screens. Certainly with sleep, I would strongly recommend not having connected devices in bedrooms overnight, especially for younger adolescents who will really struggle to self regulate, or tweens, or younger kids.
[00:15:47] And the challenge is sometimes kids are getting phones so young that they're still little and compliant. You know, your 5th grader, if they get a phone, might be super compliant and put it away at night. But you gotta think ahead to that 8th or 9th grader in love and think about, do I want them texting their sweetie all night?
[00:15:59] Do I want them, you know, on social media late at night? And so it may be that the bedroom is a place where tech doesn't go or it doesn't go during sleep and overnight. And I think that's important to think about. So some of their tech use hopefully is around the house for younger kids. If they're gaming with friends, I would suggest not having headphones on all the time.
[00:16:17] It may be annoying. It was definitely annoying for me living in a small apartment through a lot of remote school in the pandemic. And my kid was gaming without headphones. It was extremely annoying, but I knew what the friends were talking about. And when some things came up on Roblox, where they ran into some content that was a little bit of a surprise, as in, like, naked blocky people having sex in Roblox.
[00:16:38] When I heard them start to talk about that, I was like, walking over to the computer, like, what's that? And so I think that's, that's a helpful way. It's a little bit less big brother-y than using your device to kind of spy on or get your kids data later, but just being in a place where you're adjacent, you can overhear some of the activity can help you know.
[00:16:57] As kids get older, their privacy is going to be more and more appropriate, but you can still check in with them when they're in the car. We have a no phones in car rides rule for under a certain amount of time. So, you know, my kid can't like put on a podcast and listen to it with his headphones for a five minute ride if I'm driving him somewhere.
[00:17:14] If we're going on a road trip to another city, podcast and listen together. And some of his time might be in the backseat. with music on or something. But shorter rides, we have to talk to each other. And some of that is like, he gets to pick the topic because he doesn't like to share about school, but he has to tell me about something, right?
[00:17:32] And it might be the video game he's playing, but we have to talk to each other. And family meals are important. Finding a time that actually works. And with busy teenagers who do a lot of activities, that might be late at night. And that's when your kid's ready to spill and you might be ready to fall over, but if your kid is ready to tell you about things, that's a good time to be listening.
[00:17:52] If there's a specific where you have, like, say you think your kid is. checking out pornography or something where you're like, this is a specific worry. I do not want you doing that. Then I would address it directly. A lot of us are uncomfortable there, but if you have evidence that your kid has looked at pornography, I would definitely talk to them directly about it and talk to them about why this isn't where you want them to learn about sex and consent and relationships.
[00:18:14] And we can do that in a non-shaming way. We can normalize and humanize that human beings have been preoccupied with the body and sexuality and art for a long time. This is not new. For an adolescent to be curious about sex and what that looks like and what people do is very typical and normal.
[00:18:30] But this isn't a useful way to get information and it can actually be misleading. It can offer misleading ways to get information about what partners might actually like. It's very misleading on the consent front. And so I think we, and we want to make sure they get alternative information. The older your kid is, the more I would want them to read… certainly younger kids should get have books about puberty and sexuality.
[00:18:52] Hopefully you live in a place where they can also get good sex ed in school, but we know that's not the case everywhere. So we know kids need to be able to talk to their pediatrician and other things. But we need to make sure that they have good information. And then for older kids, like reading a steamy love scene in a young adult or even an adult novel is preferable to me by a lot.
[00:19:12] I mean, there's a lot of books I would want my kid or be comfortable with my kid reading as opposed to seeing pornography. And I think that's really important to make sure that kids do have access to information. And we need to know that it's not just boys looking at porn. Girls will look at it too. A lot of kids are accessing porn for, for sex ed purposes, or that's what they think it is.
[00:19:30] LM: Yeah. And one of the other specific worries I think that comes up for parents of girls in particular, not that boys are immune to this, is the focus on bodies and thinness and diet culture and comparison culture. And I think it's really hard to avoid those, the constant barrage of images of… and now that we have AI where these faces can all of a sudden look perfect and you can see your real face compared to what your face might look like if you had plastic surgery and you were on the red carpet in Hollywood. I mean, that is a pervasive phenomenon and it's concerning as a mother of a daughter and sons, this constant sort of focus on appearance. But again, as I think you're saying, lwe cannot take screens out of their hands.
[00:20:19] We cannot make risk zero. We can do what we can as parents to help our kids kind of have a relationship with screens. So, I was counseling a patient last week who's a mother of a teenage girl who's struggling with her eating. So she's got some binge eating and some restricting behaviors and she's on screens all the time and Focusing on her appearance and the girls, her friends are in bikinis and she's not included in all the events where the girls are wearing bikinis and it's just, you know, it's torture as a mother to watch her daughter kind of go through this and you think to yourself, Gosh, I could just get rid of the screens and everything would be okay.
[00:20:57] Let's acknowledge that wouldn't be the case. And let's acknowledge that's not realistic. So my advice to her was to have a conversation with her daughter that's led with curiosity and empathy. So instead of saying, you really need to get off your screens, that's bad for you, ask the question: “honey, I wonder what it feels like when you're sitting at home and feeling uncomfortable about maybe your body or your social life and you see your friends looking perfect because they've got this curated image of themselves and you're not there. What, I wonder what that feels like.” I mean, and you might offer even an example of what you might feel like. Like it might make me feel awful. You know, when I was a kid and I knew my, my friends were hanging out together and living this so called perfect life, it, it hurt. I wonder what that feels like to you. So curiosity is always a good way to lead a conversation. And then also with empathy and say I just feel bad for you guys that this is such a hard thing to have to navigate. You can't avoid looking at these images.
[00:21:54] You can't avoid comparing yourself to other people. And then sort of open the conversation like that instead of going at it as you really need to get off screens. You need to not look at these images. You need to just stay away from that friend group or stay away from that social media feed. These are their friends.
[00:22:07] These are their lives. But I think it's very hard to know how to have those conversations as parents. And I think the world we live in as parents consuming social media seems to suggest that there's the right way to talk to our kids and the wrong way to talk to our kids. That we have to read the right parenting book.
[00:22:25] We have to follow the right expert on Instagram. We have to listen to the right podcast and that our kids are so fragile and so vulnerable that if we say the wrong thing by just two phrases, then we're doing all this harm when I think that for parents is scary and we need to understand that just by showing up as parents, and just by being empathetic and curious about who our kids are, and showing them that we love them no matter what, that is good enough. Sure, there are parents who are doing harm. Sure, there are parents who need help. I need all the help I can get with parenting, but I also have learned to trust my instincts and intuition, and I need to listen to my kids and meet them where they are.
[00:23:06] There's no parenting book that is going to tell me how to parent child one versus two versus three. So this is a long winded way of asking you, are you saying that parents need to be able to read the room with their kid, they need to be able to understand the person they are talking to, and have a relationship at baseline with their child that involves discussing who they are, what their interests are, and understand that screens are going to be an inevitable part of it.
[00:23:34] DH: I think that empathy and curiosity as you say, is huge and just slowing down, like really saying, what do you notice when you look at Instagram and letting your kid talk. Ideally not even leading with like exclusion or your own feelings, but you can go there and in a conversation, but I would let them what it's like for them and see what insights you can get from there.
[00:23:59] And certainly with body image, as the example you used it can be an exacerbating factor. Like it probably didn't originate with screens, the eating challenges you're talking about, but that doesn't mean that screens couldn't exacerbate. And if a kid is in treatment for an ED, for a substance, for anxiety, for another mental health issue, 100% with that therapist, I would be working on a screen plan with that therapist.
[00:24:25] Especially with a teenager, it's helpful to have someone that's not a parent coming up with, like, if you are going to change the screen plan and your kid is in treatment for an ED or coming home from the hospital even or something. Those are kids who are going to need some support. And sometimes it's apps we don't think of, like Pinterest is actually filled with diet content that is quite toxic.
[00:24:44] If I had a kid with an ED. I would be thinking about, like, how can we encourage them to maybe avoid Pinterest? This may not be a good place for them. If I had a kid who's really into redecorating her bedroom, or a kid who's really into crafting, Pinterest could be fine. So it's not about the app. It's about what experiences and connections and content your kid will seek out within that app. Because I could say the same thing about discord, you know, discord could be totally positive for a kid Who's using it to connect with other anime fans? It could be very negative if kids are doing like how to on an eating disorder or something or self harm. So I don't want to scare people but there are places on the internet and and communities and sub communities that aren't going to be a positive place to be if you're struggling in those ways and asking kids to reflect on their experience, asking kids to consider taking a break.
[00:25:35] Cutting a kid off completely from an app is a pretty big step, but even taking it off your most frequently used device without closing your account can be helpful. And for some kids doing that, even for a few days, just to take that app off your most frequently used device for a weekend and spend a weekend where in order to see that app, you would have to go to your computer and log in.
[00:25:55] I have that suggestion for a lot of kids who are stressing about their grades and actually over checking their grading app. I'll say actually take your grading app off your phone. If you're checking your grading app multiple times during the school day and getting distracted in one class because you saw a test score come in from another class, that's too much. And so some kids are compulsively checking those apps. So I do think in those cases, again, it's not like we never want to see the grading app again. You may need to check it at some point, but like if you have to go to your desktop or your janky school laptop that you don't use that much and check it there, but it's not on your phone, which for 99% of teens is going to be the most frequently used device...
[00:26:32] That's really helpful. So creating those friction moments to make it less automatic and less habitual to go to the places that maybe are kind of death by a thousand paper cuts—maybe it's not like, you know, your phone is hitting you over the head and giving you a substance use disorder and eating disorder, but it's not helping either.
[00:26:51] Maybe that's where change your access. And the more kids feel empowered about that and the more… I talked to several kids who were intentionally following size positive models, people who made them feel good about their bodies. So going in the other direction, using the algorithm intentionally. So for Growing Up In Public, I did talk to some kids who felt like it wasn't great for them.
[00:27:11] And they started using those apps more just for messaging and not posting pictures as much and kind of feeling like they had to post. And again, the people who are curating first, you know, either size positivity or following athletes that they felt like were more body positive and not giving them kind of kicking off or catalyzing feelings that were more negative was so important. But that's a lot of sophistication. Even adults often don't recognize this content is adjacent to this content. But for any kids, I would say fitness content is always going to be adjacent to diet content and diet content is not safe for children. I think it's toxic for all of us, but definitely for kids, you know, if you're looking at your eating or anything with fitness, like talk to your physician. Do not get that from TikTok because it's all very dangerous on there.
[00:27:57] LM: Absolutely. And there's a sort of moralization of human behavior that happens that's just hard not to internalize. I love what you said about suggesting these breaks from screens. I mean, I find it hard as an adult to do that myself, right? When I'm standing in line at the grocery store and it's taking too long, I'm tapping my toe, you know, I'm kind of like scrolling through Instagram to pass the time and it becomes this habitual thing you just go to your phone when you have time to kill and there's a downside there. And so what I sometimes will ask my patients, I will ask myself this too, is what does it feel like internally, and how do you feel sort of mentally and physically when you take a break from, say, Twitter or Instagram for a weekend?
[00:28:38] When you take it off your phone, you don't delete your account, but you take the app off your phone, do you feel less tense in your jaw, less tense in your back? Do you sleep better? Do you find yourself drinking less alcohol because you're less kind of outraged or kind of overstimulated? Do you find yourself gravitating to the book that you put down six months ago? So I think it's not just about restricting the apps. It's about noticing how you feel mentally, physically, how are your behaviors different? If you could give up some apps that you frequently use or gravitate to for a week, what does that feel like?
[00:29:13] So I think what we're talking about really is control. Are we in control of the screens and our utilization, or are they controlling us? It's the same thing I talk about with alcohol.
[00:29:23] DH: I always say that to kids. Yeah, I always say that to…
[00:29:25] LM: It's the same thing I talk about with alcohol, you know, sugar, like, are we deciding how to use it? Or is it deciding for us? And when it is deciding for us when there's a Twitchiness in our brain that gravitates to the phone when you're standing in line at the grocery store or you're lying in bed and you can't fall asleep and you pick up your phone just to kill more time, that may be a sign that is controlling you. And so that's a moment to decide, let's pull back, not because we can't come back into our lives at some point, but let's recalibrate that relationship. Let's put us in the driver's seat of this relationship because it's such a slippery slope, even for grownups.
[00:29:59] DH: Yeah, what I say to kids is you want to be running your devices, not letting them run you. And that's, I absolutely feel that way. And that could be my inbox some days. It's like, wait, I need to set my priorities and not let my inbox set my priorities, right? I need to not just be reacting. I need to be planning and prioritizing and doing things in a way that makes sense like most of us check email too often too frequently throughout the day. So it's really important to talk with kids about that. And when I talk with kids about running our devices and not letting them run us I talk a lot about distraction and even what are the intentional things I do as an adult and as a writer like when I go Speak at schools or is like she wrote books like I'm like, oh, yeah like that's so easy because most kids find writing hard and guess what?
[00:30:38] I do too. I have to give myself rewards for every 500 or 1000 words I write. Like, it's not easy. And if I have to do an edit, which is even a next level challenge, often I will print it out and do it offline because of distraction, because I would much rather check the news or I mean, check the weather or scroll Facebook and see somebody's cute baby, whatever, then do that edit. And so I talked to kids about what do I do to set myself up for success? And when we as parents see our kids going down that rabbit hole, I mean, A) we have to look at how did we spend our time as teenagers? Did we always spend our time in the highest and best way? We did not.
[00:31:14] Like you probably spent some time sleeping very late. You probably spent some time, you know, like I spent time like playing songs on the radio for my friends over the phone. Wasn't like the highest and best use of, you know, our time. Like I wish I had been more like Greta Thunberg. We'd be in a much better place now if my generation had been environmental activists instead of playing songs for each other on the phone.
[00:31:35] But that kind of downtime and like watching a TikTok video with friends isn't necessarily bad for kids. They need some of that. But if you feel like it's a huge rabbit hole for a kid, your kid, and they're losing time that they need on other things like sleep or homework or, you know, any physical activity, chores around the house, Then we can talk to them about how can you choose your time? Especially when you have something with no ending cues, like a TikTok or an Instagram. How can you decide I'm going to do my hardest subject homework first. And then maybe I am going to scroll Instagram for a few minutes. And then I'm going to do another subject.
[00:32:09] And then maybe I will look at TikTok, but I'm going to set a timer on myself. Because there's no end to it. And the algorithm is really good. They're going to give you something you like. Like if they know what you like, they know what you like. They've got your number.
[00:32:21] LM: Yeah, I think at the end of the day, it's incredibly overwhelming, as you know, incredibly stressful for parents to think that we can put our arms around this behemoth of social media. And we really can't. And so I think what you're saying, Devorah, is to know our kids, to have those open lines of communication, to lead with empathy and curiosity for who they are, how they spend their time, what social media means to them, and then to recognize the good of social media, the good, the practice it can offer kids, setting boundaries and setting limits, and where to spend their time. It sounds like you also think that we can kind of tap into their interests.
[00:33:02] If you notice your kid on, you know, baking shows, then hey, maybe it's time to take a cooking class together. I mean, that would be sort of... The dream is that your teenager would want to take a cooking class with you, but I think we can use it as a road.
[00:33:14] DH: Even they could just make dinner. I mean, honestly, like if you're, if your kid is watching cooking shows, like have them make dinner. I want to eat those cupcakes. I want to, you know, eat that homemade pasta and truly like your kid will be the most popular kid on the floor of their dorm if they can make a good meal or even just some nice cookies.
[00:33:30] And so, and, and even if they're watching like how to make slime, like I want to see some slime. Like I don't want endless how to content filtering into a kid's brains without them putting it out. And the other thing we really want them to remember is there's other human beings on the other end. So when they are connecting with kids, those people have feelings too. If you're going to make a snarky comment on somebody's YouTube, that's a real person. And not only is it to that person, but you're also dealing with the people who will read it. So if you can't say something nice, it's not a good thing.
[00:34:00] You don't want to put that out there. And if someone is really bringing about your ire and your rage, and there are people on YouTube that bring, and Twitter and other places, that bring out my rage and my frustration, but my frustration is best channeled finding people I agree with and doing something to solve the problem.
[00:34:14] If somebody's being a racist or misogynist mouthpiece on YouTube, responding to their YouTube with a comment criticizing them isn't going to fix it. They're not going to say, “Oh, well, Devorah in Chicago thinks I should change my ways. I'm having a mea culpa moment. Here I go. I'm going to go down a new road.”
[00:34:31] Instead I want to do, think about like, what can I do in my own community to fight racism? What can I do in my own community to build an accepting school district for LGBT plus students? What can I do in my community to fight misogyny? And make safe spaces for women and girls? So I think it's really important to focus on what we can do to make the world better when we see things that enrage us and not get into like an outrage cycle online. And I think unfortunately that is another thing that the algorithm is really good at is like churning us up in that way. And that's something we want to resist.
[00:35:03] LM: That's right. And being in control of our own emotions. Recognizing that it wants us to be afraid and outraged. Fear and outrage is how they, how the social media algorithms work. So if we can say, look, I'm of course entitled to be afraid. I'm of course entitled to be outraged, but I'm going to calibrate that to my understanding of the facts and not calibrate it to what the social media algorithms are serving up.
[00:35:28] Now that's a tall order for kids. It's a tall order for adults, but I really like what you're saying again, just to frame it is that we as parents need to understand that there's good, there's value in social media. We have to feel that way because it's not going away, but it's true. There is good. There is value.
[00:35:47] In fact, during the pandemic, I was grateful in many ways for social media, for my kids to be able to connect with their peers and classmates, despite being out of school. So let's end with this question. What do you think a healthy relationship with social media looks like? What is the sort of definition of healthy social media habits?
[00:36:06] DH A healthy social media relationship is one where you're using it if you want to, because you want to, and you're getting pleasure and distraction and entertainment from it. You're getting maybe ideas and inspiration from it as well. And you can have a sense of humor about it. You know, everybody's posting about living their best life, because nobody wants to see you unloading the dishwasher.
[00:36:28] But the reality is most people's lives are a lot more about cleaning the cat box and unloading the dishwasher and running around and getting things done or if you're a kid like doing your homework or whatever and that very little of your time is on top of the mountain with the sunset or at the party.
[00:36:43] And so it's good to remember that it's a performance and to just have that sense of humor about it. I mean, I try, even though, of course, like my publisher wants me to be famous and get likes as well. Like I have that pressure as an author and a speaker, but I also have to have a sense of humor about it and say like, okay, this time, I'm not going to do the reel and chase the numbers, or this time I'm going to do it, but I'm going to try not to keep checking my phone to see how many likes I got, because I know that's the app getting me where I'm the most human, where I want to be seen and regarded. And that's where we all are.
[00:37:12] So if we can let our kids know that we have empathy for them, and that we see them, and make sure that they have things that they're doing outside of social media that bring them real self esteem, which is being helpful at home and in the community. to balance out that sense of chasing that algorithm or the numbers or the followers or the likes, I think that's a healthy relationship with social media. So use it for what it's good for.
[00:37:34] LM: I love it. I love it.
[00:37:35] DH: And be able to take some space.
[00:37:38] LM: And as we've talked about earlier, acknowledging that it is. An input, just like food, water, screens are now, you know, sort of part of our sort of nutrition, sometimes good, sometimes bad, but we have to metabolize it and we have to be aware of how it affects our bodies and minds.
[00:37:56] DH When it makes you feel bad, definitely put it away. That's I mean, That's definitely time. When it makes you feel bad, that's the time. If you're watching other people do stuff without you and it's making you feel terrible, put it away.
[00:38:05] LM: So Devorah, thank you so much for joining me today. It's been a pleasure and I've learned a lot.
[00:38:09] DH: Thank you so much. It was great talking with you.
[00:38:16] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.
You can also listen to this episode on Spotify!
What gives you meaning and purpose? How do you measure success? What does it mean to be healthy?
Suneel Gupta is helping people grapple with these essential questions.
His new book, Everyday Dharma: The Timeless Art of Finding Joy in What You Do, is about reconciling what we do with who we are. Gupta describes our “dharma” as our calling—or what Gupta’s grandfather called our “essence.” Gupta recognizes the central tension between outward markers of success and finding this internal sense of purpose. A successful entrepreneur and bestselling author, Gupta has also grappled with depression and self-doubt, fueled by the natural tendency to measure success with external metrics instead of asking ourselves the “Why?”
On this episode of Beyond the Prescription, Gupta explores the harms of hyper-vigilance and the power of vulnerability. They discuss the “Arrival Fallacy,” the false assumption that once you reach a goal, you will experience enduring happiness. He shares parts of his own process of self-discovery that allowed him to pursue his inner purpose and help others do the same.
Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond The Prescription. My guest today is the ever dynamic. Suneel Gupta, who's passionate about helping people achieve success in a healthy, sustainable way. Suneel is a beloved speaker, a visiting scholar at Harvard Medical School, and best selling author of two books. His new book is just out. It's called, Everyday Dharma: The Timeless Art of Finding Joy in What You Do. It's really a practical guide to finding your dharma, your inner calling, and learning to integrate ambition, work, and well being to create a balanced life. The book combines Suneel's own stories with history science, Eastern philosophy, and Western methods. Suneel, thank you so much for joining me on the podcast today.
[00:01:49] Suneel Gupta: Oh, Lucy, I'm so glad we were introduced and it's good to be here.
[00:01:52] LM: So let's talk about Dharma. There's something about it that resonates with me as a physician who's in the constant quest tohelp patients pull the curtain back on their story. So what is Dharma?
[00:02:04] SG: Yeah, I mean, I wrote this book really for the same reason. I think that we are experiencing an overwhelming sense of emptiness right now and society sort of speeding up. All right, we're using artificial intelligence, we're using automation to continue getting faster and more productive. But I think as individuals, we're kind of in a lot of ways moving in the opposite direction.
[00:02:28] We are starting to feel like we are disassociating with our work, we are quietly quitting. And I think the result of all of it is that we are losing an emotional connection to what we do, which I think is a shame because we spend so much of our time either at a job or with the work that we do.
[00:02:45] And to not feel that connection is, I think, I think it's devastating, right? It causes, I think, a lot of the symptoms that you talk about on this show. And so the reason that I wrote this book is because I wanted to to talk about how do we bring that emotional connection back to our work in a way that really feels real to us? And dharma is an age old philosophy really about that connection and one of the underpinnings of dharma is that while it may be tempting sometimes to try to find happiness and bliss outside of your work, there also is another path which is finding it through your work, right?
[00:03:22] And Dharma is really the alignment of who you are and what you do, because when those two things are lined up, you feel creative, you feel energized. My grandfather called this your essence, right? And when you are expressing that essence, you're lit up, you're energized. But when you're not, you feel depleted, you feel burnt out.
[00:03:43] And so I think the question for us is, how do we now start to come back to this essence, right? And it's something that's available to I think all of us. It's not the kind of thing that you get to luxuriate about when you've hit a certain level of status or wealth. I think it's it's available to every single one of us no matter where we are in our career the the challenge though is that most of us don't know what our Dharma is and even if we do understand to a certain degree, what our Dharma is, what our inner calling is, we don't necessarily feel like we have the time or the space or the money sometimes, or even the courage to pursue it. And I wanted to write this book because I wanted to go directly into those struggles. Not to write a book about what purpose is sitting behind a desk, but how do you take this thing that you feel that you need to express, right, it needs to speak, and how do you once and for all start to bring that into your everyday life?
[00:04:39] LM: I love that I commonly talk with patients about this gap that exists in all of us between our best intentions and the execution of them. Meaning, like, we know we want to eat healthy. We want to exercise. We want to be more purposeful. We want to be more intentional. We want to put our phones down. We want to be happy and pursue things that are joyful, but there's that gap and the river is wide between the intentions and the execution. And you just said it, Suneel, sometimes the gap is filled with financial insecurity. Sometimes it's filled with logistical obstacles. Sometimes it's filled though, with fear and maybe even ambivalence, and then maybe even not knowing what your purpose is. So talk to me about how you might mind the gap. Those are my words, but how you kind of actualize and take control over your sort of sense of purpose and meaning.
[00:05:37] SG: Yeah. So two different things that come together, right? Who I am and what I do, right? And I think the what I do is the execution. Who I am is really sort of getting into like, what it is I care about. Let's start with who I am because I think that's just a natural place where I think a lot of us, I think me, me included would skip over. And the reason I would skip it over is because I would look to what everybody else sort of had, right? I would look to people I saw with nice cars and nice homes and really nice sounding LinkedIn profiles and bios. And I'd say, let me go follow that. And what I found over time is that I was really walking somebody else's path, not my own.
[00:06:12] And I think the work to sort of coming back to yourself and understanding what you want, it doesn't have to be something that you go on a huge meditation retreat. to do, right? I think it comes through starting to ask yourself certain questions. And in the book, I go through a list of sort of questions that really sort of helped me kind of get to this point.
[00:06:31] I call these the chisels. And the reason I call these the chisels is because Michelangelo, when he would look at a block of marble, he would say the sculpture is already inside. All I have to do is chisel away the layers. I don't have to create something from the ground up. And I think dharma, or calling, is very much the same thing.
[00:06:48] I bet that at some point in time, you have experienced your dharma. Like, you have lived up in a certain way. It may have been when you were a child. It may have been last week. It may be something that you're actively doing even at your job right now, but you're just not, you're not in tune with that.
[00:07:03] You're not in touch with that. So what I think of one of the very first things that we can start to do is start to identify the bright spots, whether that be in a past role or in a current role, these moments that really made us come alive. I think the key here that I think that we sometimes miss, I know I did, was that when we think about things like purpose and dharma, we think about a job.
[00:07:23] And so like in the book, for example, I tell the story of a woman named Mila, who really wanted to be a teacher. She was a project manager, but she really wanted to be a teacher, right? And she was frustrated because she couldn't, like, realistically, she had kids, her family relied on her health benefits, like the idea of leaving her job, going back and getting a teaching certificate was just not something that fit her practical life.
[00:07:46] And she was frustrated by that. And I think a lot of people sort of find themselves in a similar position. But when she was able to peel back the layers and understand, well, what is it about teaching that I love, right? When I dig below the occupation and into the essence of teaching, what ultimately arrived for her was that she loved to help people grow.
[00:08:05] And there was this emotional conversation she had with her mom, where her mom's like, Yeah, you've always loved helping people grow. Ever since you were a little kid, you were the kid who helped the kids on the other, on the block, like, learn how to ride bikes. It's the thing that's always been a part of you.
[00:08:19] And once she sort of reconnected with that essence, all of a sudden, all these different ways of expressing that began to open up for her, right? Teaching was obviously one of them, but she could start to coach people at work. She could step into a lateral shift into HR and start growing people inside the company.
[00:08:35] And all these options started to pop up for her. When that happens, Lucy, it's liberating because how many of us right now are like, Oh my God, like if I just took that other fork in the road in my career, then I would have ended in this job that would have been perfect for me right now. And I would be so much happier.
[00:08:52] Well, the reality is that over 90% of us right now are looking for jobs, right? In 2023. Over 90% of us right now are looking for our next job, and what the data almost overwhelmingly shows is that we're going to jump to the next job, and within a few months, we're going to feel exactly the way we feel right now, right?
[00:09:09] So I think with Dharma, with who I am, we're peeling underneath the occupation layer, and we're going into the essence layer. When you tap into that essence, you can start to figure out how to express that, and your world kind of opens up.
[00:09:21] LM: It's amazing the way you describe it. I love the Michelangelo image, right? The block. And he says, I'm just repeating it back to you, but he says the sculpture is already there. It's just that you have to pull back the layers and that's exactly right. I think when people are able to do that, as you've described in your book.
[00:09:40] LM: To me, that's the definition of health. I mean, health also includes having nice cholesterol levels, not having a heart attack, doing your cancer screenings, but health at its core is about awareness of our stories and how they live in our bodies, awareness of medical data, our own data, and the way our data is contextualized in the literature and then accepting the things we can't control, so other people, our genetic predisposition to breast cancer, and then finding agency where we can, because we can't control other people. We can't control certain genetic predispositions. We can't control the fact that we may be financially bound to stick with a job we're not fully actualized in, but people often have more control than they think.
[00:10:28] And I think what you're saying, Suneel, is that part of the control and the agency we have, which is ultimately. To me, a part of definition of health is simply querying our own bodies and minds and asking ourselves, like, what is my passion? What am I here for? How do I feel when I'm doing something that gives me joy? And can I recreate that in other spheres of my life, whether it's at work or parenting and ultimately that feeds back onto our health. I mean…
[00:10:55] SG: It does.
[00:10:56] LM: During the pandemic, for example, I saw people every day who were experiencing physical manifestations of emotional distress. And some of it was burnout from caring, caregiving and parenting and living through a pandemic, just being a human.
[00:11:08] But even now, I mean, people are wired and tired and they don't feel well. And so it's reassuring to me to hear someone like you talk about, to me, what is really the essence of health in your book.
[00:11:24] SG: Dr. Tal Ben-Shahar, who you may have crossed paths with at Harvard, really sort of, I think, Explains this nicely, which is like he has this phrase called the arrival fallacy and the arrival fallacy is basically this idea that like we're going to hit this moment where we've attained enough wealth, enough status in order to feel this lasting sense of joy on the inside.
[00:11:47] And until then, we're willing to suffer. Until then, we're willing to sort of grit it out, grind it out, do whatever we need to do because we believe we're going to hit this moment where it's all going to have been worth it. And at some point in time, I think we all get wiser to this idea right? And I would argue that We're starting to realize that earlier in our lives.
[00:12:05] I think Gen Z is asking difficult questions that older generations sometimes don't like because they're like we didn't ask those questions when we were your age, right? And they're, I think, very understandably saying, yeah, but you don't seem very happy. And we want to do things a little differently than you.
[00:12:20] I mean, the country has gotten richer, we've become more productive, but we're also more lonely than ever before. Mental health issues have never been higher, right? We feel disconnected from one another. That's not necessarily sort of the train that I want to get on. And so to ask the difficult questions right now, and to your point, to be inside out about it, right, to peel back the layers, I think it's a very reasonable thing. And then the question I think becomes, well, then once I start to peel back those layers, how do I actually put it into practice, right? Because there's nothing more frustrating than understanding who you are, but showing up every day and feeling like you're walking in somebody else's path.
[00:12:55] And what I try to do in the book is really get into those struggles again, like we may not feel like we have enough time. We may not feel like we have enough money. We may feel like we know exactly what it is, but we're scared of that. And so I wanted to tell like the everyday stories of people who were able to not necessarily even leave their jobs.
[00:13:14] Like one of my favorite stories in the book is, is about a nurse who really wanted to be a writer. And her parents said, no, you can't be a writer. You're first of all, writing is not a profession. It's going to make money. You're not a, you're not a man, right? Like, and, and like, if you're a son, if you're a son, maybe, but like, as the daughter, no, you're not going to be a writer.
[00:13:31] And so she got pushed into a different field and became an outstanding nurse. But one of the things that she realized is that she was able to bring her persona as a writer into her work of nursing. And one of the ways that she did that, it was through her patient paperwork. So, while most people like, try to get through, and you know this Lucy, try to get through the paperwork as quickly as possible, like put the clinical details in, she started to actually expand on those clinical details into like, who were these people?
[00:13:56] What did they care about? Who do they love? What was their life like at home? What was their experience of being a human like? And she would start to pour her heart as a writer into these clinical patient forms to the point that like literally this paperwork was getting passed around the hospital like novels people loved reading it because it gave them a sense of purpose and what they were doing and so she was able to express this dharma as a writer through her occupation as a nurse and the point of it all is that oftentimes we think that in order to live our purpose we have to blow up our lives. We have to leave our jobs, right?
[00:14:30] We have to move to a different place and become a painter or leave everything we have behind. Not true. And there's so many situations and stories in the book. We talk about sort of how Dharma doesn't have to be a separate path, but it can be a permutation of what you have right now. You don't have to leave everything behind. You can start to bring a new persona into where you are today.
[00:14:49] LM: I love that Suneel, I think you're right that life happens in the mundane in a way, right? It's not in the big sort of huge moments. It's really in the everyday moments that sometimes we don't even know exist. It's just a tuning to the present. How did you get to be so wise? I mean, you're young and you talk a lot about burnout and failure.
[00:15:12] I love that story you told about. You told your wife, I'm a failure and she's like, no, you're not a failure. And you're like, well, the New York Times says I'm a failure. And then you showed her the article about your talk about failure. And so like, what is your story? How did you get to the place where you are now writing and speaking and talking about these very soulful topics?
[00:15:36] SG: Yeah, I mean, I think success is a lousy teacher, there's no doubt about that. It's wonderful, I'm not trying to downplay success, like, I think that I've had some success in my life and has been able to provide the sort of, I think, a life for my family, it's allowed me to sort of take care of my kids, and I'm very thankful for that.
[00:15:54] And yet, if I look back at sort of where the learning really came, where the growth really came, it didn't come from success, it came from setbacks, it came from mistakes. It came from change when I coach sort of organizations and leaders today, and I asked them, what was the most important part of your career, right? Most important year of your career. Very rarely do they say like it was the winning year when I had the most profit or it was when I earned the biggest salary. Most of the time it's like something big happened, it was a big change and usually that change isn't positive. It's like it was something that got knocked back on their ass and they had to sort of learn and that changed everything for them.
[00:16:32] But that was really meaningful. And I think I've had no shortage of I think those moments where I felt like I wanted something really badly and I put myself out there and it didn't happen. I think the learning for me, though, sort of came from sitting down and writing about that. Right? So, I think, if I'm being honest, like, I started writing because I was depressed.
[00:16:55] I was feeling anxious. And I realized that I was dumping a lot of that on my wife. I was spending a lot of time talking to her about that, and I realized, and as, like, loving as, like, Lena is, I realized it was unfair for her. She was always listening, but it was unfair to just, like, almost, like, vomit my trauma on her.
[00:17:13] And so I started to use the page, right? Literally sit down at my desk every morning and I started to write about these things that I felt like I was struggling with and searching for answers to that would do it every morning because the page always listened, no matter what it just listened. And I'd say 99% of what I've written in my life has ended up in like a trash bin, nut there were some pearls there were some little pearls that was able to string together along the way and eventually those pearls started becoming blog posts that became published articles. Eventually they became books and that's just kind of the thing like I think if you look hard enough There are these poor these pearls of wisdom.
[00:17:55] I talk about this a lot in the book is like I think I was following sort of an outlook of resilience before right and now I feel like I'm following an outlook of growth and the difference between the two is that like with resilience, there can be a tendency sometimes to just like want to get back up right like pull yourself up by the bootstrap, let's get back up. But I think growth is getting back up, but also taking some time to understand. What did I learn. If my kid was in a similar situation? Well, how would I sort of help coach them through a situation like this? What would they learn from my mistakes? Taking such a taken like a reflective view on that.
[00:18:35] Even just spending some time moments, right, to write about it, to learn about it, even if it's just for your benefit. Nothing you're gonna publish, but just something that you're gonna reflect on yourself I think can be the difference between cycling through the same mistake over and over again, and I think actually using a setback to create genuine.
[00:18:56] LM: I love that. I have a comment and then a question. The comment is about the writing. Like you, I find writing to be very therapeutic. I find that I can really crystallize a lot of my thoughts. I mean, writing ultimately is about thinking. And when you're putting things on the page, it's clarifying to oneself about how you're thinking.
[00:19:17] It also can disarm some sort of scary thoughts. I have found, like, when I've had depression symptoms or I've been anxious, when I journaled, I was a journaler from a young age. Just intuitively, I knew to write. When you look at the words, A day or two later, you realize that with time and with perspective, they're not so terrifying.
[00:19:37] And so, I too find writing really therapeutic and I recommend it commonly to patients who are experiencing depression or anxiety or trauma as an adjunct to other sort of treatment modalities, but certainly kind of writing down our thoughts can help disarm them.
[00:19:52] SG: Yeah. One of my favorite techniques is to write what I call sort of the if true, then pattern.
[00:19:58] LM: Tell me about that.
[00:19:59] SG: going a little bit deeper into the fear can be a really illuminating thing. So if I'm scared that I'm going to blow a presentation, right, I'll write that down. Like that's the thought inside my head, you're going to blow this presentation.
[00:20:12] And then I kind of talk with the fear. I say, okay, let's pretend that happens. If true, then what? And then it's, you're not going to get the deal or you're not going to get the, you're not going to get the job or whatever it is. Right. And they say, if that's true, then what? Well, then you're, you're not going to have this role that you wanted.
[00:20:27] If that's true, then what? Well, then you're going to blow up your career. And if that's true, then what? And I continue to just sort of go deeper down. And when it starts to make me realize is that underneath this surface level fear, all these sort of deep seated concerns that almost in all probability will not come to happen, but the other thing is that at the very bottom of that list Right when I really dig down to the root of it It always ends with something like well your wife is no longer going to love you, your kids are no longer gonna love you, right?
[00:20:59] And I think to myself Wow, that's the deepest root of my fear and I actually have more control over that right now Then I do whether I get this presentation done like I can go give my kids a hug I can go tell my wife I love her. I can do that right now. What happens inside that presentation, I don't know. But I know the deepest fear, I can deal with right now.
[00:21:21] LM: It's such a powerful point, Suneel, because I think all of us have at our core, the fear of not being loved or being worthy. Like shame and feeling excluded or not loved are like the deepest fears. And I think a lot of those fears come up in our childhood naturally, right? Like I think of life as this set of experiences and we're like a blank canvas when we're born and then you experience loss and challenge and hardship and dings on your self esteem.
[00:21:57] And then we create this sort of network of connections in our minds. In fact, we call it the default mode network. It's a set of neural pathways in the front of our brains that basically are derived from a lot of pattern recognition so that we don't reinvent the wheel every time we come across a new scenario, right? Like, we lose that wonder and curiosity of childhood.
[00:22:20] But we also gain some street smarts, but the downside of that default mode network in the front of our brains is that we can start to make assumptions about things and make connections and thought and behavioral patterns that actually aren't serving us at the time. In other words, you can have an experience as a child where you were terrified and felt vulnerable.
[00:22:41] Maybe you weren't picked for the team or something. And then you wrote a story in your mind about why. And then the next time something happens to you that's like that, even in your adulthood, you might then go back to that sort of I'm not worthy narrative. So, this is a long way of asking you, about your childhood.
[00:22:59] And now we're going to do like go deep here. Like, I love that pinned tweet on your Twitter feed. I guess it's called X now, about your mom. And I'm like, okay, there's a story there. First of all, her story and then your story of her being your mother. Someone says to her, “go back to your country.” And she says, this is my country.
[00:23:17] And then I think the man says, get out of my kitchen. She says, this is my kitchen. And then there she is in all of her glory on time magazine, telling her story. Tell me about like growing up in your family. What was her story? How did that affect your story? And then your telling of it to yourself and then the experience of fear and vulnerability, like you just described,
[00:23:37] SG: So, mom grew up on the border of India and Pakistan, right? When it was all one big country, when it was India. When the country split, during partition, was one of the bloodiest conflicts that humanity has ever known and she was part of that. She was in, she was right in the mix of it and their family fled.
[00:23:56] She ended up in a refugee camp as a kid, very little running water, no electricity, but she decided that she was going to teach herself how to read. And she felt like that was going to be sort of her path out of poverty. And so she did. And she knew she had enough foresight even back then to know that like English was sort of the language that she would have to learn if she wanted to get herself to the United States because that was her dream. And so she started reading and the first book that she read from cover to cover was a story about Ford Motor Company because Ford Motor Company was literally the Google of its day.
[00:24:30] The big, it was the big company. Everybody knew about it, right? If you were rich and you were driving sort of a Ford car, even around sort of certain parts of India and she would see that and that's what she wanted. And she wanted to be an engineer, as well, and she set her heart on that, and it was a very unlikely dream because people from her country, especially women, that period of time were destined for the kitchen, right?
[00:24:53] And I mean, the best case scenario for her as told to her by some of the other people in her village was Find a rich man, find a wealthier man, somebody who isn't in poverty, and that's your path out. She wanted more, like she wanted to express herself. And so she studied hard and people got behind her, her parents got behind her, they saved every rupee that they had.
[00:25:13] She was able to get on a boat to eventually the United States. She got a scholarship to Oklahoma State University. The day after she graduates, she finds herself to Detroit, Michigan. She applies for her dream job. There's a lot there. There's another story there. But she gets it. And in 1967, the reason Time Magazine wrote about her is because she became Ford Motor Company's first female engineer.
[00:25:34] Ford Motor Company had thousands of engineers on staff at that point in time. Not a single one of them was a woman. And so here she is, this woman who tends to dress in saris, and she cooks and eats mainly Indian food back at home, and she is now amongst this, like, sea of mainly white men who are doing this job, and she finds a way to sort of fit in, or I shouldn't even say finds a way to fit in, she finds a way to be herself in a very different environment.
[00:25:58] And, and I think that for me as a kid growing up in almost the opposite situation. I'm an Indian kid now growing up in America. I live in suburban Michigan. Everything is compared to my mom. We lived in a pretty, we lived in a three bedroom house, but like it was a night and day difference from the conditions that she grew up in.
[00:26:17] It was the equivalent of a silver spoon in my mouth and the fact that I could eat every single night. I think that for me, what. I've learned about my mom and what I've learned about, I think other leaders who I spend time studying and I think admiring who have done difficult things is I think that the thing that holds a lot of us back are the words, “I'm not ready.”
[00:26:40] Right? Like, I'm not ready to, to run with that thing. I'm not ready to step into that role. I'm not ready to speak my mind. I'm not ready. And I think the confusion sometimes is in believing that the people who did difficult things, my mom included, is that they were somehow ready to do what they did, but they weren't, right?
[00:27:01] I call this the game of now, in my book, versus the game of someday, right? The game of someday is you wait for courage. You summon up enough courage, and once you actually have enough courage, you take action. And I think that's the way that most of us behave. There is another game, and that's the game of now, which is that instead of waiting for courage in order to take action, you just take action, and you let courage catch up along the way.
[00:27:27] And I think the thing that I've learned is that it almost always does. If you just say like I'm gonna go do that thing courage will come even begrudgingly courage will be like, okay. I'm with you, right? That's the thing I learned about her story is that it wasn't the story of a little girl in a refugee camp who said f*ck it all I'm gonna go do this thing. It was more a story of a scared person who said I want this really badly and I'm scared And I'm going to do it anyway.
[00:27:58] LM: that is a huge lesson. And I wonder how she expressed that. I mean, you told me in so many words, but like. Did she talk about like the lack of courage? Did she talk about her fear and just doing it despite having the courage or did she just model it? Was it the kind of thing you talked about as a kid?
[00:28:17] SG: Not as a kid, no. I think as a kid, I had very surface level conversations with my mom. I marveled at her story, I marveled at who she was, but I didn't really dig into the how. If there's anything that I felt as a kid, I felt like kind of almost insecure because here was a parent and I have a brother who's done amazing things as well and my father's an immigrant too.
[00:28:40] And so I sort of, I felt like I kind of came from this really brave family and I felt insecure because I actually didn't feel all that brave. I just didn't. And, and that made me feel bad because it was just, I felt like, wow, like, gosh, I'm surrounded by all these incredibly courageous people and I'm not one of them.
[00:28:58] But. I began to realize over time, more from the stories that I would dig into, more from hearing about what it was like at Oklahoma State University when she was sitting in her dorm alone, right? What was that sort of like for her because she didn't eat meat and she couldn't go to the cafeteria because she was a vegetarian?
[00:29:17] What was that like for her? And I think when you dig into people's stories and you get beyond this happened and this happened and you just simply start to ask the question of like, what was that like for you? And that's when you start to get insights, but I didn't start asking those questions until I was a teenager or maybe even in college when I would come home and have conversations with her.
[00:29:35] And the thing about it, Lucy is like, I love that question now. Like I host a documentary series where I travel around the world and I meet with all these leaders who've done crazy things. And I almost always dig into less of what they did, but what were they feeling in those moments along the way?
[00:29:54] LM: It's the essence of who people are. Right? Suneel, I can't thank you enough for joining me on the podcast. You are such a bright light and I can't wait to share your book more widely and to reread it. And I just thank you so much for your pearls of wisdom and for acknowledging that you're a work in progress too.
[00:30:13] I think that we're never done. We're never done in the process of self discovery and then bringing our best selves to our relationships, to our work. And so I appreciate the humility that you offer as well. So thank you.
[00:30:26] SG: Thanks, Lucy. It's so good to be here.
[00:30:35] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it, and if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
You can also listen to this episode on Apple Podcasts or Spotify—or wherever you get your podcasts!
Confused about how to handle COVID this fall and winter? Wondering how to think about masks, boosters, and reducing your risk of getting sick?
On this episode of Beyond the Prescription, Dr. McBride talks with Monica Gandhi, MD, MPH, who became one of the most prominent public health experts in the country during the pandemic. Dr. Gandhi is a Harvard-trained physician, expert in infectious diseases, and professor of medicine at the University of California, San Francisco (UCSF). She is the director of the UCSF’s AIDS Research Center and the medical director of the San Francisco General Hospital HIV Clinic.
Dr. Gandhi’s career centers on the principle of harm reduction, born out of her decades-long work in HIV. Harm reduction is the belief that public health policies should consider not only the pathogen (i.e., HIV or COVID) but also people’s basic needs for social connection, intimacy, and agency—and that public health’s job isn’t to shame, stigmatize, or even to eliminate risk (that’s impossible) but rather to arm people with information and tools to mitigate the inevitable risks we face.
Her new book, Endemic: A Post-Pandemic playbook, published in July 2023, aims to reckon with the country's present condition: comprehending and living with a new respiratory disease and how to face the coming variants and next pandemic with reason, science, courage and compassion.
Listen to hear Drs. Gandhi and McBride discuss where we have been, where we find ourselves now, and how we ought to manage the virus this season, and in the coming years.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of our conversation is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go beyond the prescription. Let's talk about Covid. Joining me today is my dear friend, Dr. Monica Gandhi. Monica is a physician and professor of medicine at the University of California, San Francisco. She's the director of the UCSF AIDS Research Center and the medical director of the San Francisco General Hospital HIV clinic.
[00:01:21] She studied at Harvard Medical School and then at UCSF where she focused on infectious diseases, specifically HIV. She holds a master's in public health from UC Berkeley, with a focus on epidemiology and biostats. During the pandemic, Monica became one of the most prominent public health experts in the country.
[00:01:42] National and local political leaders, medical professionals, and the media often turn to Monica for her thoughts and recommendations on how to handle the constantly shifting dynamics and demands of COVID. She has now put her thoughts together in a new book, Endemic: A post pandemic playbook out in July 2023.
[00:02:02] It aims at reckoning with the country's present condition, comprehending and living with a new respiratory disease back in 2020, and how to face the coming variants and the next pandemic with reason, science, courage and compassion. Monica is not only an accomplished physician and public health star, she's also a dear friend.
[00:02:24] I got to know Monica during the pandemic when I started noticing that patients were suffering not only from COVID, but also from the sustained fear, anxiety and social isolation of the pandemic. I was immediately drawn to her straight talking, evidence based and compassionate voice.
[00:02:42] It was a rarity in a sea of COVID experts. She seemed to consider the whole patient, to value the importance of human connection as much as guarding against an infectious disease. So we became fast friends. We've written op eds together. And we started a group text of seven women in medicine and public health who now have communicated multiple times a day for over two years today, Monica and I will discuss where we have been, where we find ourselves now and how we ought to manage this virus this fall and in the coming years, Monica, it is so fun to have you on the show today. Thank you for joining me.
[00:03:21] Dr. Monica Gandhi: Thank you so much. It's so good to see you.
[00:03:23] LM: So tell me about your book, let's start there. What are the lessons learned and then how can we move forward with COVID in our midst in perpetuity and the potential for new viruses coming along? So tell me about the book and what are the major themes in the book?
[00:03:40] MG: Yeah, so thank you. It starts out with an introduction to the concept of why I was so interested in infectious disease and I went into it and that really had to do with my interest in HIV, even from a very young age, my interest in social justice, my interest in disparities, and my interest in the fact that people are stigmatized for infectious diseases, which I always found completely shocking in the world of HIV.
[00:04:04] It's kind of Lehman's language on the whole pandemic and where we are with vaccines and therapeutics. And then it goes into harm reduction. And what that means is really that you have a pathogen. Let's say we had HIV which we did and we still do. And the way that we dealt with HIV, at least those people who are expected dealt with HIV is they dealt with this kind of whole person aspect of care.
[00:04:29] So you have a person living with HIV, but you also have their mental health and their sexual needs and their needs for companionship and their needs to have hope and it to become an HIV doctor became a really, I think, a doctor that sees the whole person and doesn't just see the disease or the pathogen or just the virus.
[00:04:51] And what I saw with COVID 19 is that we used the same bad stigmatizing language that we used with HIV with COVID. There were actually public health people that said, COVID idiot, or you're a bad person for getting COVID, which I still will never understand. And then I thought of harm reduction. What are the ways that we can absolutely fight the pathogen?
[00:05:12] In my mind, it's biomedical advances, but also minimize the harm done to society. And the three I think, or supposed mitigation, because I don't think they helped, that did harm, in my opinion, were prolonged school closures, were closing other medical care, not taking care of other medical needs, especially mental health, and then third is not letting people see their family members in the hospital.
[00:05:36] I think that's actually, frankly, inhuman. So I dwell on those for some time, chapter five is all school closures, then the subsequent chapters on around global equity, because if biomedical advances are your way out of a pandemic, you need to give them to everyone. And then the last chapter is a 10 point pandemic playbook.
[00:05:54] How do we go forward. If this happens again, and I hope it doesn't for 100 years and not get to this point where we are now, where there's about a 30% trust in public health. By the latest poll, a health affairs paper showed that in March of 2023, 30% of people trust the CDC. I mean, there must have been mistakes made for such a low number of trust.
[00:06:14] I don't subscribe to the view that Americans are anti science. I think they saw all the confusion. They saw the harm and they don't trust. And how do we get to a pandemic playbook that makes sense, that takes other people's needs into account, societal needs into account, outside is safer, therapeutics, vaccines. And then we're in the building of trust phase and we can go into that.
[00:06:36] LM: Yeah, harm reduction makes sense on a population level. It also makes sense on an individual person level, just for people who are listening and you don't know what that exactly means. It's rooted in the idea that risk is everywhere, that being a human being involves risk by being in relationships, by driving a car, by existing with bacteria and viruses, merely being a human carries occupational risk.
[00:07:08] And we cannot make risk zero. In the case of HIV, correct me if I'm wrong, the message never should have been abstinence only. Because what abstinence only as a message does... is it deprives people of their basic biological needs to have sex and intimate relationships, and it stigmatizes the person for having human needs.
[00:07:33] So, Harm Reduction's message to HIV patients and populations is, let's not tell you no, let's tell you here are the risks, let's arm you with facts and nuanced information, and give you the tools. Condoms, education, and a way to frame risk so that you can make your own decisions based on your risk tolerance, which you're entitled to.
[00:07:58] You can be very afraid of HIV and never have sex, and that's Up to you, you can be less afraid, but as long as you're aware of the data, you're talking to your partner, then you do you. So I think what I saw in my practice was people suffering from being shamed for going to their child's graduation, even after they'd been vaccinated.
[00:08:24] You remember those pictures of people. On beaches and media pundits were shaming them for being outside when we knew from get go that outdoors was pretty darn safe. And we know that people need to be outside. So somehow we lost the plot and we of course cared about death and dying from COVID, like that is a given, right?
[00:08:47] There's no question that human tragedy. I mean, zero question, but somehow people started moralizing human behavior. And then, if you spoke out, like you and I did, about trying to balance the harms of the virus with the harms of not living a life that is just meeting basic biological needs, somehow if you're talking about that, you're morally reprehensible.
[00:09:15] So, it's a really weird time in our country. I don't need to say that to you, but I just wonder, what do you think is that in inherent tension? Like, where does that come from? That this concept that like doing things, living your life, even if you've been vaccinated is morally reprehensible. I just don't understand.
[00:09:37] MG: Yeah, I didn't understand it until I really went back to the history of HIV, and then I think I made a connection, which is that in the history of HIV, 1981 was when these case reports were first described in the CDC, MMWR, and the President of the United States of, at the time was Ronald Reagan. And because of that, he and his wife also with Just Say No as a campaign for addiction, pushed an abstinence only approach.
[00:10:03] He actually didn't even talk about HIV until 1985. And there was a very like, just say no, there's just something wrong with you if you want these needs. And so the public health community. who tends to be left, as I am, completely pushed against that and said, no, that is a absence based only is an awful approach.
[00:10:22] And it's really unkind and not compassionate. And we can't tell people what to do. And instead we'll give you tools to stay safe. And we'll tell you about condoms and later prep and treatment, but really like it is up to you. You are a human being with your own needs, like you said, in your own risk tolerances and what happened during COVID, as Trump was president, so the public health establishment who's left, and so are ID doctors. They pushed against him no matter what he said, even when it was reasonable, like prolonged school closures weren't happening in Scandinavia and Europe. And he said, let's open schools in summer of 2020. And then people were all writing about opening schools, public health officials, and then they changed their mind when he said that.
[00:11:02] So I think it is actually a push against, it was not reasonable because it was clearly A reactionary pose against the right. And the problem with that reactionary poses at harm children. And it was completely topsy turvy from what we did with HIV. And I think there were two other reasons. One is the media thought that would with a lot of fear, they thought that would kind of scare people into compliance with masks or public health measures. But the problem with that is fear doesn't work. It makes people like paralyzed. I mean, that's what it does in nature. And so it doesn't make you say, oh, I completely understand that even though we have vaccines, they're still telling me to socially distance, even though Europe's gone back to normal with the vaccines.
[00:11:48] Instead of understanding that again, distrust came. And then I think that the third was that we just didn't celebrate the vaccines and no physician is really against vaccines in general. Like it's just a degrading 96% of physicians got vaccinated for COVID with the first two shots. Boosters I think have to be nuanced, but it was a celebration of the vaccine of the HIV therapies in 1990s and with the vaccines. At least the media still made it seem like it was really negative and that didn't unlock the key to normal life, but they didn't do that in Europe. They did. They unlocked the key to normal life. I don't know where anyone thought that normalcy wasn't an important human need, like being connected, being together, joy.
[00:12:37] Being around people, celebrations, church, synagogue, temple, these are part of the rituals of human existence. They're so terribly important for our mental health. So when the vaccines came we could have really celebrated them and instead there's been so much fear still.
[00:12:53] LM: And it's so funny how anti vax, like true anti vax sentiment, people who are saying that the vaccine, you know, alters your DNA and, you know, turns you into an alien, that messaging almost touched the messaging of let's have a vaccine that's life saving in some high risk populations, but it's not enough.
[00:13:15] Let's continue to mask and distance. It almost felt anti vax, as you just said, for me, the moment, I mean, there are many moments during the pandemic when I thought, golly, Baba, we are not messaging this Right, was Provincetown. So Provincetown was that weekend when it was rainy and cold up in Provincetown, Mass. There was a lot of people in intimate settings, post vaccine, and a lot of people got COVID. But no one died. A lot of people got colds, flus. To me, that should have been the CDC's moment to say, “Oh my gosh, this was the stress test for the vaccine. These people have been vaccinated, they got together, they had sex, they had fun.
[00:13:58] And they got colds. And they got flus and that's terrible and we don't want that.” But you know, what are you gonna do? And we should have said, “that's a vaccine success story.” But instead, that's when the CDC said, “nope, put masks back on. And that's when, among other moments where I thought, oh my gosh, we've lost the plot because we're moving the goalpost.”
[00:14:17] It's like kicking a soccer ball down the field and you're, you shoot for the goal and then the goal gets moved. And again, just to be clear to people who are listening, this is not to say, go get COVID, And you know, who cares? Not at all. We can do two things at once. We can be mindful of our risks for a virus and arm people with tools and information.
[00:14:38] We can also be mindful of the risks of living in a state of hypervigilance and fear where we aren't allowed to be ourselves and be in relationships and go to school and see the faces of our teachers. Like, we can do hard things. We can do many things at once. And I think it was this sort of paternalism from public health institutions, it felt very draconian and sort of condescending like that we know better when the vast majority of people who got COVID particularly after the vaccine did extraordinarily well.
[00:15:07] MG: I mean, I think that the interesting thing about what you just said and where I had a little different twist to the conversation was my history in HIV. And so if you look, people were saying a lot of people around that time was saying the same thing, actually, CDC's moment and they blew it, but I could bring in this concept that HIV.
[00:15:28] We never judged people, or what I mean is the people who judge people, we didn't like those people. We didn't like those public health officials who judged. We thought they were really out of line. And we used a harm reduction pro, in this case, sex approach. And so in the case of COVID, what happened with the Delta variant surge in Iceland is the Iceland prime minister came out and said, Look what's happening, everyone.
[00:15:55] You all got vaccinated, the hospitalizations are extremely low. This means the vaccines work. Go back, go forth, be with one another. This is an excellent example of how the vaccines work. And then everyone got vaccinated and the appropriate people got boosted, like older people, and everyone moved on. And they really did move on in Europe.
[00:16:14] So there was this kind of celebration of that moment, and I do write about this in the book. That was, I think, the moment. where the CDC really did lose its trust with the American people and we need to rebuild it, which is a lot of what the latter half of this book is, that the people who are talking right now, like the vaccines and therapeutics don't work are not actually rebuilding trust and certainly not rebuilding trust in technology and advances.
[00:16:42] Like we rebuilt hospitals. Trust in antiretrovirals with HIV to say that life wouldn't change after these advances didn't make sense. This is the other thing that's really important is that beyond bringing the HIV angle to it that I could because I've just thought about it for so long. [00:17:00] It's also important to say that respiratory viruses, cause I live, I'm an infectious disease doctor have always plagued humanity and I worry every winter about respiratory viruses.
[00:17:11] I worry about RSV, and I worry about influenza, and rhinovirus, and other coronaviruses, and adenovirus, and human metapneumovirus. But, actually the difference is, we have better tools for COVID than we do for human metapneumovirus in an older person, for example. I can give Paxilovir to an older person. There are boosters.
[00:17:29] There are no vaccines for human metapneumovirus. There are no treatments for that virus. RSV, we just got a vaccine. So, it means... That we really moved quickly, and we didn't celebrate that, that rapid movement, that incredible biomedical advances. But we did in HIV. We did. We said undetectable equals un-transmittable.
[00:17:49] You don't have to use a condom if you're on antiretroviral therapy. And we were just much more harm reductionist and sitting with the patient, making shared decision making. At least that's what, again, the good HIV doctors were doing. And here it was top down decision making.
[00:18:03] LM: And the MRNA technology that is so incredibly advanced is being deployed now for potential vaccines in HIV.
[00:18:12] MG: it's very exciting. Yes.
[00:18:13] LM: It's very exciting. I mean, I'm with you. Like, you and I got accused, both of us, for spreading hopium. It's so funny
[00:18:22] MG: It's a strange word. Yeah.
[00:18:23] LM: It's such a strange word. Like, you know, but it's sort of the way American medicine addresses patients in general. We think about health as this sort of set of boxes to check. It's about your cholesterol, it's your height, your weight. When hope, joy, and the sense of an end point to a crisis are really important for health. I mean, it's foundational. It's fundamental. The other thing is that hope and caution are not mutually exclusive.
[00:18:50] You can protect yourself like you and I did by getting vaccinated and boosted as needed and staying home when you're sick and celebrate the successes of the vaccine. Celebrate that. Now, as you just said, we have so many more tools to protect ourselves from COVID than we do for, um, metadenoma virus or para influenza virus, which every single year get many of my patients sick and in the hospital, because this is not a new concept that viruses tip people into crisis when they're particularly vulnerable.
[00:19:22] I mean, again, this is not new. We have done this before.
[00:19:26] MG: Well, I mean, I'll give you a good example of what you just said, what it reminded me of. Number one, my husband passed from cancer three months prior to the pandemic, and actually we didn't have hope fundamentally with bad cancer and we had moments of hope, but there wasn't. The thing about infectious disease is it's the other, unlike cancer, which is the self.
[00:19:48] I just wish, I kept in thinking as we were going through the beginning of COVID, I wish that I had someone to turn to during the worst parts of his cancer who would say vaccines work, therapeutics work. And so I wanted to be that person to help tell Americans that advanced therapeutics for an infectious disease, which is other. work. And it's not hopium. It's actually modern medicine technology. And then the second thing is it also could be that if you look at the world right now, I think there's a kind of a microcosm maybe on Twitter, but if you look at the world, I went to a large concert at something called the Chase Auditorium in San Francisco, which is like 20,000 people in an indoor space.
[00:20:30] And it was a large rock concert. And then later I went to Cirque du Soleil and. All these people, because I just was on the news a lot in San Francisco, came up to me at the concert and they said, Hey man, got vaccinated, rock on, you know, like, and they weren't, you know, distancing or masking. They were really living back with that joy that made life so meaningful.
[00:20:51] And I was really happy to see that is. It's kind of the point, right, of combating infectious diseases or combating anything that you're doing in medicine is the point is to infuse as much joy and normalcy into human beings lives as possible. And the other thing, and I really want to mention this, is my father was immunosuppressed during COVID. He was 88 and going through B cell lymphoma treatment. So this is as you know, when we talk about the vulnerable, this is really as vulnerable as we can get because he's not only vulnerable to a virus that is really age stratified in this risk. But he was on chemotherapy. And I kept on writing about how well the vaccines were working in my father.
[00:21:32] Trying to give people the personal anecdote. Because after vaccines and a booster, he had sky high antibodies during chemo. He sailed through his episode of COVID that he got at a family wedding, you know, very well. We did give him Paxilovid and I think that's very appropriate. I couldn't get at why... People didn't think the vaccines worked among the immunocompromised because the mRNA vacs, and I work with an immunocompromised population because I work with HIV, these mRNA [00:22:00] vaccines are so immunogenic. They're much more than like a whole virus vaccine or old protein based vaccine. So I'm really pushing the mRNA vaccines on my immunocompromised populations because they work so well.
[00:22:10] If someone wanted a Novavax, I was not encouraging immunocompromised, but Novavax was great for others. So it was just, again, like knowing that they really work. Even there was this idea that we would leave immunocompromised people out of the loop, but we weren't because we had this new technology that didn't leave them out and I kept on bringing my dad up to try to tell that I'm not just saying that even though I do work with an immunocompromised population.
[00:22:36] This is as bad as it gets and he's done very, he's done very well and he's back to normal life. He's, he went to the Shakespeare Festival in Utah the other day with his 92 year old friends. Yeah, he's 88, he's turning 89 soon.
[00:22:49] LM: It's amazing. I mean, you were always the champion of the T cells being cellular immunity, the arm of the immune system that protects against severe disease. So we learned pretty early on that it was post Delta that the vaccine could no longer block infection. That ship sailed, you could get 4, 5, 10 vaccine doses and still get infected,
[00:23:13] MG: Yes, exactly. T cells and B cells together are literally arming us from future protection from severe diseases. That's why it's so enduring.
[00:23:20:] LM: Right. And somehow that message just didn't get across, like the waning immunity conversation, it's like, I felt like, probably like you, I wanted to poke my eyeballs out because people thought waning immunity meant you were naked, like you're running outside of your house without any protection, when that just was never true.
[00:23:38] MG: These are basic principles of immunology that we learned in medical school. And I wrote a thread on Twitter just two days ago, cause I'd been thinking about it for a long time. How long does immunity last? Cause we've had some very nice new data about antibodies and it looks like it's going to last a long time for years actually.
[00:23:55] And so, and. The reason I thought about T cells so much is it's so hard to have seen an early AIDS and infection that HIV that hurt the very arm of the immune system, T cells that helped you combat infection. So I think about T cells all the time. I say the word T cells to my patients because what's your T cell count?
[00:24:14] But beyond the basic concepts of immunology, we've had a wealth of immunology information during the pandemic from really sophisticated groups in the UK and San Diego. They have done beautiful work that shows T cells cover all variants, and that's really important because I know we think we have to update the vaccine all the time, but they really do cover all variants because it's kind of a blanket of protection, and then B cells adapt their antibodies towards new variants.
[00:24:41] So there is really an adaptive immunity that we've shown both in this pandemic and from basic principles.
[00:24:47] LM: Monica, let's do a rapid fire Q and A. I'm going to ask you the questions that patients ask me every day About COVID and how to face the upcoming fall winter season. So there's a lot of buzz about these new variants, right? The BA
[00:25:03] MG: 286. Yeah. Yeah. I remember it because it's like 86, Ward 86. Yeah. Our
[00:25:09] LM: right. And the fear about this is that it has so many mutations that it may be, it may have escaped immunity from the vaccine. So when someone asks me, what should I do? Should I mask? Should I distance? Should I get another shot in the face of this new variant? What do I tell them?
[00:25:28] MG: So, there's two variants that keep on being talked about in the news, EG5 and BA286. And the one thing I will say is, actually, BA286 is not taking off like EG5 is. So we keep on saying, hey, there's a case in the UK, and there's a case over here. Actually, it seems extremely not very transmissible, and I think it's going to end up being one of those ones that go away.
[00:25:49] Because... If you're more transmissible, then you keep on rising in incidence. And the one that's rising in incidence is EG5. It looks like it's more transmissible than XBB1.5. These new variant directed vaccines that are coming out in mid-September are directed against XBB1.5, and they're going to very happily cover EG5 because there was just a paper on that. That EG5 and XBB 1.5 just differ by one mutation. So that's done with EG5. We'll know it's going to work.
[00:26:18] LM: But, let me ask you this. When you say cover, it doesn't mean you're going to, you can get the new booster and you won't get COVID. Right. So let's clarify that; it doesn’t block infection.
[00:26:27] MG: what's so important going back to BA286, which you were asking about originally, is that there's a concept of sterilizing immunity. What is sterilizing immunity? It's what we saw with smallpox infection or smallpox vaccine. And that was really the ability of Antibodies in the nose, which are called IGA to block all infections and the intramuscular vaccines that we get for COVID-19 do not produce that high of IGA in the nose.
[00:26:55] Guest: They did actually earlier on, or at [00:27:00] least the IGA was adequate to cover alpha. So there was blocking of transmission early on, but when Delta came along, 2 things happened. Number one, our antibodies go down with time and Delta had mutations across its spike protein and the vaccines didn't work as well against Delta, at least in terms of antibodies.
[00:27:16] But this is where our T and B cells are so important because there's never been a variant or a sub variant where the vaccines or your natural immunity don't work against at least in terms of cellular mediated immunity because T cell coverage is very broad so you can have lots and lots of mutations. But it still provides a blanket of protection and that's been shown again and again by Dr Setti's lab and other UCSD and then the second reason is B cells which T cells help produce more antibodies from those B cells are sitting dormant.
[00:27:50] Like you said they're in memory And then if they see another subvariant, even if it is BA286, they say, Oh, I, my job is to make more antibodies. I'm not going to make antibodies directed against some old variant in the past. That's not how these work. They're adaptive. I'm going to make antibodies directed against what I see.
[00:28:05] It will take a couple of days, but they will make, and you'll get infected, but you will be protected against severe disease. So there will be ongoing protection, even with both of these new variants with severe disease. If you've been naturally infected or had he vaccine before, and most people have had both, many people have had both. What about who needs boosters? That's the next question. I
[00:28:29] LM: Yeah. So as for boosters, so people are asking all about these boosters coming out at the end of September, early October, I remind people, cause most of my patients. I've had COVID and have been vaccinated. So they asked me, what's the optimal timing? I'm going to my daughter's wedding in November. What should I do?
[00:28:46] I remind them that again, you can get 10 shots and still get COVID. So they're not, these vaccines are not sterilizing. But if you wanted to try to time the vaccine to get a transient bump in your antibody levels before the wedding, which again, may not. It's like, if you jump into a freezing cold swimming pool and you're wearing a wet suit, aka vaccine, you're still going to get wet.
[00:29:11] MG: but it doesn't harm you with the severe disease. Yeah. Like it doesn't harm you.
[00:29:15] LM: Exactly. It's not, you're not going to have severe disease, but having had COVID and having had the vaccines previously is already going to likely protect you from serious outcomes. But if we're talking about the new booster, you might time it to get two weeks before the anticipated crowd you're going to be in.
[00:29:35] But, I mean, what do you think? Do you believe in like timing the vaccine to an event?
[00:29:37] MG: I don't actually believe them in timing them to an event because like you just said, I don't know if it's going to rise high enough to prevent infection at that event. What I actually really believe in and I wrote about this a lot of times is spacing the vaccines appropriately to get the best immune response.
[00:29:51] So I'll give you a good example that it looks like you should definitely wait at least four and likely six months since your last infection or last booster, whatever, they're the same thing. They're showing you the virus or parts of the virus in the case of to get another shot because you're essentially, you're going to interfere with that B cells trying to settle into memory, and this was data from the NIH.
[00:30:13] So, for example, my father, I would have encouraged him at 88 and going through chemotherapy to get the fall booster. However, he got, just got COVID, and it was in mid-July when he got COVID. So I'm going to ask him to please wait four months, regardless of events. So July, August, September, October, and then get the vaccine then. At least four months, maybe six so that he is doing exactly what vaccines are supposed to do, which is help refresh his immunity.
[00:30:41] Again, his immunity is more needing of refreshment than a young person's because young persons have very good immune responses to vaccines or infection.
[00:30:50] LM: It's a great point. And the other thing to remind people is that, you know, you can go to your daughter's wedding in November as planned. And if there's no one in the room with COVID, you know, it doesn't matter if you had the vaccine or the booster at all. In that moment, you can also be in any room anywhere because COVID is ubiquitous and it's not a wedding, but just because it's a wedding doesn't mean you're more likely to get it.
[00:31:08] That said, the virus tends to spread in closed Poorly ventilated spaces. It's just an odds ratio. It's not like weddings equal COVID and walking to the, the small boutique pharmacy, you're not going to get COVID. The virus isn't that smart. It's just different.
[00:31:24] MG: yeah, I think that's a really, not only is that a really good point, but the inoculum question, which I wrote about really early on. Oh, by the way, I was really mask focused very early on. In fact, when you say that I was on the, on the news, actually the first year and a half, it was all about masks, but I actually was talking about masks and this concept of inoculum.
[00:31:43] And there was just a recent paper that showed this is likely true, but it's amount, it's the amount of virus that you're exposed to. So that's why, yeah, dose. Right. And so, That's why in a closed indoor space, you'd be more likely if someone has COVID. Because the other important thing is not everyone has COVID all the time.
[00:31:59] That was the issue about treating people like they were vectors or something was wrong with them. Or we taught people to be scared of breathing. Actually, that is a thing that my patients said again and again to me. They said, I've been through one pandemic and I was told to stay. These are people living with HIV.
[00:32:15] And they said, I was told the way to stay. Stay away from people now. You're telling me to stay away from people and I can't even breathe like it was so hurtful the messaging a very soundbite messaging wear a mask save lives stay at home save lives Because it was not nuanced and spoke to the fact that It's really more likely when you have COVID that you're spreading disease.
[00:32:37] That was another interesting thing that changed with time is the degree of spread is really most when you're symptomatic and now we have really updated data around that But there was this idea that and I also wrote about that idea at the beginning but I changed my mind with time when I saw the data that you were spreading it when asymptomatic Just like most other infections. The majority of it is spread when you're symptomatic And that's good because that's what updating of data and recommendations means, right?
[00:33:01] LM: We have to have the epistemic humility to acknowledge that when we have new knowledge, we can change recommendations. That's not rooted in politics or ideology or, you know, who we vote for. It's, it's science change. It's iterative.
[00:33:14] MG: There was this idea that Americans needed simple messaging and I thought that was really insulting to the American public because I actually find Americans very pro science and very sophisticated. And I mean, just like everyone else. And so I didn't think they needed simple messaging, boosters for all mass for all. Like I thought they needed, you know, an explanation of the data instead of just say no.
[00:33:35] LM: Yeah. So there is sort of no more hot button. Issue than masking in this country, right? It became this sort of lightning rod and. It was just a fascinating sort of display of vitriol and science entangled with politics when masks are just masks. So when patients ask me now, should I mask in the fall?
[00:34:00] Should I wear a mask in an airplane? Should I mask when I'm outside? I tell people that despite searching for data to show that masks Reduce the risk for transmission. We failed to prove that they are that effective, particularly cloth masks and so even surgical masks. we do think is that a well fitted mask that is worn consistently and that is high grade can protect the wearer and whether or not to wear it is really up to you and your personal risk tolerance. Will I wear a mask when I'm sick with COVID? Well, I'll probably be at home in my room anyway, I wouldn't want to go to work sick or go to a social event sick. So first of all, I think there's no role for band aids because again, masks are for the wearer.
[00:35:00] But I also am trying to manage people's expectations because I think most people want to understand the reasoning. At the same time, there are some people who just want to be told. Mask up.
[00:35:10] MG: Yeah, I mean, so I will say that you're absolutely right, like I really go over the data on masks in this book. So it, because it was such a contentious issue, I really wanted to go over the data and it's kind of a vast section about all the studies, the Cochrane Review and negative studies in children. I mean, meaning negative harms in children, especially those who are learning how to speak.
[00:35:32] And so I really try to. comprehensively review that. And I agree with you that the only conclusion we can make as physicians and those who evaluate data is that if you all the time, we're a very well fit and filtered mask, like N95, KN95, KF94s, that you're going to protect yourself to a certain degree, but not always actually, cause it loosens, you'll take it off to drink something like it's not always, but that is all we can say. In medicine, putting all of this data together and I wrote the chapter actually for our infectious disease Bible on COVID and we really with another infectious disease doctor and we go over the data on masks. And that's what we conclude. You really mass mandates. It's not appropriate to put them back because of the different ways people are mass.
[00:36:16] And also because there is personal determination. If someone chooses to wear a mask or not, for example, my father. Again, I like to bring him up because he's high risk, except that I don't actually think he's that high risk because he's been vaccinated and now he's had COVID, but he doesn't hear very well because he had an accident 10 years ago.
[00:36:33] So masks are really, he doesn't like them because they interfere with his hearing. So it's when we think about people who are living with disability, um, it's a nuanced approach to what they would like to do. It has to be a personal decision, but I also reassure people so much about the vaccines that it's really interesting to see I don't think I have a single patient who's still masking. To my knowledge. They come in and they're like Hey, you convinced me. Like, you know, you got me to even take it sometimes if I didn't want to. And I, now I'm living with this risk like I've lived with other respiratory viruses.
[00:37:05] LM: At the same time, I, you wouldn't either shame anybody for wearing a mask if you want to wear a mask. That is your prerogative.
[00:37:13] MG: We are not very kind. Why don't, why are we so unkind? Like, we never, I don't know, in medicine the nice doctors are the ones who don't tell people how they have to be. I don't know, like, you just give them tools and then you let them...
[00:37:24] LM: Wasn't that the deal in medical school? I was, like, humility, empathy, compassion.
[00:37:30] MG: Not stigmatizing, not blaming, not people calling them idiots. So I can remember we treat lung cancer with compassion. If there's maybe an associate, you know, there is an associate of smoking. I mean, we'd never say, well, they don't deserve care. And in this epidemic, we were so unkind. We said the unvaccinated don't deserve care. Some people said…
[00:37:48] LM: Right. And we called children vectors of disease, grandma killers. I mean, you know, it's just not appropriate. It's not really in keeping with the sort oath of kindness that we take as doctors or
[00:38:00] MG: It really isn't in keeping with the principles of physicians.
[00:38:03] LM: it's also just not accurate. I mean, like, okay, let's talk about long COVID, which is real. I have a patient who has, I'm not satisfied with the diagnosis, by the way, like he carries a diagnosis of long COVID. But I look at the diagnosis of long COVID in this patient as a placeholder for when we actually get the diagnosis. I think COVID tripped a wire such that he has myriad. I mean, he has every organ systems on the fritz.
[00:38:30] He has profound dysautonomia. He has neuropathy. He has new anemia, renal insufficiency. I'm like a dog with a bone with my patients. We're going to figure out what's going on. He's going to have a bone marrow biopsy, a kidney biopsy. But my question is about long COVID. What is it? What is it not? And how did we get to a place where some of my patients and the general public are really afraid of it.
[00:38:57] MG: So I think that three and a half years and almost four years in, unfortunately we've done a disservice in terms of catching too many things into the long COVID diagnosis and not really being clean about our examination of data. So, What it looks like through all that noise and the WHO calls it an infodemic because you can put out papers that aren't very good and that's too much information and then you really look into it and you see that analyses were done improperly or it was observational confounded data or you didn't control for X or was ICD 10 not codes and it wasn't, you know, really understanding if they're inflammatory biomarkers.
[00:39:33] And if you put all the data together, it does look like any severe illness, sepsis. Influenza, COVID causes longer symptoms, but we knew that because as a specialist in infectious disease, I knew that from influenza. And that's why the incidence of this has gone down with the reduction of severe disease.
[00:39:52] So that's one good thing. That's good thing because we have the tools to prevent severe disease. Second is that we don't know all the contributors to. Why when you've had a severe infection that you get lingering symptoms, but in general, it has something to do with inflammation. We knew that for a long time in HIV and the anything that's even remotely promising or being tested as promising has anti-inflammatory properties, meaning like metformin looked promising in an observational study and it has anti-inflammatory. Property. So it's gonna go ahead and there's gonna be a study of randomized metformin, or a paxlovin study, like trying to kill the virus that actually closed early at Stanford. They are gonna study it more, but that would really imply that there was persistent R N A virus in multiple parts of the body.
[00:40:37] And we haven't seen that with other R N A viruses like hepatitis C, which is an RNA virus, does stay. But only with hepatocytes, only with liver cells. So we haven't seen that with other coronaviruses either and we do have six other coronaviruses. So that'll be studied but I'm more interested in the anti-inflammatory and I'm very interested, actually committed to preventing severe disease among, you know, the entire planet.
[00:41:01] And again, we have those tools to do that now with the vaccines and therapeutics. We need therapeutic access globally. We need something besides Paxlovid, which is Shinogi Protease inhibitors being studied. There's a Gilead nucleoside analog that's being studied. We're gonna have two more antivirals if they work.
[00:41:18] Hope they come soon because we need ongoing therapeutics and ongoing booster vaccination for people who are at persistent risk like older people and those on immunosuppressants in perpetuity for COVID because just like influenza, it will never go away.
[00:41:32] LM: Right. And we also need, as you talk about in your book, vaccine equity
[00:41:38] MG: Yes. It was so unfair.
[00:41:40] LM: The travel bans. I mean, as someone said early in the pandemic, that's like create it, trying to create a urine free zone in a swimming pool,
[00:41:47] MG: Oh no. Yuck. Yeah,
[00:41:50] LM: …until we vaccinate the world. First of all, that's just not, that's just not right. But secondly. Helping the collective [00:42:00] with immunity helps
[00:41:59] MG: It does. And that is, there's a long chapter on the book or like extensive on global equity and also how we should have learned more from HIV equity. And again, the same people who were urging HIV equity and of antiretrovirals weren't beating the drum. I thought for COVID vaccine and therapeutic equity, there was a lot of judgment being applied to human beings in this pandemic.
[00:42:19] I hope we get past this polarization, this politicization. I hope we increase trust in public health. We're going to have other problems in life and other pathogens, and we shouldn't be at this point.
[00:42:30] LM: I mean, if I were going to follow any guidance for the next pandemic, it would be your book.
[00:42:36] MG: It is a step by step, so I hope people do. The last chapter is a 10 point step by step.
[00:42:42] LM: It's a brilliant book. You're brilliant, Monica. And you kind of embody the humility and kindness that we hope other physicians and public health leaders adopt.
[00:42:51] MG: Thank you, but that's why I was drawn to you too, because I find you very compassionate, very kind and very loving with your patients. And that is the only duty of a doctor is to be kind, compassionate, meet them where they are and consider the entire patient. When I disappear into a room with a patient, it's just that patient and I, and that's, it is all about that person and it is holistic, every aspect of their life.
[00:43:16] LM: Monica, thank you so much for coming on the podcast and I hope to see you next time you're in
[00:43:21] MG: Thank you so much. I will.
[00:43:24] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
You can also listen to this episode on Apple Podcasts or Spotify!
Manish Agrawal MD and Paul Thambi MD are oncologists who have spent decades caring for patients with cancer. They realized early in their careers that chemotherapy could treat the cancer—but what about the emotional, psychological and spiritual impact of facing mortality?
When they learned about the potential for medications like MDMA and psilocybin to help people gain access to parts of their minds they didn’t know existed—and to address the human experience of suffering—they quit their day jobs as practicing cancer doctors to found Sunstone Therapies, the sole psychedelic-assisted therapy research and treatment center in the Washington, D.C. area.
The data are increasingly clear: these non-addictive substances hold the power to expand consciousness and improve quality of life.
When guided by a trained therapist in the appropriate setting, even one experience with a psychedelic medication can help people unlock closed doors in their minds and to feel safe enough to explore its contents. They can be the catalyst for patients’ ability re-route well-worn pathways of negative and maladaptive thoughts, feelings and behaviors.
It turns out that science and spirituality aren’t mutually exclusive.
On this episode of Beyond the Prescription, Drs. McBride, Agrawal and Thambi discuss the inseparability of physical and mental health; the promise of psychedelic therapy to treat the psychological impact of cancer and other diseases such as PTSD, anxiety, and depression; and their shared excitement about the potential for these drugs to fundamentally expand the standard of care in medicine.
Bios:
Manish Agrawal, MD
Manish brings an extensive background and experience that spans medicine, engineering, philosophy, and ethics to his role as CEO of Sunstone Therapies. Driven by a deep interest in healing, Manish is particularly passionate about whole person healing and the transformative potential of psychedelic therapies. Manish previously held the position of Co-Director of Clinical Research at Maryland Oncology Hematology, where he dedicated 15 years to the care of cancer patients. He completed a fellowship at the National Cancer Institute, National Institutes of Health, and his residency at Georgetown University Medical Center.
Paul Thambi, MD
Paul brings deep experience in oncology care and clinical trial design to his role as Chief Medical Officer at Sunstone. He is a proponent of strong organizational culture and strives to create a compassionate, open and accepting workplace to advance whole person healing in medicine. As a medical oncologist, Paul developed important and meaningful relationships with patients, witnessessing their emotional and physical distress upon diagnosis and throughout treatment, leading him to explore psychedelic therapies to improve the emotional and mental health of patients fighting cancer. Paul completed his oncology fellowship at the National Cancer Institute and, prior to pursuing medicine, he began his professional career in engineering and consulting.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight. We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go Beyond The Brescription.
[00:01:03] Buckle your seatbelt. Today we are going to talk about one of my favorite subjects, the re emerging field of psychedelic medicine. I truly believe it is going to change the landscape of modern mental health care in this country. I cannot wait to introduce you to my guests today, Dr. Manish Agarwal and Dr. Paul Thambi. They are oncologists who have spent decades caring for patients with cancer. They realized early in their careers that chemotherapy could treat the cancer, but what about the whole person? What about the emotional, psychological, and spiritual impact of facing a hard diagnosis and mortality? When they learned about the potential for psychedelic medicines like MDMA and psilocybin to address patients’ whole health, to offer some acceptance and insight and access to the patient's interiority in ways that they had never seen before, Paul and Manish left their day jobs as practicing cancer doctors to found Sunstone Therapies.
[00:02:13] This is where I am now sending some of my patients, not just to face cancer diagnoses, but also for anxiety, depression, and PTSD. Sunstone Therapies is the sole psychedelic assisted therapy research and treatment center in the Washington, D. C. area. The goal of Sunstone is to better treat the emotional and psychological impact of cancer and other disorders. Paul and Manish are contributing to the fundamental expansion of the standard of care in medicine and it is a wonderful thing to be part of and to watch. Paul and Manish, thank you so much for joining me today on the podcast.
[00:02:53] Dr. Paul Thambi: It's a pleasure to be here. Thanks for having us.
[00:02:55] Dr. Manish Agarwal: Yeah, it's great having you. Thank you.
[00:02:57] LM: The two of you together have backgrounds in medicine, engineering, philosophy, data science, and research, yet you landed in the field of psychedelics for a reason. Tell me why that is. What is so exciting about this field to you?
[00:03:15] MA: Paul and I both have been practicing oncologists for almost 20 years, and over time we got really good at taking care of cancer patients, their physical symptoms, but their quality of life was not always directly proportional to how they physically felt. And over time it really starts eating away at you, that you're not able to take care of the emotional health of cancer patients.
[00:03:35] When we saw this emerging field and started looking at the data, We visited and learned about it and then got training and explored to see is this real. And that's what sort of led us down this path is, for me personally I've always been into philosophy, that's why I have my masters in philosophy.
[00:03:54] I've been interested in the human side of medicine not just the science side. Both have fascinated me and this really brought both of them together. The reason that Paul and I both went into medicine is to treat people and to make them feel better. And really, for the cancer patient, for any patient, you have to take care of everything, not just the physical symptoms.
[00:04:14] PT: Everything that Manish said is echoed in my life and how I was drawn to this. And I think there were a few patients that really suffered emotionally that really hit home for me. And I carried that pain from what they went through with me. And when Manish showed me the data on psychedelic assistive therapy, it wasn't really the data, it was really more these YouTube videos where we saw how there were a couple of patients on the NYU trial and the Hopkins trial, and how they were before they went on that treatment and after. And there was a palpable change that you could feel through the video even, and it was just something that I wanted to be able to see if we can bring to our patients.
[00:05:00] LM: Can you give me an example of a patient who has been served by this treatment, maybe a cancer patient? I'd love to hear an anecdote.
[00:05:08] MA: There's a young patient with kids and a serious cancer, and had struggled with depression, didn't know anything about psychedelics, but really applied. And to see the change in his life, he's changed the relationship with his mother, who had a hard time with her son having cancer. And he was able to have a conversation with her afterwards, saying, I want my mom back.
[00:05:29] And then he was bleeding, when he went home for something else, he got a cut. And his young boy sat up and said, “Dad, are you dying?” And he was able to sit and have a conversation with him. He said, I would never be able to do those things before. And he was able to really sense into that. And then the other group that's really, I've sort of been really blown away by is the military that we've been treating recently.
[00:05:51] They have such complex things that they've seen, such complex trauma. And they've tried everything. I mean everything. For a military person to come and seek this care is not easy because the entire institution, it can affect their career if they talk about mental health. So they're desperate and to see the lives that are turned around, I literally wouldn't believe it if I didn't see it.
[00:06:15] And it's been powerful to see them going from, thinking about suicide regularly, to really no meaning, to a sense of despair, to not where everything is great and perfect, but they're having a fundamental change, and they want to live, and they want to reconnect, and they're building their lives back together.
[00:06:33] LM: I mean, that says everything that you need to know about why this is important. Acceptance, hope, peace, which isn't possible every day of the week, nor is it mutually exclusive with ongoing pain, as humans experience a myriad emotions on a day to day basis. But to think that there's something out there that could give people more agency and acceptance is pretty extraordinary given that we've had pretty poor tools to help people with emotional health and mental health. And so I guess my question to you is then, how do you see the psychedelics changing the way we think about mental health?
[00:07:19] PT: One of the things that can help to do is just to shine a light on this is a part of our health that we need to focus on. There is now these tools that are being talked about that can be helpful, perhaps more helpful than the existing tools and that allows people to start talking about their emotional health more to their doctors, to their family.
[00:07:44] And in terms of how these medicines can help, I think it's not just the medicine. I just want to talk a little bit more about that because the medicine does some things and would act on some of the same receptors that SSRIs act, but there's more to it than the medicine. You talked about it being an experience and it is that, and it's not always that it finds stories that are hidden, sometimes those stories are there and people feel them all the time, but they turn away from them. And what you need to do, what we're starting to learn with this is that you need to create an environment, a container as it's called in this space, that feels safe, that allows people to trust and be vulnerable in that space.
[00:08:32] So that when they experience those fears, and some of those stories may be hidden, some of them may be ones that they've lived with their whole lives, but now they can look at those. They can be with that story that they've felt, and face it. Because they feel a sense of trust, and they're with therapists or people who care about them.
[00:08:53] Who created a relationship with them that allow them to go deep into that story and find the pieces of that story that serve them and the, and the pieces of the story that don't and talk about that, integrate that into their lives, integrate that into their conversations with their families. It's that that does the healing more so than the medicine or as much as the medicine.
[00:09:17] LM: It's such an important point because I see patients Who I will kind of raise this idea to—people who have complex PTSD or who are facing terminal diagnosis. And sometimes they'll say to me, well, I tried mushrooms in college and [it] didn't do much then. And I just had a bad experience. I remind them that that set and setting matters so much.
[00:09:40] And I think it's such a good point that it's not just the medicine.It's the ability to feel vulnerable and safe, which is sort of this mystical aspect of the medications and then to face some things that you already did know you had and that weren't hidden. I think that's a great point.
[00:09:57] MA: Yeah, I mean, I think it's actually pretty nuanced in all of that, because one thing I tell people is, I think psychedelics allow you to access psychic material like no other thing that I know of. But they're not a magic bullet. And if MDMA cured PTSD, I tell people that anyone that goes to a rave wouldn't have PTSD anymore.
[00:10:22] But lots of people go to raves and still have PTSD. And so it must be more than the medicine. So it's not to take away from it, because I think you have access, but it is again, the context or, or how it's received. And so, it's like any medicine, the wrong dosage in the wrong context can be harmful or beneficial.
[00:10:37] And what you talked about, I think, is really nuanced, and I think it's important. We actually call it sometimes therapy assisted by psychedelics. Because a relationship allows you to really trust, and to trust yourself, and to go deep. And if you have that sense of trust, you're able to access material that you may not otherwise be able to.
[00:10:56] And a lot of times, sometimes injury or things occurred in a relationship and to have another wiring of your brain in a healthy relationship, to be witnessed when you were in pain or just to be held or to be supported is a different experience now than it might have been the time that it happened. And you're able to almost nurture that younger part of yourself.
[00:11:18] And so that's, it's really, it is quite cutting edge and that's one of the things that fascinated us because it's not… people want medicine therapy. It's like, it's really this combination of the two and, and so you can emphasize one, emphasize the other, but without the two and done in concert and the right setting, it just is not as effective.
[00:11:37] And so, you know, for us the therapists and the medicine are super important, but so is everything else. So the way the room is set up, the furniture, the music. The person that answers the phone, the way you're received, the way the follow up is. Because if you think about it, we all are sort of on alert, and you get a sense in your gut, can I trust this place? Can I trust this institution? Can I trust this store? We have relationships with people and institutions, and you start… some part of your psyche that's assessing for danger knows, how deep can I go? And so, you really have to build a place that tries to reassure even the unconscious part that it's okay to go deep here.
[00:12:18] LM: I think it's such a good point. And because I was going to ask you how much… let's take psilocybin, for example, which is the active ingredient in mushrooms, how much of that feeling of safety and trust is the chemical itself, and how much is the therapist, the experience of, you know, calling the front desk, scheduling, seeing the lighting, seeing the room, because I have patients who are in therapy for 30 years, even, who trust their therapist, who feel safe, they have a comfortable experience, but they aren't actually making the kind of progress that you sometimes see in patients who have three experiences with psychedelics in the right setting.
[00:13:08] MA: I don't think it's medicine that causes the trust. I think it's the environment. I think the medicine brings to the surface the issues that are there, and without the trust, you are not able to process them. And so, yeah, if they have a trusting relationship with their therapist, that's probably a really important piece, but then it's also deeper than that.
[00:13:29] Can the therapist handle whatever material comes up? Are they able to be with that? Do they know how to navigate that? And so, if there's distress or anxiety or fear, what they don't necessarily need is reassurance or minimizing of it, and it's how to navigate those waters that's a different skill set than traditional therapy. I don't think the medicine in itself causes trust, it just amplifies what's there, but in a therapeutic relationship trust can be built, and trust is an intrinsic part of each one of us, but it's to rediscover that.
[00:13:58] LM: Such a great point.
[00:14:00] PT: I echo all of that. I think also, what the medicine does is when you feel that trust, the medicine is a catalyst for you to go into those crevices that you talked about within the story. It may be a story that you know about, but now there's going to be chapters of that story that were hidden to you. And if you feel the trust, it allows you to do that in a way that I think is hard to do on your own. So there is that catalyst that you get from the medicine around that.
[00:14:30] LM: It's so gratifying to hear you talk about these sort of mystical and, and visible elements of the human experience because, again, I think that's what's missing in modern medicine, at least in the United States. We don't think about the 364 days a year you're not sitting with your doctor as health.
[00:14:52] We don't think about the way we feel in our bodies, the way we think, our self perception, the way we approach stress or vulnerabilities as health. When actually there are direct physical impacts of chronic stress on our bodies. There's direct physical impact of what you described as a vigilance.
[00:15:16] In fact, so many patients I see have been diagnosed with anxiety. And we'll use the word anxiety kind of casually, because it's so commonly used, people know the word, but, but actually when you dig deeper with a lot of these patients who have “anxiety” it's not necessarily that they worry excessively, or that they feel even anxious, they don't even often identify with that word, but that's the code in their charts: F41.9, but a more nuanced description of the way they feel, I think, is this vigilance, this sort of emotional, behavioral, and then sometimes medical reaction to feeling threatened that stems from an experience or set of experiences in their childhood. And we talk about adverse childhood experiences having physical and emotional mental health manifestations later in life.
[00:16:06] But I see patients all the time who have been diagnosed with anxiety, but whose symptoms stem directly from some adverse childhood set of experiences or experience. And then they have hypertension, binge eating, cardiovascular disorder, cardiovascular disease, racing thoughts, sort of like a twitchiness physically and emotionally when they are faced with stress. And I think that those are the people, as far as I understand it, who have had PTSD who are being studied first and foremost with psychedelics. Is that right?
[00:16:41] PT: Yeah, that's right. Right now, that's the indication that has shown the most benefit with MDMA.
[00:16:45] MA: Yeah, and to piggyback on, I mean, you've made a couple of points, I guess, and we should probably just touch on them. I think just working backwards… the last point, I think that if people do have these feelings of anxiety or depression, and I think when, um, a disservice we've done is pathologize them, that somehow that's the problem.
[00:17:05] And it actually is a sign of health because they're having a normal reaction to abnormal situations. And so, what trauma can sometimes be is that when you're very young you have a situation that was very difficult. But you responded normally, you would feel anxious or you'd feel depressed or sad. But then you didn't have support in that situation and so it got stuck.
[00:17:27] And then, now you react when things arise, your body, your psyche has a visceral memory of that, of that lack of safety or that issue that occurred. And so, it's not that the person is a problem, it's not a pathology. They had a normal response to an abnormal situation, whether it was an abusive family member or neglect or abandonment, whatever it was.
[00:17:50] It's just that, that situation isn't occurring now. And they need support to be able to work out of that. And what they do, what I've seen sometimes, is that actually becomes their superpower. So they get really sensitive. If you had power issues and somebody that powered over you wasn't, you get really sensitive to that.
[00:18:07] And you know in your body when something might be happening even before your mind does. And so, it's turning that story to say it's not a problem as much as how you can move on with it. And then the only other comment I was going to make is on the first part you were saying around, medicine, not looking at these other aspects of our emotional health and I think it's a historical time, really. I think for much of history, the shamans were the physicians and there was a connection between the mind, body, and spirit. And then to great progress, we developed a great scientific understanding of the body and develop antibiotics and other things that help us live a lot longer.
[00:18:47] And that's helped us, but then because your blood pressure is good and because your coronaries are clean and you don't have cancer, it doesn't mean you're happy. Now I think things are turning again, that the human is not just a biological entity, but it's also a spiritual, emotional, psychological… whatever you want to call it.
[00:19:06] And until you have all of that together. You're just not going to feel fully human. And so before there was this science versus religion or science versus woo woo or whatever it is. But I think more and more you'll see really respected neurobiology labs that are starting to, to talk about that. And you're doing MRIs of monks of brains and you're seeing that meditation causes certain changes.
[00:19:27] And then when we do MRIs of patients on psychedelics, going back to your point on vigilance, there is something called the default mode network. And that part of the brain is always looking for problems. It's the default mode. It's being vigilant. And that's the part that quiets down, other parts of the brain wake up, and they're able to start connecting.
[00:19:49] And so science now is backing up what's happening. And so there's not so much this tension there, and people are wanting to both be physically and emotionally whole.
[00:19:58] LM: It makes so much sense. I've heard Roland Griffiths talk about the experience that long term meditators can have as being the closest to the experience or benefits of psychedelic. Is that something you agree with?
[00:20:18] PT: Yeah, I think that, that makes sense. I mean, I think deep meditation allows you to see or feel things that you're feeling with a little bit of removal from that. And that allows you to have a different perspective. So, there is a correlation that can be made.
[00:20:36] LM: So, when people look at the New York Times and they see an article about psychedelic medicine, I think they automatically, in many cases, go to two thoughts. One, aren't these recreational drugs that are just for people in rock concerts in the 1960s? And two, that doesn't apply to me. This is for people who are really far gone. And so I'd love for you to speak to the sort of stigma around psychedelic medicine, where that comes from.
[00:21:08] PT: Yeah, and Michael Pollan talks a lot about this in, in his book How to Change Your Mind and how there was social and maybe political pressure around creating stigma. So I think that's some of what happened and then also you get into the 1980s where, you know, this is your brain on drugs, those commercials that would come out that really heightened my sensitivity as a child growing up in the 80s around that.
[00:21:34] And I think those are things that are hard to release. And now that we're starting to understand, and this is coming up again, psychedelics, realizing that these have been around for millennia. And they've been used by cultures as rites of passage for ways to solve the problems of a community. And I think now that those stories are coming back up and also the scientific data which provides people with a level of comfort, especially those people that have this fear of addiction and drugs and all of those things that I had when I was a kid, knowing that this is coming up in the medical institution. Along with the stories from the past are allowing for people to see this in a different way and to accept it more… I think one of the reasons that people feel safe doing this is that, especially like in the environments that we have at Sunstone, where it is in a sort of a medical environment, where our office, where we treat people, is on the campus of a hospital, and they can see the hospital out the window.
[00:22:36] And we're clinicians that have treated patients before as doctors, and it's in a research setting. That allows them to overcome that stigma, to feel safe as they embark on this thing they were told never to do in the past.
[00:22:51] LM: And so what do you make of this kind of... Emerging industry where people are taking the medicines off label with various healers and going on retreats in Costa Rica, because I worry, I don't know if you worry that if the set and setting are not appropriate, if the person who is supposed to be the guide isn't trained or perhaps worse, if the recipient of the therapeutic isn't aware of the potential risks and isn't guided in an appropriate way, then, then we might end up losing all the ground and getting these medications approved through the appropriate medical channels. Do you have that concern?
[00:23:32] MA: For sure, to some degree I do. I mean, I think there are probably great practitioners around some of those settings, but there's just no way to filter through that. And what I worry about, and I get more worried about, is the longer we're doing this, because we're treating complex PTSD patients, they're complicated. And things that come up, if you're not trained and equipped to do that well, it actually... it causes more harm. In fact, I was speaking with a senior psychedelic therapist who's worked for MAPS in Colorado, and she does only things legally, but she does a lot of integration work, and it's integration work for people that did psychedelics underground.
[00:24:17] And the biggest thing that she sees... As people got re-traumatized because they would have an experience and it was severe and the therapist wasn't able to be there. So then again, it felt like what I'm feeling is not okay, which is a feeling that they had the first time. And so she's having to rework through that.
[00:24:35] So in that way there's legitimate concern. And the other thing that I worry about is, we've seen this, that you talk to people, they seem fine, or you have one assessment of their mental condition, but it gets more complex and even they're not aware of it fully. And so you have to be really prepared for that.
[00:24:56] And the other point I was going to make is what you said, what you asked initially about the underground. But then you also said, people said, I'm not as sick, or how about that stigma? So I think there's a real stigma around mental health. There's a stigma around psychedelics and there's a stigma around mental health.
[00:25:13] And so this is both. What it still surprises me time and time again is that people just under report their symptoms, but they still seek it out. So there's sort of this dance. They're like kind of… I'm really kind of okay because it's how they dealt with it. It's like we don't have an environment where you're able to be sad or anxious and there's not something wrong with you and so people play it down and… this is totally anecdotal, but I swear it's worse with men. We'll see, they'll come in, and they're like, I'm fine, I'm fine, and then you, well I drink a lot, and then, yeah, I guess I have feelings of sadness, and then you do the scale, and it's like, wow.
[00:25:53] I think it's even harder for men to admit their emotional struggles and that's just a generality, but overall I think there's a collusion of denial around our emotional state and somehow you just have to be, present a certain way, and there's something wrong with you if you're struggling.
[00:26:07] LM: I mean, I have a couple of thoughts about that. One is thank you for saying out loud that men are more walled off than women to a woman. No, I'm kidding. I think you're generalizing, but yes, let's just acknowledge that we are very self aware species, women, that is. Secondly, I think we all have a level of denial.
[00:26:22] I think denial serves us sometimes, right. Denial is a way of partitioning off pain so that we can cope and function. But then when denial takes on a life of its own and the stuff that is in the denial closet is sort of seeping through the edges and like running out of the bottom of the closet and informing our health, that's when denial is no longer serving us. It's when it's actually in the driver's seat. So it strikes me that the experience, in an appropriate setting with a psychedelic, could help people pull that wall down or open that closet and, and take a look inside and maybe rethink how they approach that thing they didn't think they could approach.
[00:27:08] And then secondly, yeah, mental health still has a bad rap when, as you both know, we all have mental health. It's not a feature you can kind of opt out of as like the human without the mental health. And as you said earlier as well, we tend to medicalize and pathologize mental health.
[00:27:30] So in a way that's good because we are acknowledging that these have medical consequences, that an anxiety disorder is a medical condition, as opposed to just a personality flaw, which was what some people think of it as. But we also tend to label and sort and diagnose conditions that are just normal.
[00:27:50] Like, of course, when someone has been raised by an alcoholic parent and they have been conditioned to sort of be a certain way, sort of invisible or good or not a problem, that is going to have an impact on their health such that when they get into a therapist's office or a doctor's office in their forties and their maybe that's not depression.
[00:28:13] Maybe you had a response to an experience and sure the symptoms are that of depression, but it's actually something more complex, more nuanced. And so I'm not really asking you a question. I'm just making an observation that we're up against a lot as we market these medicines and therapeutics to people because of the stigma around mental health because of the stigma around drugs But I think if it's done well—which is why Sunstone and other research institutions exist—if it's done well, and we can actually help people understand that their interior lives their past their stories have relevance to their health. And that yes, having clean coronary arteries and nice blood pressure is great, but it's not sufficient for health, then it really, I do think is going to change the way we think about health.
[00:29:04] It’s already changed it for me. It's just that it's not legal yet in DC. And I haven't tried psychedelic medicine. I want to, it has changed the way I think about emotional health. I mean, I've been thinking about mental health and health in this way, my whole career, but I don't think modern medicine has given doctors really permission to do that.
[00:29:20] And so I wonder what you think is in the pipeline. Are these things going to be FDA approved in the next five years, ten years? Are people going to be able to access these therapeutics? Are there going to be enough guides to appropriately shepherd people through the process? What are we looking at in the next year or five years.
[00:29:41] MA: I just want to comment a little bit on what you said around the denial piece. I think that denial actually is quite healthy. And on where your neurological system was, when you experienced something, it might've been, it probably was overwhelming and the proper and healthy response would have been denial and to put it into a box.
[00:30:00] It's just that now it's not necessary and it's not integrating back into your life. And so I'm very wary of pathologizing any of these things because they're usually healthy. It's just in the context now. And so I just make that one point and the other one around the mental health issue that, it's good that we're talking about it, but I think that we wouldn't want a life without emotions, right?
[00:30:23] If you push down your anxiety and your fear, you also push down your joy and happiness and love, the things that we humans live for. And so they sort of go both hand in hand and you can't have both of those.
[00:30:38] LM: Yeah, sort of like when we talk about alcohol when we're sort of self medicating, right? It blunts distress, but also blunts joy, libido, life. So you can't selectively numb. You also can't selectively be the human without an emotional life because that wouldn't be good. Then we'd all be like chat GPT or AI, right?
[00:31:00] PT: Yeah, yeah, and it just, I'm just going to piggyback on that denial part of things too, because I think one of the things that's important to remember is that people have built up these ways of denial, of sort of pushing things away. Psychedelics, like we mentioned before, can be a catalyst to break through that denial.
[00:31:17] That can be, you can lose your balance when that happens. So I just want to highlight again how important it is to have that integration and that container afterwards because you can't feel that way afterwards. You have to be with people that help you find that centeredness again.
[00:31:35] And in terms of access and what's happening, we talked about how MDMA has been studied in PTSD for some time now. And there are two phase three trials. They're showing significantly positive results. And that might be the first medication that gets approved as a psychedelic for PTSD outside of esketamine, which has been approved for depression. And that might happen in the next year or two and we will hope for that.
[00:32:01] And psilocybin is behind that in terms of how it's being used in various types of depression, and more and more information is coming out around that looks good, and perhaps if it continues to look good, that could be the next medication that gets approved. We'll see. So I think those are the things that are happening in terms of access and how we get this to people if they are approved, if they do show that they are effective, You're right, I don't think our healthcare system is built for this right now and there aren't enough therapists that are trained in this to treat everyone that has PTSD or even a half the people that have PTSD that might qualify for MDMA or for psilocybin in some sort of depression. And that's what we're thinking a lot about.
[00:32:48] We have investigated how to do this in a group setting, with group preparation, taking the medicine as a group, and having integration as a group. We find it is not only a way that introduces efficiencies, but we also see therapeutic healing with that approach, too. To be able to be connected with another group of people that have something similar to what you have or what you're going through, whether that be cancer or PTSD or depression, and to develop this bond during the sessions that you have with each other around preparation and integration, we think that's probably going to be therapeutic, too.
[00:33:29] That model also allows for more people to be trained on this. So, we're trying to think about how to do that from a group setting. We're trying to think about how digital tools can be used to improve or to give us efficiencies in this setting, but also remembering that there's compassion that's needed with this, so not to overuse digital processes. We're thinking about that as well. How do you do scheduling and other things? So, I think there's a number of problems to be solved around access, but they're solvable.
[00:34:00] LM: And so if you're listening to this and you're thinking to yourself, wow, I've been in therapy for 10 years. I'm on Prozac, but I still feel anxious. I'm sure there's some parts of me I haven't really discovered. This sounds really interesting. Or if you're just listening and want to try psychedelics, where would you go?
[00:34:18] Would you have to enroll in a clinical trial? Would you call Sunstone? Would you wait until MDMA is approved? What would you do if you were curious and wanted to participate in the research or the therapeutic elements here?
[00:34:31] MA: I think the first thing you would do is look for a clinical trial. And so, there are many, many places now that are doing research throughout the country and internationally. And certainly at Sunstone, we have five studies open now, and we will have another three more open this year. We have them in depression and anxiety and PTSD and cancer and family members of cancer patients and so there's other places that have that. So I think that's sort of the most rigorous way to get that. And I do think that some medicines, as Paul said, will be approved next year. I think that, I cannot underemphasize the importance of the context and the safety. What you don't want is to do something and get worse and so you want to make sure that you have safety if you're not good on that road.
[00:35:16] And I think we've talked a lot about the upsides of psychedelics and we're talking about that because so much of mental health right now, we don't have great treatments for, but we're still really in early days and we still have a lot to learn. Who's most going to benefit? Which people are completely contraindicated for?
[00:35:36] How do you get people ready? And so I understand the hype because people are desperate. And at the same time, I want to be cautious in that I think we're still learning about how to use these powerful medicines.
[00:35:50] LM: Yeah, I mean, I think one thing I am concerned about in particular, and I know this is out there in the public, is the potential risk for someone, particularly in their 20s who may be predisposed to schizophrenia. Is there a link between the use of psychedelic drugs and either the awakening or the schizophrenia or mental illness?
[00:36:09] Plus, as you've already talked about, this idea of not having the right set and setting not having the appropriately trained guide or the feeling on the patient side of of safety and trust such that people get worse. So what are the absolute contraindications right now in your mind?
[00:36:28] PT: Some of them are around people who have a tendency towards manic episodes. Like bipolar disorder with mania because that has been described where people had manic episodes after having a psychedelic experience, so I think that's one firm contraindication right now, at least in research trials.
[00:36:49] The others are—there are some cardiac effects that people worry about with some of the psychedelic medicines, so if there's a history of abnormal heart rhythms or a potential tendency to have an abnormal heart rhythm, that's another contraindication. Some of them like MDMA have sympathomimetic effects, which means they can cause the heart rate to go up and the blood pressure to go up. So if someone doesn't have controlled high blood pressure, or if they have underlying heart disease, they may need to get evaluated with a stress test and things like that to show that things would be safe if those conditions happen.
[00:37:27] LM: And what about, so many Americans are on SSRIs, so is there a contraindication? For people who are on SSRIs or who are on any other medications at all?
[00:37:38] MA: In terms of the SSRIs, right now we taper people off of them, and it's less about safety as much as efficacy, that we think it might blunt the depth of the response of a psychedelic. Although there are ongoing studies that are bringing some of that into question, and so they probably do work maybe at a higher dose, and so it's not an absolute contraindication, it's certainly not a contraindication for safety, it's just a, you might limit its efficacy.
[00:38:02] LM: Interesting.
[00:38:03] MA: And some of the drugs that can prolong the QTC, there's some concern around that, and so we certainly do EKGs on all the patients.
[00:38:11] LM: What is so great about the way you're describing the research is that you have a healthy level of respect for these medications. You have enthusiasm, but it is tempered with appropriate caution. So thank you guys for joining me. It's been so fun learning about Sunstone. I've been grateful to you guys for taking some of my patients into your clinical trials, and I can't wait to see what's next.
[00:38:37] PT: Thanks for having us, Lucy.
[00:38:39] MA: Yeah, it's just been great getting to know you.
[00:39:03] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
You can also listen to this episode on Apple Podcasts or Spotify!
Kelly Casperson, MD, is a urologist, sexual medicine expert, and best-selling author. She is on a mission to empower women to live their best love lives.
In her wildly popular book, You Are Not Broken, Dr. Casperson breaks down the common narratives that women have been told about their bodies such as “I shouldn't enjoy sex,” “I can't get any better at sex,” and “It is my partner's job to give me pleasure,” in order to help women play, explore, and normalize their sex lives.
Combining the power of mind, body and relationships, she breaks down the societal barriers that keep women from fully embracing their sexuality and intimate experiences.
On this episode of Beyond the Prescription, Dr. McBride and Dr. Casperson discuss desire mismatch, relationship communication, and tools to help put women back in charge of their health and sex life.
It is time to normalize healthy, enjoyable sex worth desiring, and Dr. Casperson is here to help!
Submit your question about sex (or anything else) for this Friday’s Q&A right here!
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. McBride: Hello and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my Dr. Caspersons like I do my patients, pulling the curtain back on what it means to be healthy and redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their stories and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond the Prescription. Today on the podcast I have the honor of speaking with my friend who's also a doctor, a urologist, and a sexpert: Dr. Kelly Casperson. Last year, Kelly published the wildly popular book You Are Not Broken: Stop shoulding all over your sex life. It's a combination of real stories, conversation starters, and journaling prompts about how to have a better sex life. Kelly and I agree that mental health is health, that sexual health is health, and that women and men are unstoppable when we're armed with tools, facts, and the agency to be healthier from the inside out. Kelly, I'm thrilled to have you on the podcast today. Thank you so much for joining me.
[00:01:53] Dr. Casperson: Thanks for having me.
[00:01:54] Dr. McBride: So let's get right after it. You are someone like me who believes that health includes many of the invisible components of our everyday life, including sexual health, mental health, a sense of agency over our everyday thoughts, feelings, and behaviors. You're someone who was trained in urology, which is a surgical field. And when people think about urologists, they typically think about male doctors treating male genitalia.
[00:02:27] Dr. Casperson: That's right.
[00:02:27] Dr. McBride: So, talk to me about what it's like to be a urologist in a male dominated field that people consider as a male dominated field, and then tell me how you came to understand Sexual health as a sort of a moral imperative to dispense more information about.
[00:02:44] Dr. Casperson: Well, currently practicing urologists in America, 9% are female. We’re getting there. We're about 30% of the residency slots. There's only like 200 residency slots a year. So it's not like we're going to change the 9% much quickly. It's been great. I kind of… It was challenging to get into urology.
[00:03:01] I loved that. I loved the instant gratification of urology. And people are still surprised, you know, that there's women in urology and it's like I've been out of residency for 10 years now. So I don't know if that's gonna change in my career at this point. It's not changing fast. But the superpower that being a urologist brings to this whole sex medicine discussion is that I treat men.
[00:03:22] And so I get to see every single day how men are treated, and I see how women are treated, and it just becomes so glaringly obvious that we treat these two people very differently, and I get to have a voice because of that. In contrast to the gynecologists who don't see that we don't downplay men's complaints, and we don't say, well, that's just a quality of life issue, or yeah, you're just getting old.
[00:03:42] We don't treat men the same way we're treating women. And the sex meds and… I met a patient who was crying in my office, and the more I opened my eyes to what was going on, the more I said, I thought, “this is a huge problem, an absolute huge problem,” which I hadn't really seen before because I was not taking care of women's sexual health before I kind of got awakened to it. It's going to be lifelong work because we've got a lot of work to do.
[00:04:11] Dr. McBride: Let's, so let's talk about that for a second. I think what I'm hearing you say is what I experience myself as a doctor and as a person is that we countenance men's sexual dysfunction with ease and there's a whole specialty built around men's sexual health. It's urology. But in reality, urology encompasses everyone's pelvic floor, everyone's sexual health.
[00:04:37] It's just that men tend to go into the surgical field, men tend to treat men, and then the narrative is that it's really for men. So, it sounds like that was your professional path, and then you began noticing, like I do, that, hey, guess what? Women have sexual health as well. Women have pain with intercourse, low libido, pelvic floor dysfunction, vaginal dryness. And like men, women are entitled to pleasure, the absence of pain, and most importantly, in my mind, is access to nuanced information about their own bodies.
[00:05:13] Dr. Casperson: Yeah, we do a very interesting thing… to stereotype what we do, we say all of men's problems are biological and all of women's problems are psychological. And so like, you know, he's got erections issues. That's a blood flow viagra problem. We've totally forgotten it could be anxiety, depression, all that stuff going on.
[00:05:30] And conversely with a woman, we're like, oh, she's just depressed. She’s just too uptight. We're like, no, she can have a hormone problem. Women are allowed to have biological issues also. And we really put them in these little containers and then forget about the humanness of everybody.
[00:05:47] Dr. McBride: Yeah, I think, you know, we can walk and chew gum at the same time. We can have anxiety about performance, and that can be rooted in an experience that was traumatic. It can also just be rooted in low self esteem, or... Body image issues. You can also have low libido from not having enough estrogen because you're going through menopause.
[00:06:08] In other words, human beings are the complex sum of different parts. So to assume that women have sexual dysfunction because it's all “in their heads” and to assume that men have sexual dysfunction because it's all just a blood flow problem is to reduce people to these very simple parts and then assign them by gender. And that is not our job as doctors. It's also just completely inappropriate. It's really depriving people of the deep understanding of how their body and minds work in tandem.
[00:06:40] Dr. Casperson: That's right. Absolutely.
[00:06:42] Dr. McBride: Okay, so you are sitting there with a patient who's crying. Who's and by the way, I tell my patients when they cry in my office, like, you know, they're sort of apologizing or “oh, sorry. I'm just emotional.” And I'm like, oh my gosh. I mean, it’s not that I want you to cry. It’s a sign that we're getting somewhere that we have something to talk about. Let's peel back the curtain on what that is. It doesn't always mean you're depressed, it doesn't mean you're a hot mess. It just means there's something that's going on that we need to connect to your body.
[00:07:10] So what are you finding women come to you to complain about vis a vis sexual health, sexual dysfunction? What are the main issues they present to you with?
[00:07:19] Dr. Casperson: The two main ones in my office would be vaginal dryness/general urinary syndrome/menopause. Right. So low estrogen in the pelvis causing pain with sex, burning, tearing, low lubrication, decreased arousal. It's kind of this umbrella cause. And then the second one is I don't really want to have sex, or a.k.a low libido. Oftentimes, that one's so fascinating, because it's often times not a low libido problem. They don't know what it is. They come in and they say, “I have low desire,” and you talk to them and you're like, that's not what's going on at all. And a lot of times with sex, they think it's about sex, but it's just a couple's communication problem.
[00:07:56] You’re assuming what he's thinking, he's not talking to you about what he's thinking, you think this is a sex problem. You're like, no, no, no, this is just a relationship communication problem. But like sex gets involved and like, it just all goes haywire.
[00:08:09] Dr. McBride: Yeah, I think you're right. I think sex can be the final common pathway for a lot of personal and then relationship challenges. I was talking to one of my patients who is actually a family lawyer, like she helps people get divorced or helps people not get divorced. And she, not surprisingly, said the three things that people commonly fight about or have troubles with in their relationships are kids, money, and sex.
[00:08:33] Those are three very vulnerable touch points in our lives. And so I think you're right, that sex can be kind of a symptom of other issues. But in and of itself, it's important. It's part of how we connect with our partners. It's how we experience pleasure. It's a part of the human experience. So to deny someone a conversation about what it is, whether it's truly like a body parts malfunctioning problem or it's an emotional challenge is really not okay.
[00:09:02] And your book, We Are Not Broken, speaks to this notion. That having trouble with sex, whether it's desire or the parts not working isn't a personal failure or a commentary on your ability to perform as a human. It's—the diagnosis here is human. It's common. I've, I mean, patients come into me all the time, I'd say of all ages, but often in their middle age and they'll sheepishly say to me, “I'm really embarrassed to say this, but I just don't want to have sex. I love my partner, but I'm just not interested.” And they act like they're the only person who's ever thought that before. And I'll say, “Oh my gosh, I could feel in an auditorium full of women who feel the same way.”
[00:09:47] They feel ashamed. They feel guilty. It's not a lack of love for their spouse. Sometimes it is, or their partner. It's simply that they are struggling to connect the body and mind and they need some support and they need to be given permission to have that conversation.
[00:10:04] Dr. Casperson: Yeah. Or they've just been having crappy sex their whole life.
[00:10:06] Dr. McBride: Well, that's also true.
[00:10:08] Dr. Casperson: And I don't want to downplay… there is now an actual medical condition called hypoactive sexual desire disorder because they have to DSM this stuff to get FDA approved for meds, like the entire thing that medicine is, but a lot of this “low libido,” I never believe them anymore because it's there's oftentimes something else and so I'm like, “well, what about sex? Is sex good? Do you like it?” And either the answer is “yes, I love it.” And then I say, “well, you don't have a problem. Stop worrying about low libido. Just go prioritize that amazing sex you're having.”
[00:10:38] It's not normal to have a spontaneous desire in a long term relationship. And number two, if they're like, yeah, I could take it or leave it. I'm like, well, that's how dopamine works. You're never going to desire something you could take or leave, right? Like anchovies on my pizza. I'm whatever, right? Like I don't desire it.
[00:10:54] And then it's just like, go have the sex worth desiring, which is very stuck in depth. That's easier said than done for a lot of people. They've spent how many years having the exact same unsatisfying sex because they're having sex the other person's desiring. And really prioritizing desire equality and pleasure equality within a relationship. It's like, you don't actually have a low libido problem. You have a sexist man problem.
[00:11:18] Dr. McBride: interesting. So to break that down a little bit, and I'm assuming you're talking more about women, are sort of subjugating their needs and not allowing themselves to experience pleasure as much as men are. And therefore they are just having bad sex, which of course they don't desire because why would you desire something that's not that great.
[00:11:38] Dr. Casperson: I'm stereotyping, you know, a heterosexual relationship here. Within any partnered relationship, you're going to have somebody who wants sex more than the other person. That's just, that's desire mismatch, and it's completely normal. And we need to normalize that. Like you, you want to, you know, drink seltzer water way more than I do.
[00:11:54] Why is there so much seltzer water in our house? Between two people, there's always different things going on. So just normalizing desire mismatch, normalizing it. The other thing to normalize is it's not the lower desire person's job to come up to the higher desire person's level. It's to work within the relationship, to be like, what does our relationship need sex wise to keep everybody happy?
[00:12:14] You can fulfill some of your needs outside of my vagina, right? Now, I can say that very easily because I've been talking about sex for years, and you have to be a little more nuanced in a relationship where you've maybe never talked about sex before. Because couples don't talk about sex, and then there's a problem with it.
[00:12:31] Well, I don't have the basics of how to talk about sex when it was good. Now it's broken and I really don't know how to talk about it. So even just communication skills about sex is important. But yeah, I think a lot of women and there's we do not have much research on this…We've got decent studies in like college students, which are not long term committed relationships of “well, that's what he wanted. He wanted to do it. I did it to keep him happy.” Kind of this like mercy sex to control another person's behavior. I don't want him to get grumpy. I don't want him to get mad. And so you're having sex for that reason instead of connection and pleasure. And then you come in thinking you're the problem for having low libido. It's not a low libido problem.
[00:13:13] Dr. McBride: Well, and there's nothing like shame or guilt to crush a libido that's already low, right? If your relationship with your partner is rooted in shoulds, then…
[00:13:24] Dr. Casperson: You need to have sex with me more is the least sexy thing you can say to somebody. The partner is telling the low desire person that they're broken and they need to up their game. Like it's worked zero out of one million times to approach it that way.
[00:13:38] Dr. McBride: Well, it's also, it's probably less than zero of a million times in the sense that the telling someone how to feel and then promoting the sort of shame narrative is like the ultimate libido crusher.
[00:13:50] Dr. Casperson: Yep. I'm inadequate and I'm supposed to love this thing that I don't love more.
[00:13:54] Dr. McBride: So I think you're right, Kelly. I think at the end of the day, it's about communication. It's about shared responsibility for meeting each other's needs. And I think that's hard in the modern era. I mean, who has time to sit down and have a nuanced conversation about sex? But I think we have to.
[00:14:11] Dr. Casperson: Right. And even I, I live, I work in a very traditional medical 15 minute visit, right? And now through my years of work, I have the podcast and the book because I cannot explain this to anybody in a 10 minute visit and undo the years of socialization that women are passive and women's pleasure doesn't matter as much.
[00:14:30] Male orgasm is what we prioritize—penis and vagina sex for heterosexual people. That's the only sex you should be having. All of this stuff. And they come in with low libido, and then somebody's gonna slap them on a drug. And not undo all this biopsychosocial stuff. I saw a woman literally yesterday. She had a painful vulva and vagina from menopause. Painful to the touch, like even her just touching herself hurt. Somebody threw her on testosterone for low desire. And she's like, “well, what do you think about the testosterone?” And I'm like, “I'm a urologist. I love testosterone. I'm very comfortable with testosterone.”
[00:15:06] But putting somebody on testosterone who has a painful vulva, who's never going to want to be touched in the first place, you're completely missing the boat on this. We have to address the pain before we can address the desire. And so it is complex, which is why I love this topic. And I get to keep talking about it for years.
[00:15:22] Dr. McBride: Yeah, I think it's treating people from the inside out, right? It's like not band-aiding them with prescriptions and referrals and drugs before we understand the patient. We are not just a set of organs. We are thinking, feeling people who absorb the public narratives, who have been raised perhaps in our own families to think about pleasure and desire and sex itself in a certain way. I think deconstructing those narratives in our own lives, and then being comfortable talking about those things is key. And I think having people like you, Kelly, out there talking about these things in a very matter of fact way is gradually changing the narrative and hopefully empowering women to ask the right questions and give themselves permission to feel.
[00:16:09] So it's interesting because you and I both know that doctors are hurried, doctors are rushed. No one has time anymore with their doctor, unfortunately. You've got the field of gynecology, which is tasked with doing your pap test, writing your mammogram order, you know, checking your pelvic exam, and how can they possibly fit into a 10 minute or even 5 minute visit a conversation about pleasure, desire, feelings, behaviors, your relationship. It's just a tall order for a single specialty, right?
[00:16:45] Dr. Casperson: they can't. I mean, the other thing that we completely forget in this narrative is that women are 50% of the population, that we've completely ignored in this arena, talking about both menopause and sexual health. 50% of the population, there's not enough gynecologists. Even if they could spend 15 minutes, there's not enough of them.
[00:17:02] This is primary care, internal medicine, psychiatry. We really all have to get on board, because, like, we're not a minority recessive gene problem. This is 50% of the world.
[00:17:16] Dr. McBride: Right? Yeah, so one of the things I try to help patients navigate is the medical system, given that we have needs the medical system cannot meet. Arm people with the questions to bring to their gynecologists. Instead of being a passive recipient of like the pap test and the referral to the mammogram, make sure you're bringing your needs to them and asking for their advice and then making a separate appointment just for a conversation if needed because it's not the doctor's fault necessarily that they don't have time to talk about sexual desire.
[00:17:49] Patients are conditioned not to ask about it. Doctors don't have time. It takes a whole lot more time to counsel someone on the nuances of behavioral health and pelvic floor and the nuances of hormone replacement therapy, which we'll talk about in a minute, than it does to hand someone a referral for a mammogram and say, you look great, see you next year.
[00:18:07] Dr. Casperson: Totally. And that's where good resources like your podcast, my podcast, the book is like what you read it, you can consume it. And then our podcast will give you better resources. So you come in with the current menopause guidelines. You come in saying, “I've already talked to my partner about this.”
[00:18:22] Dr. Casperson: You're telling us what you've already done. You're an engaged person. We actually want to help, right? And so it's like setting that person up to be successful in the doctor's office and to ask why so many, like, you know, the hormone thing. So many women will come to me and they'll be like, well, they took me off my hormones.
[00:18:38] And I'm like, “why?” Why is a very natural question for me, right? And they're like, oh, I don't know. I didn't ask. So it's very okay to just ask why in a non threatening way to your doctor. Like that's my other doctor pro tip and how to talk to…
[00:18:51] Dr. McBride: Ask why.
[00:18:52] Dr. Casperson: Ask why so you understand!
[00:18:53] Dr. McBride: This is your body. This is your life. So let's talk about hormone… it used to be called hormone replacement therapy, HRT, now it's called menopause hormone therapy, MHT. Whatever the acronym, what I want to talk about, the conversation every woman should be entitled to about hormones and using hormone replacement therapy to offset the symptoms of menopause and to prevent the myriad potential downstream effects of the absence of hormones.
[00:19:25] Just to frame the question and to give listeners a little bit of a sense of what I'm talking about, what is menopause? Menopause is defined as the absence of a menstrual period for a full year. The average age in the U.S. of menopause is 51 and a half years. That stretch of time of not having a menstrual cycle can occur in the mid 40s, it can occur in the mid 50s, there's a range.
[00:19:46] And during the lead up to menopause, people can experience a variety of symptoms. As a result of our ovaries no longer making robust amounts of estrogen, progesterone, and some testosterone. That can be hot flashes, night sweats, vaginal dryness, urinary tract infections. Pelvic floor, pain with intercourse, mood instability, rage, although maybe the rage is just that we're pissed off, but yes, rage.
[00:20:15] And then, of course, there are the less immediate and the long term effects of not having estrogen and progesterone in our bodies, which can be downstream osteoporosis, accelerated cognitive decline, cardiovascular disease, risk of heart attack and stroke, and then the accumulated... downsides of having painful sex or having urinary tract infections.
[00:20:41] How many women do I see in their 80s, for example, who end up having recurrent urinary tract infections? They're not even sexually active, necessarily. And that could have been ameliorated with hormone therapy from the get go, when they went through menopause at age 50, for example. So, the question I want to ask you is rooted in the reality that since June 2002, when the Women's Health Initiative study was halted prematurely and the headlines read, “hormone replacement therapy is bad for you.” We really took a hard right turn in the public square on the narratives around hormones. People, patients, doctors included, have been loath to prescribe estrogen and progesterone for menopausal symptoms.
[00:21:30] Because the narrative that came out of that 2002 press release was that we're doing harm to women. And that wasn't the narrative before 2002. In fact, hormone replacement therapy was almost standard of care. So you probably read the same article I did, the Susan Dominus article in the New York Times.
[00:21:51] I cheered. I also was sort of pissed off reading it, thinking where has the New York Times been for 20 years, but we'll take it better late than never. Her article was a very beautiful explanation of why we deprive women of conversations around hormone replacement therapy. It's easier to not talk about hormone replacement therapy because it's a long conversation in the doctor's office.
[00:22:18] There are risks of hormone replacement therapy, potential risks, but there are potential risks of not being on hormone replacement therapy. And you and I both know, and even the expert society for menopause has said that if given within the first 10 years of a woman's last menstrual cycle, hormone replacement therapy in most women does more good than harm.
[00:22:47] In other words, protecting you from long term downsides of not having estrogen, osteoporosis, heart disease, stroke, etc., and treating the menopause related symptoms that you have right now, arguably is better for most women than it is to not be on hormones. Now, of course, there's nuance. If you have a personal history of estrogen sensitive breast cancer, that's going to be a different conversation.
[00:23:15] To deprive women of that conversation and the choice, given that risk is everywhere and there's risks of hormones and there are risks of not being on hormones, that is where we need to start. Empowering women with facts and rooting their decisions. In their risk tolerance, not ours.
[00:23:32] Dr. Casperson: Yeah, I mean, I'm to the point now in my journey of like you want to control women? I got a good idea. Make them afraid. Now you have complete control out of them.
[00:23:41] Dr. McBride: Oh my gosh, Kelly, amen, hallelujah. And I'm not a conspiracy theorist, but sometimes I think I am.
[00:23:46] Dr. Casperson: Well, you start, I mean, you just do this long enough and you're like, I see what's going on because you know what you do when you empower women and you take their fear away, you give them agency and you give them the ability to choose what they want to do with their body—you give them a hell of a lot more power. So, that’s my whole thing now—I'm here to get rid of fear.
[00:24:04] Dr. McBride: It's very simple. If you have fear and shame in the driver's seat…
[00:24:07] Dr. Casperson: Boom. Control.
[00:24:08] Dr. McBride: We are castrated, literally. If you have fearlessness and facts in the driver's seat and a good guide, like a Kelly Casperson or some other doctor who knows the data and is focused on you, not risk aversion for their own protection, liability wise, reputation.
[00:24:29] I don't know what doctors are doing when they're depriving women of the conversation or gatekeeping on hormone replacement therapy. But when you put women in charge of their own health and give them tools and information, watch out world.
[00:24:42] Dr. Casperson: Yeah. Totally. I mean, the other thing, the other piece I think that Western medicine's very bad at is preventative health care.
[00:24:49] Dr. McBride: A hundred percent
[00:24:49] Dr. Casperson: And if we look at menopause hormone therapy as preventative health care because what we're doing is we're preventing heart disease We're preventing dementia. We're preventing osteoporosis. We're preventing genital urinary syndrome of menopause. We're preventing diabetes. And you can't see that—you can't measure that especially on an individual scale. And so you're like well just come in when you've got osteoporosis and diabetes and heart disease. We know how to treat you; we've got tons of meds for those problems. But to change the paradigm and be like, I would like to actually not need to be treated for those things, so I want to choose hormones. Hormones aren't perfect, but they will certainly help prevent to a decent amount.
[00:25:27] Dr. McBride: Right, I mean people get strokes, people get heart attacks, people get dementia for other reasons, age related, genetics, environment. But certainly the data are clear that again starting hormone replacement therapy within the 10 years of the last period tends to decrease those risks. I think what you're touching on, Kelly, is a really important point that Western medicine does a very poor job—arguably abysmal job—at countenancing things we cannot see, we cannot measure.
[00:25:56] So, we can measure cholesterol, we can measure your pap test, we can look at your mammogram result. We can hold it in our hands and look at the number on the computer screen. It is less easy—it takes more time, it takes more conversation and it takes an appreciation of the invisible components of the human condition—to weave in the invisible components of life.
[00:26:20] If you live to your 105 and you have perfect cholesterol and no stroke and you're, that's great. But if you are suffering for 50 years from pelvic pain, the absence of a healthy sex life, depression, anxiety, that's not necessarily a good thing we've done for this person. We can help them live long, but what about living well?
[00:26:43] And by the way, they're not mutually exclusive, right? It's not like I'm saying, oh, let's knock 10 years off your life to give you a good sex life. I'm saying, let's give you both. Let's be greedy. Let's give you quantity of life and quality.
[00:26:53] Dr. Casperson: I think the other thing is menopause is 30 years of your life. Right? Like, maybe you aren't going to decide to go on hormones this year, but go learn some more. You can start them next year, if you want to. Who do you want to be? What do you want your health to be? What do you want to be doing when you're 70?
[00:27:12] And think about your future self, and think about how I can set her up. Because once you're 70, once you're 75, you can't start on hormones. The risk is… because, I mean, you can. Technically, you can. But the risk goes up if you don't start during what they call the healthy cell hypothesis. You’ve got to start on healthy cells, keep them healthy, not start hormones on unhealthy cells. So we're going to think, and I asked these 50 year old women, I'm like, what do you want to be doing when you're 72? What's your plan? And a lot of them see moms with dementia, moms with osteoporosis, they've got stiff joints, they can't get on off the ground with the grandkids.
[00:27:49] And you don't have to be that. You can choose, as best as you can, to set yourself up for great health. But it requires making decisions in your 40s, in your 50s, to eat right, sleep well, exercise, possibly use hormones. We don't think about our future selves, and then, you know, she might be kind of miserable.
[00:28:08] Dr. McBride: It's true. You know, you probably get this question, and I do too, from middle aged women. How can I age gracefully? What can I do to preserve my cognitive, mental, physical health over time? And that's a great question and oftentimes patients have gone on the internet and they've bought some supplements, they've bought some gizmos, they've bought some gadgets.
[00:28:26] They've bought into, unfortunately, the sort of worshiping at the false idols of wellness. Not that I'm anti wellness. Wellness is part of our job, right? It's just that let's be real about what is evidence based and what is woo woo in a nice package. As you can tell, I have an opinion about that.
[00:28:43] Dr. Casperson: A woman sent me on Instagram today, what do you think about this supplement? And I'm like, are you drinking alcohol? Stop. Are you exercising? Start. Are you working on love in your life and keeping your brain expanded? So many people, they get narrow in their brain and their flexibility to think as they get older.
[00:29:03] Dr. McBride: Well, I think that we think that, not that people are not smart, but I think we start to think that agency exists in a pill. That we'll have control if we can just take the right supplement or pay enough money for some guru, right? And it's not that I know everything. I certainly don't. You can ask my children. It's that there is no vitamin, supplement, or pill for quality of life. It's an integrated sum of different components, and that includes agency. And hormone replacement therapy, arguably, is one of the things we can do to help people “age gracefully.” There's a whole industry, as you know, about treating the symptoms of menopause by nibbling around the edges of the symptoms, like giving you a little eye of newt and a tincture of whatever to treat the various symptoms.
[00:29:50] And people will go, women will go to extreme lengths and extreme costs to avoid being on hormones because of the narrative. And so the industry is now promoting, look, you can do non hormonal treatment. And that's fine. I'm not saying, I don't think you are either, that every person should be on hormone therapy.
[00:30:09] Not at all. It's not appropriate for everyone. It's not even necessary for everyone. It's just that we should be honest about the data and not steer people down the path of the sort of pseudoscientific wellness industry at the expense of their actual mental and physical health.
[00:30:24] Dr. Casperson: Our good friend Rachel Rubin is quoted in that New York Times article: “menopause has the worst PR campaign in the history” of health problems which is just brilliant.
[00:30:32] Dr. McBride: What is it about Rachel? She has these sound bites. That was such a freaking brilliant quote. I'm just cheering for her so big, like you are.
[00:30:39] Dr. Casperson: mic drops, but it's true. Like we just, we think it's a hot flash and then we think it's done. I literally saw this woman this week. She's 52. She's having heart palpitations. She's having weight gain. She's having a moodiness. Her hot flashes are so debilitating. She has to pull over her car because it's unsafe to drive during her hot flashes.
[00:30:56] She went to her provider. They're like, we'll run some tests, see what your hormones are. She's 52, hasn't had a period in two years.
[00:31:03] Dr. McBride: smells like a duck, sounds like a duck, looks like a duck.
[00:31:05] Dr. Casperson: To me, I'm like, you're in raging menopause, you need no blood work. Get this woman on some hormones. Like, it's so obvious to the people, because menopause and hormones actually isn't that hard. We just didn't get educated. It's not hard. We just didn't get educated for two decades. We've had two decades of doctors who didn't get taught how to treat menopause because of the Women's Health Initiative.
[00:31:27] Dr. McBride: Right. And so people who are listening are going to think I'm making this up to make a point, but I'm really not. I spoke to a gynecologist this week who is someone I've worked with for decades. And again, like I'm not in the business of like demonizing other doctors. In fact, I am only as strong as my community of doctors I work with, but my patient is experiencing menopausal symptoms that are hard to measure.
[00:31:49] Depression, some heart palpitations, anxiety, sleeplessness, and just feeling like she's a broken person when it's all menopause. So I call the gynecologist because I want to be a team player and ask the gynecologist, what do you think about putting her on fem ring and progesterone? This is a low risk person.
[00:32:08] And she's a year and a half out of her last menstrual cycle, this was her response. She said, “can't you just put her on Prozac for the depression?” And I said, well, I'm not sure she's actually depressed. I think she's just experiencing menopause. And I think that the Prozac would maybe help with mood, but it's not giving her the treatment that is going to actually help, in my opinion.
[00:32:34] She said, “can't you give her gabapentin for night sweats?” I said, absolutely. We can do the workarounds. But what are you worried about, if I may ask, about putting her on true hormone replacement therapy? Basically, the hair of the dog that bit you. And the answer was, “well, the FDA has really only approved hormone replacement therapy for vaginal dryness.”
[00:32:55] I said, “well…”
[00:32:56] Dr. Casperson: Not true.
[00:32:57] Dr. McBride: Look, I believe in our federal government. I'm a registered Democrat, but the FDA does not know my patient. The FDA, as far as I'm concerned, is a gatekeeping apparatus to deprive women of these medications. So, as her doctors, you and me, I feel obligated to offer her something that would actually help with her symptoms instead of nibbling around the edges. What do you think? And she agreed with me. But it took a long conversation. She agreed.
[00:33:24] Dr. Casperson: Well, it's the… hormones are this, it's this myth that they're so dangerous. It's like Zoloft has a black box warning for suicide. Is that the preferred drug? Besides the fact that it isn't treating the root cause, which is low hormones.
[00:33:36] Dr. McBride: Exactly! The level of scrutiny on hormone replacement therapy is beyond any degree of scrutiny I've ever seen for any medication, right? Urgent cares are prescribing Z packs for viral colds. I mean... What are we doing by not giving people a natural hormone if they need it, if they want it, and they know the potential downsides?
[00:33:57] Dr. Casperson: 100%. Like, once you, like, as you see, you see this. It's absolutely insane. If there was a drug that helped men live three years longer on average, every man would be on it. That drug is called menopause hormone therapy. Multiple studies showing decreased immortality, increased longevity, and not only living longer, but living quality of life longer.
[00:34:22] And I'm like, do you, do you think the man would be on that if he had a chance to be on that? Heck yeah. And it's like, there's no other drug. What other drug is going to give you three extra years of life? None of our drugs, to my knowledge, have that kind of longevity data.
[00:34:37] Dr. McBride: That's right.
[00:34:37] Dr. Casperson: Estrogen has that longevity data. We blow it off. We would not blow it off if that was given to men.
[00:34:43] Dr. McBride: So tell me what your advice to people listening to your audience, Kelly, is, when they are experiencing symptoms of menopause, their doctor may not be... interested, have the time or be informed with all the data to have a discussion. What do you tell patients to do? In the power dynamic in a doctor's office, patients assume that their doctor knows everything.
[00:35:06] They're making a good judgment when frankly we are experts and we do know a lot, but it is not our job to tell you what to think, tell you how to feel or to gatekeep on medications. It's really to arm you with the tools you need to manage your everyday health. So what do you tell people? In your audience as a good kind of like three or four rules of thumb to bring to your doctor when you're experiencing menopausal symptoms or want to just have the conversation.
[00:35:35] Dr. Casperson: Yeah, I would bring in the 2022 North American Menopause Guidelines. That's a great document. Doctors are going to respect that document. And it really downplays a lot of fears. It says how safe it is. So come in prepared with something that the doctor, they speak that language,
[00:35:50] Dr. McBride: Great. And I'm going to link to that document in the show notes.
[00:35:53] Dr. Casperson: Yep. And the other pro tip for talking to a doctor about something that they might not be comfortable with is to say, you know what I'd like?
[00:35:58] I would like just to try this for a couple of months and then I'll come back and I'll report back and if it didn't go well, I'll stop. Does that sound okay to you? Most doctors are going to say yes to that. Because now they've got a plan, they know you're not going to follow up, right? I'm like, I just want to try this and see if it works.
[00:36:17] Dr. Casperson: Because I think people get so bent out on hormones, they're like, “should I do hormones? Should I not? Should I? Should I not?” It's like, “just try them. You could stop. This is not an amputation. It’s all okay.” But having that sort of plan with your doctor, I truly believe in a long term doctor patient relationship. They're going to know you. That is the best case scenario. That doesn't always exist in our current culture. And when women don't get what they need, the smart ones are going to go online. And that's where these online clinics for menopause are coming from, because they see we are underserving women.
[00:36:51] Doctors do not have time. This is a nuanced conversation. And I think for better, for better or for worse, but I think for better, you can get your hormones online now, because you don't have to spend two hours on hold trying to make an appointment with somebody you might not even know anyways. The healthcare system is kind of bad.
[00:37:08] We're not set up for this, right? We're not set up for the New York Times changing, like, how many millions of women are like, maybe I can consider hormones now. We're not set up for that. We're already full, right? So, I think that's the role of where these online clinics are going to come from. I think some are doing it well.
[00:37:26] Certainly, I don't think it's as good as an inpatient, in your town doctor patient relationship. But we do not have capacity to start tackling these issues like we should. And so I think that's the new role for the online clinics.
[00:37:39] Dr. McBride: Yeah, I think you're right. I mean, it's sort of like the sort of outcrop of mental health providers who are doing virtual care to kind of meet the demand. I don't think online virtual therapy is ever going to replace in person therapy, but it's better than nothing. And if they're doing good and people have managed expectations about what an online therapist can do, Great. Similarly, a lot of these outposts, these online businesses helping people with menopause and hormone replacement therapy are really doing good work, like MyAlloy, which was founded by a friend of mine, Ann Fullenweider. Their medical advisor has been Sharon Malone, who's a really well respected OBGYN in DC.
[00:38:20] She's a friend of mine as well. And they're doing really good work trying to empower women with facts and information because not every woman, A, has a primary care doctor, B, is comfortable talking about these things with that doctor, and C, has the time and the visit to even discuss these things. So I think it's a net.
[00:38:38] I just think people need to be careful about the snake oil salesmen that are telling you to just take this little eye of newton—whatever the metaphor is—because we run the risk of misinformation running rampant as it already is.
[00:38:52] Dr. Casperson: Well, yeah. And people's dollars are limited and you go online and it's this supplement, that supplement, what's the new trendy thing? And at the end of the day, I want you to save your money. Like, you really don't need a lot of that crap. And hormones are pretty darn cheap. They've been around since the 60s and 70s, right?
[00:39:08] If we came out today with a drug that made you live three years longer, you know how much that would cost? Right, and you can get that in estrogen for pretty darn cheap. So that's…
[00:39:17] Dr. McBride: The other point I'd love to make that people don't always understand is there's a lot of brand sort of marketing lingo around hormones that in my opinion is unnecessary and make people think that there's like a right way or a wrong way to take hormones. The word bioidentical is sort of having a moment and I would just say to people you don't need to buy fancy brand name hormones.
[00:39:41] CVS, Walgreens, not that I'm a big believer in chain pharmacies, but your regular pharmacy has “bioidentical hormones.” In other words, micronized progesterone, which is the safer progesterone and estrogen in the form of a tablet, a patch, a ring is as close as it can get to not being actually your tissue.
[00:40:03] So, I think that people need to be educated on the fact that it doesn't have to be fancy, formal, or brand name, and to be suspicious of anybody who says that they have the best bioidenticals and someone else doesn't, because that is just made up.
[00:40:20] Dr. Casperson: It's made up. Well, I mean bioidentical came because we were so freaking afraid of hormones That it was a way to help people stop being so afraid of hormones. So it was kind of like this lead in to safety But I tell people it's like you know when you like you have a granola bar and it says natural on it and I'm like, you know what the natural means like legally And they're like, no. And I'm like, it means nothing. It doesn't…
[00:40:43] Dr. McBride: It's a marketing word. It's a marketing word. It's a way to deescalate fear and to make people feel like it's their own body. When... if we can just get rid of the charade and just get people what they need, we'd be a lot better off.
[00:40:55] Dr. Casperson: Yeah. And most cheap FDA approved products are “bioidentical.” They're the same.
[00:41:00] Dr. McBride: It is funny. I mean we're all victims of sort of messaging and narratives and we're beneficiaries of it too. But it's just you have to know what the landscape is because otherwise we get tripped up and believe things that are just sort of hoo ha. I'm a victim of that too. And do I buy soap at CVS that says lavender scented calming soap?
[00:41:24] I was laughing at that the other day and I was like, as if this soap is going to calm my noisy brain down. If it did, that'd be awesome, but I'm just going to manage my expectations that this soap is just going to clean my hands.
[00:41:37] Dr. Casperson: Yeah. A hundred percent. The power of the mind, man. I mean, going back to sex, placebo gives you an erection 40% of the time. So, the mind is very powerful.
[00:41:45] Dr. McBride: It's true. So Kelly, as we come to the close of our conversation, I'd love to just thank you for helping change the narrative for arming people with facts and tools and for reaching people where they are, because this is where we need to be in the modern era. We need women to have truth, access to tools and to take shame and fear out of the driver's seat.
[00:42:12] Thank you so much for joining me.
[00:42:13] Dr. Casperson: Thanks for having me.
[00:42:15] Dr. McBride: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
You can also check out this episode on Spotify!
Dr. Mary Claire Haver is a board certified OBGYN and women’s health advocate who has helped thousands of women going through menopause actualize their health and wellness goals. Dr. Haver’s goal is to empower and educate women in their mid-lives, and help women advocate for themselves in the doctor’s office.
On this episode of Beyond the Prescription, Dr. McBride and Dr. Haver break down the myths and facts about menopause and hormone therapy. They discuss the harms of fear-based narratives in medicine and the importance of balancing risk to help women live longer and healthier lives.
So, should you or shouldn’t you take hormone replacement therapy? Dr. McBride wrote a longer piece about this decision-making process here.
The upshot?
* Menopause is defined as having gone a full calendar year without a menstrual period. A woman’s midlife decline in estrogen and progesterone levels can cause short-term symptoms (like hot flashes, vaginal dryness, and insomnia) and can increase the risk for long-term health problems (like cardiovascular disease and osteoporosis).
* In general, menopausal hormone therapy (MHT) is considered safe for most healthy women when it is initiated within 10 years of menopause.
* Estrogen itself does not seem to increase the risk of breast cancer for the vast majority of women.
* Unless she has had a hysterectomy, a woman should take estrogen and progesterone together.
* Micronized (aka “bioidentical”) progesterone does not increase the risk of breast cancer; synthetic progesterone does seem to increase the risk, but only slightly.
* Dr. McBride recommends not panicking about the new Danish study suggesting an increased risk of dementia in women who take MHT. Why? It was an observational study (not a randomized controlled trial or RCT) therefore it cannot prove causation; the study population used oral estrogen and synthetic progesterone which are not the standard of care in the U.S.; myriad RCTs show the opposite finding: that MHT is likely protective against premature cognitive decline, especially when started early.
* Too many women needlessly suffer through menopause because of false narratives about the safety of MHT and because discussions about quality of life often aren’t prioritized.
* Don’t take it from her! Dr. McBride encourages you to share the latest expert statement from the North American Menopause Society with your own doctor to help guide your decision-making process.
* Women are entitled to make their own decision about hormones, armed with the data, and with an understanding of their unique risks and benefits.
Dr. McBride will answer your questions about menopause and HRT on Friday. Submit your question right here!
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond The Prescription. Today on the podcast, I'm talking with the incredible Dr. Mary Claire Haver. She's a board certified OBGYN who has helped thousands of women who are going through perimenopause, menopause, and beyond actualize their health and wellness goals. She realized after decades of practice that she hadn't learned as much as she should have about the science of menopause, aging and inflammation.
[00:01:27] She really took a deep dive into the science and has created an online course called The Galveston Diet with the goal of empowering and educating women in their mid lives. Mary Claire, thank you so much for joining me today on the podcast.
[00:01:41] Dr. Haver: Thanks for having me.
[00:01:42] Dr. McBride: Let's talk about the fact that women have been notoriously excluded from medical studies. Women have also been deprived in many ways of access to nuanced information about their own bodies and health. And so it's interesting right now that menopause is having this moment, right?
[00:02:01] It's like Susan Dominus wrote this beautiful article about how women have been misled, and I think women around the country, around the world were like, “yes. Oh my gosh. Thank you for seeing me and hearing me.” And I think it's a historic moment where women are finally recognizing that they need to be seen and heard, and that their menopausal symptoms are not just in their head and that it's time to get the facts to put ourselves in the driver's seat. So let's just start with that article. So tell me what happened when that article in the New York Times came out, did that change increase the volume of phone calls coming to you? What? What did it mean to you?
[00:02:39] Dr. Haver: I think it just validated and reinforced what I was already doing on social media and that really people were sending me the article by the thousands—I was getting tagged. I was getting, “why aren't you in this article?” I didn't even know it was being written, and I just felt like it was really well done and it really was the tip of the iceberg, but it was the first meaningful publication—in such a respected area—that really was drawing attention to the problem. But women have been screaming about this for years, and I'll tell you, so I finished my OBGYN training in 2002, which was also the year the WHI stopped the study on hormone replacement therapy and basically ended any meaningful research into menopause care for at least 20 years.
[00:03:36] And when I graduated from that training program, I would've sworn on a stack of Bibles based on my board scores and my level of training that I was a world-class menopause doctor. And it wasn't until 20 years of clinical practice that I realized in going through my own menopause journey that I was not a good menopause doctor, that there were serious gaps in my own education and training.
[00:04:03] So when you look at an OBGYN residency, and I know this because I was a former residency program director, and over half of what we do, probably 55 to 60% of what we do is obstetrics. All important stuff. Then everything else gets shoved in the box called gynecology. And in that gynecology box we have pediatric gynecology, we have GYN oncology, we have reproductive endocrinology, which is fertility.
[00:04:29] We have everything, and menopause gets a tiny sliver of that time and education. There are only 20% of residents coming out today who feel that they had any clinical menopause training, meaning went to a clinic where they were specifically addressing a woman in menopause. When multiple surveys have been done, the doctors are realizing this is important, but they didn't get the training.
[00:04:56] Nothing was really focused on that. Not to say that what we learned wasn't important. It's just menopause has never been prioritized.
[00:05:03] Dr. McBride: Why do you think that is?
[00:05:05] Dr. Haver: So I think it's a perfect storm of societal norms of medical education, how women have been treated through the years in medicine. I don't know about you, but we had a saying, if it walks like a duck, it talks like a duck… we love a differential diagnosis.
[00:05:22] We love a standard set of symptoms, and I think one of the problems is that menopause has a very diverse presentation in each woman. Even identical twins can have completely different symptomatology. We're all going through something very similarly endocrinologically as far as our ovaries beginning to lose their eggs, and the decrease of estrogen and leading to the full menopause with no estradiol. But how that presents in our bodies is very different. So unless you've been trained in the nuances of how to pick this up, then you're going to miss it unless she's just waving a flag with hot flashes and no periods. But the symptoms of menopause begin in perimenopause seven to 10 years before.
[00:06:03] So we have this entire generation of women who are suffering and going to their healthcare providers with this kind of laundry list of symptoms. And if the doctor isn't trained to realize that this constellation could all have a common denominator of decreasing estrogen levels, they may get told it's all in their head, or this is a normal part of aging, or there's nothing we can do, white knuckle it, suffer through it, you'll be fine.
[00:06:30] And we're just leaving them without… they're walking out feeling dismissed, feeling like maybe they're crazy and that they are going home to cry over, I can't get any help for this.
[00:06:42] Dr. McBride: I couldn't agree with you more that medical school and residency, while of course I learned a ton, did not do a fantastic job at countenancing suffering that you can't see, that you can't measure in a blood test or a CAT scan, night sweats, hot flashes, vaginal dryness. Pain with intercourse, relationships, struggles because of sexual dysfunction, decreased arousal—what we call low libido.
[00:07:10] Those are things you can't see. Plus, women are used to suffering. We are very comfortable in the space of suffering, right? We deliver babies. We have our nipples cracking and bleeding with these infants hanging off of our chest. And I think it's not hyperbole to say that women are pretty good at suffering.
[00:07:34] And so I think it makes sense that gynecologists who only have so much time in the office to talk to patients. And who only had a certain education and that didn't encompass menopause per se. And when we aren't comfortable talking about things we cannot see and we can't measure, we can't quantify despair, that it gets brushed under the rug.
[00:07:57] It reminds me a lot of, my interest is in the relationship between mental and physical health. The relevance of mental and physical health, how we all have anxieties, we all have fears, we all have moods, we all have relationships, and we didn't talk about that at all in medical school. My psychiatry rotation was about addressing patients who are in institutions and paranoid schizophrenics, which of course is relevant, but it's not speaking to the universality of mental health as a common sort of ground zero for our whole health. So I think what you and I are doing is trying to shine a light on these universal phenomena—grief, loss, anxiety, moods, relationships. And in the case of women, the fact that every single woman, if you live long enough, will go through menopause as defined by…
[00:08:47] Dr. Haver: A hundred percent.
[00:08:48] Dr. McBride: The gradual decrease in the production of estrogen and progesterone, and a little testosterone, and we need to talk about it. We need to be open about it. We need to empower women with the questions to ask their doctors.
[00:09:03] Dr. Haver: I think the other thing to mention here, and it's really getting brought to the forefront with the political discourse going on right now, is that society in general stops valuing a woman somehow after she's done with the ability to reproduce. And we're seeing it, and I think this is manifesting in how we are not focusing on menopause care, why the research dollars are not going to menopause care.
[00:09:30] When you look at women's health spending at the NIH, it's, I think it was several billion, but only 45 million was spent on anything to do with menopause, and that was like 0.3% of the funding in women's health was going to anything to do with menopause when a third of us living, breathing, functioning women are suffering right now due to their menopause journey. We're just not valuing them.
[00:09:58] Dr. McBride: And then we have, of course, the headlines that came out in 2002 when the Women's Health Initiative was stopped early, and the headlines screamed things like, I mean… you put the word breast cancer out there in a headline and the fear of breast cancer. What happened in 2002 is that this enormous study, that was the first study on hormone replacement therapy powered by NIH and Bernadette Healy was the first female head of the NIH was stopped early because there was a signal suggesting that hormone replacement therapy causes breast cancer. Now, when you hear that as a woman and women are—we're smart, we're paying attention, we also are not immune to fear-based messaging. And so talk about what happened and how it has taken us so long to correct the narrative on hormone replacement therapy as a treatment for menopausal symptoms.
[00:10:52] Dr. Haver: So the fanfare with which that announcement was made was pretty much unprecedented in medicine. There was a press conference called in DC and there were reporters everywhere, and one of the—it was only one person in the study who decided to release this information. This was before the study had actually even been published.
[00:11:17] Healthcare providers couldn't even read the article and decide for themselves. So everyone's in their offices, I'm in residency, and we're just doing our normal day-to-day lives. And it was like a shot went off across the world in our world that estrogen causes breast cancer, hormone therapy is going to kill you.
[00:11:36] And that was the take home message. And all of us were reeling. We're reading the headlines. No one can get their hands on the study for another week or two. 80% of prescriptions for hormone replacement therapy stopped immediately based on one announcement. And in the 20 years, that 22 years now that have ensued since that publication, so much of that has been walked back on multiple levels.
[00:12:04] It's been reanalyzed, looked at, retracted. People have apologized who were in the study, and none of that has gotten any of the fanfare. It's been really hard. The best book that came out was Estrogen Matters, the Avrum Blooming book. He really broke that study apart so a layman could read it and understand, and the fallacies of the study and the things that it really represented.
[00:12:28] So the average age in the study was 65 years old. We weren't talking about newly menopausal women in the beginning of their menopause journey and the potential benefits, the estrogen only arm had a 30% decrease risk of developing breast cancer. No one talks about that. And that women who were diagnosed with breast cancer, it was itI believe the risk went from 3.2 to 3.8% if I have the numbers correct, and that represented a 25% increase, but it was still very small. And that the women who were on hormone replacement therapy at the time of their diagnosis had a 20 to 30% higher survival rate, five-year survival rate than the women that weren't.
[00:13:09] So women were not allowed to digest that information and decide for themselves what their tolerance to this risk was, and if they still, for the health benefits, for their quality of life, they were absolutely denied. So in desperation, I think practitioners began giving people antidepressants, which can be helpful, but it's never the gold standard and the gold standard for menopausal symptoms is always going to be estrogen. But doctors just were so terrified. The patients were terrified. They didn't want to get sued.I remember being fearful of being sued for giving hormone replacement therapy.
[00:13:49] And the mantra, like I was taught, kind of was only give it if she's threatening suicide, like if there's no other option, you know, otherwise do anything other than giving her back the hormones she so desperately needs.
[00:14:02] Dr. McBride: Yeah, it's such an example of the paternalism of medicine or maternalism because I think women doctors too were depriving women of these hormones, but it's more this sort of like sense that doctors should be the gatekeepers and we should be the arbiters of the patient's risk tolerance. It reminds me a heck of a whole lot of COVID when instead of giving the public sort of nuanced information about, you know, calibrating your risk mitigation measures to your actual level of risk, given your age and underlying health conditions and number of vaccines.
[00:14:39] Instead just telling people, here's what you do. Regardless, we are going to tell you how much risk to tolerate in medicine, as you well know, first of all, patients don't trust doctors who think they know everything. I mean, I don't, and I certainly don't know everything. And I think we owe patients…We owe women the ability to make their own decisions based on the facts and the information they have, and we need to countenance the invisible suffering, just like we countenance the risk of breast cancer. Certainly there are risks of hormone replacement therapy and there are risks of not being on hormone replacement therapy. And let's talk about both and let's try to thread that needle with the understanding that life is risky.
[00:15:21] There's risk everywhere you go. You could live your life not on hormone replacement therapy cuz of the fear of breast cancer that may be completely founded because of a family history, a genetic predisposition, but then you're going to have to tolerate perhaps an increased risk for cardiovascular disease, an increased risk for premature cognitive decline, an increased risk for osteoporosis, sexual side effects, etc.
[00:15:42] We owe women the discussion, the conversation. But as you know, the conversation takes time. And then it takes more time when you have to undo a fixed narrative that a woman is bringing to the doctor's office saying, “oh wow. I don't want to be on hormones because that causes breast cancer. And that's not because these people are not intelligent, it's because they've been told…”
[00:16:05] Dr. Haver: It's going to ake everybody being on board. It's going to take years, but I am so proud to be on… I can't believe this. I'm just a regular OBGYN. There's nothing special about me and, but I…
[00:16:19] Dr. McBride: Oh, there's so much special about you.
[00:16:20] Dr. Haver: I'm kicking the door down on this I feel like… And it's probably the thing I'm most proud about in medicine, and I've delivered about tens of thousand, over 10,000 babies. I've done thousands of surgeries, all good stuff. But I feel like this is the biggest impact I can make for women's health ever.
[00:16:40] Dr. McBride: I think you're making a big difference. I mean, it's amazing to me how menopause is having this moment right now. My friend Sharon Malone, who's a dear friend and colleague, was just on Oprah talking about menopause. I mean, thank you Oprah, for shining a light. My friend Rachel Rubin, our mutual friend, Kelly Caspersen, I mean, we're talking about sex, we're talking about vaginal lubrication, libido.
[00:17:01] We're talking about taking control of our health kind of for the first time in a long time. I don't know if you think it's related to COVID and to me COVID laid bare our vulnerability to narratives that aren't always rooted in truth. COVID laid bare the vast marketplace of sort of pseudoscience and weird stuff.
[00:17:24] It also laid bare how vulnerable we are as consumers of the healthcare industry. And how we really need to know what questions to ask. And so then I think, that's where I came in. I started writing and podcasting and you started doing your messaging and it's, I think people are really glad to have people they trust without any sort of agenda.
[00:17:42] Dr. Haver: Social media for me opened my eyes to how much misinformation as far as menopause care, how much disinformation and misinformation was out there. And then one of the caveats of this menopause explosion and what the New York Times touched on is the gold rush. And so my… I live in the menopause metaverse, I call it, and my social media feed is just filled with everything menopause.
[00:18:13] The wackadoodle companies that are coming up with miracle cures and vitamins and promising you're getting your unrealistic expectations of what this one little herb or something can do and get your life back and lose weight and get your sex life back and all this stuff. And none of it is founded in any evidence.
[00:18:32] They're marketing to a very vulnerable population. They're desperate and willing to try anything at this point because they can't get it from, most of them can't get it from their healthcare provider, and so a lot of these new companies are popping up and really exploiting this very vulnerable population, and it makes me insane.
[00:18:50] Dr. McBride: I know. I feel like wellness is a word that I think MDs and medical professionals should embrace, right? Like, what else am I doing other than helping people be well? But the wellness industry is taking advantage of women's vulnerabilities, insecurities and lack of access to the truth. And then it's fleeing them and giving them false promises. Not always. I mean, there's some good actors.
[00:19:16] And I believe in vitamin supplementation if you're deficient in something in addition to getting your nutrients through food. But I think we agree that there's no sort of supplement that's going to kind of fix your broken marriage and your low libido that stems from sexual trauma or… we have to do the work, we have to do the hard job of looking at these parts of our lives that doctors unfortunately haven't really countenanced and we have to understand that the treatment for menopausal symptoms and the way to prevent the downstream cardiovascular, cognitive, and bone related health problems that stem from the absence of hormones is hormone replacement therapy.
[00:19:56] Women are entitled to a conversation with their provider about hormone replacement therapy. Whether or not they take it is a different story, but in general, the benefits of hormone replacement therapy outweigh the risks in women who are within that 10 year window from their last menstrual cycle
[00:20:11] Dr. Haver: Right. And when a patient leaves my clinic, now again, I have a background in nutrition. I'm certified in culinary medicine. I can do this with confidence in myself that I know what I'm doing. I give them what I call the menopause toolkit, and so the first thing we address is nutrition. I'm lucky enough that I have a body scanner where I can measure muscle mass.
[00:20:34] All of this is all so intertwined, visceral fat, body fat. So I give them very direct nutritional recommendations based on their body composition. We talk about hormones—pharmacology, hormonal pharmacology, and non-hormonal pharmacology based on their symptoms. We talk about supplementation based on what their nutrition profile looks at.
[00:20:56] We talk about stress reduction, we talk about sleep quality, and every single one of those things is important to turn that wheel so that you can have the best healthspan and lifespan when a patient comes to my clinic. Yes, she's suffering, but her goal is not to have a bikini. Most of them… they don't care about bikinis anymore.
[00:21:14] Sure, that'd be great. But they're more looking at their parents and what themselves and their siblings are going through taking care of parents with chronic disease. When I have a patient who is caring six or 10 years for a debilitated parent or grandparent, it shapes their lives and they are so motivated. What can I do now to keep me from doing this to my children, to my loved ones, to my nieces and nephews. I want to live the most independent, healthiest life that I can. So I'm not gonna burden the people I brought into this world with my disease and illness. Now, there's no guarantees on that. They're like, “how can I stack those cards in my favor?”
[00:21:55] And I said, okay, let's get started. Nutrition, exercise, pharmacology, sleep, stress. It all works together to get you where you wanna be.
[00:22:04] Dr. McBride: You're absolutely right and it so dovetails with the way I talk to my own patients and the way I write that sleep is arguably the best chemical boost you can give yourself—getting good sleep. Now, it's easier said than done. I mean, just telling someone to sleep more is not the end of the story for most people. But managing stress, having brain space to be mindful about our eating, our relationships, being in touch with how we feel, sort of being in the driver's seat, if you can, of your everyday habits. I think all of that relates to symptoms of menopause. It also relates to just our everyday health.
[00:22:44] I think you're right. You look at our parents, our patients in their middle age often look at their parents and they see if their mom has osteoporosis and maybe some cognitive decline. Their dad may have cardiovascular disease or vice versa. And those are not a hundred percent preventable of course, but it's pretty incredible what hormone replacement therapy will and can do if you pair it with appropriate lifestyle modifications and you pair it with someone who's a good coach and a good guide because it's not enough for me to say, eat less red meat, Exercise more, sleep eight hours, manage your stress, take hormones, Good luck. I mean, first of all, I don't do all that stuff well all the time myself. Most humans need a trusted guide. They need structure, they need support, they need follow up, and they need cheerleading, and they need data and evidence and facts to guide their behavioral changes.
[00:23:36] How does your program work? Like tell me, if you have a new patient who comes in, you do an assessment, let's say you recommend hormone replacement therapy. How does that look? I mean, do you typically recommend the patch? Do you recommend the ring? Do you recommend oral hormones? Tell me about the menu of options for hormones.
[00:23:54] Dr. Haver: So I do stick to the FDA approved options. Estradiol is the number one hormone that I prescribe. So there are synthetic estrogens on the market. There's the conjugated, equine estrogens on the market. There are also different compounded options because compounding is not subject to regulation. It's not subject to testing. It can be very variable. I really want to stick to—I know when I pull it off the shelf, it's what I use for myself. There's a 98% chance of what they say is in that box, is in it, and that my patient's going to get a steady state. I usually go with a transdermal option over oral for estradiol because the first pass effect of the liver, which you and I know, when that estrogen bump hits the liver, it upregulates our clotting factors. So there's about a seven out of 10,000 women increase. So not very much, but still seven women who will have a blood clot. I can negate that and put you back to your baseline.
[00:24:55] Not saying you will never have a clot, but I won't increase that risk with a transdermal option. And because of cost, affordability, and options, I usually do an estradiol patch. If we decide on progesterone as well, There's some wonderful new data that's come out looking at different progesterones, synthetic versus progesterone, which is what our ovaries make… I hate the term bioidentical because it's become a marketing term, not a medical term…
[00:25:19] Dr. McBride: Thank you. Oh my gosh. Thank you.
[00:25:21] Dr. Haver: Women are getting sold a bill of goods and they're being told lies and they're being told the most ridiculous marketing that, oh, buy BHRT… I'm like, I don't use that term. I talk about estradiol and I talk about progesterone. I do not pick up a phone and call another physician and talk about bioidentical. That is, I would be laughed out of… I think people meant well with it, but it's turned into this crazy marketing term to get you to buy their product. So for progesterone I do the oral micronized progesterone. It has the best safety profile for breast cancer.
[00:25:57] Actually, in the latest studies, no increased risk of breast cancer. It was the synthetics. So I tend to avoid those as much as possible. So for myself, I use an estradiol patch and I take my oral progesterone at night. I still have my uterus. For me, I find progesterone sedating, which is a benefit because it helps me with sleep.
[00:26:17] Now, if someone is also having severe vaginal atrophy, I look at vaginal preparations. I love a vaginal ring. Nobody can afford it. It is top tier for most insurance plans. It's a wonderful method of delivery. I think it's amazing, but again, cost is a problem. So for vaginal estrogen, I tend to stick with the vaginal estrogen cream, which is generic and is very affordable for most patients if we decide she needs testosterone.
[00:26:47] And I pretty much only prescribe that in a case of hypoactive sexual desire disorder. There's not enough evidence yet for me to prescribe it for other reasons I don't. Everyone's testosterone is low, guys, everyone, you don't even need it checked if you're menopausal, half of your testosterone unless you have a tumor.
[00:27:06] And so if she's suffering from HSDD, then we discuss different options, the vii, the adi, the testosterone, if she chooses testosterone, because I don't have a great FDA-approved option. And it's very difficult for my patients to get the man's version because they only need 1/10 of the dose and they have to break the packets open and it's just Complicated. I will do the local compounding pharmacy to get some testosterone for them.
[00:27:30] Dr. McBride: So helpful. So I wanna ask you a couple questions and just to clarify for listeners, vaginal estrogen, in my humble opinion, I wonder if you agree topical estrogen or just vaginal estrogen in a tablet form that is not systemically absorbed, is just topical to help with vaginal dryness. It also can help with urinary continence. It can help with muscle tone in the pelvic floor if paired with PT or just Kegels. That should be in my opinion, over the counter. That should be non-prescription. It should be something women are…
[00:28:01] Dr. Haver: Yes, and I believe it is in the UK now.
[00:28:04] Dr. McBride: And even for women who have had breast cancer, it's, and look, talk to your primary care provider, your OBGYN. Don't take my advice on the internet, because I'm not your doctor necessarily, but I think it should be over the counter when you talk about vaginal estrogen, like a femme ring. The femme ring is the vaginal estrogen formulation. That is systemic hormone replacement therapy. The hormone replacement therapy we're talking about is to help with not only the symptoms locally, but also the sort of whole person, the bone density, the cardiovascular risk protection.
[00:28:38] So yeah, you're right. The femme ring is extremely expensive, but if someone's insurance happens to cover it, the femme ring, there's a nice way to go with the estrogen, and then you have to do the progesterone. In addition, if you have a uterus, you have to take progesterone with estrogen. Those are the two train tracks, because without progesterone, estrogen alone can stimulate the uterus and cause uterine cancer.
[00:29:01] So that's sort of the mantra. Testosterone, as you said, is sort of out of the box a little bit, but it is becoming clear that it's good for hypoactive sexual desire disorder. I do have patients asking me about it because they're like, “What about belly fat, muscle mass? Can I use testosterone for that?” I know you have this wonderful program you're doing on Instagram with the belly fat challenge, and you're doing this on the heels of your Galveston diet. So tell me about testosterone for women a little bit more if you could vis-a-vis metabolism muscle mass.
[00:29:31] Dr. Haver: So one of the phenomena that we know about in body composition changes through the menopause transition, we see an acceleration of body fat deposition. So it's kind of steady state and then whoop goes up in perimenopause and we see an increasing of the rate of muscle loss with age. It's called sarcopenia, which is the natural loss of muscle mass with age, and you have to combat that with consistent resistance training and adequate protein intake.
[00:29:57] There's no way around it. You are going to lose muscle if you don't do the thing. And that's just your body breaking down. And that muscle is so much more important than I ever learned in school. It is controlling our insulin resistance. It is controlling our strength and functionality. And so I am one of those girls who was genetically low muscle.
[00:30:16] I was always lean. But lean to me means muscle. I didn't have very much growing up. I could never do a pull up. I still can't do one. And so there's some thinking, so I'm using testosterone for myself off label, and I'm very clear about that because I'm genetically predisposed to low muscle mass. I measure it every day. I'm about the 90th percentile and I wanna hang on to that. So I'm doing a very low dose of transdermal testosterone in order to help my efforts of protein intake and resistance training to hang on and possibly build some muscle. So my levels are physiologic. I check my levels every three to six months.
[00:30:56] I think the last one I was 47. And so in our natural lifespan, When we're our reproductive height, when our libidos were on point, your testosterone level is never above 70, and some of these pellet companies are recommending that you be super physiologically dosed with no evidence to support it.
[00:31:18] I have had patients come and say, just check my level. My pellet should have worn off six months ago. They're still out of 300. That is men start at 246. Okay, so I asked the patient, okay, let me just make this clear. Are you transitioning? I fully support that. If this is what you're doing, I'm not the right doctor to help you through this, but, and they're like, no, I'm like, your levels are at a transitioning level.
[00:31:41] I don't have clinical evidence to support a super physiologic dose of testosterone for patients. And that's what's being sold to them by a lot of these camp bonding companies.
[00:31:53] Dr. McBride: So you're saying the data are not there yet, but there's enough evidence in your mind to use it at a physiologic dose to combat sarcopenia, which is low muscle mass. In addition to using it off label for people with low sexual desire, low libido.
[00:32:11] Dr. Haver: Yes. So we have great studies for menopausal women, and testosterone clearly showed a benefit. FDA has not picked up those studies and that work hasn't been done yet. It takes a pharmaceutical company saying, it's worth it for me to do this, and they're not doing it because it's, it's all about economics and there is ot a lot of money in it for them, which is why we don't have an option.
[00:32:34] Dr. McBride: Right. Let's talk diet and nutrition and what happens to our bodies around menopause. I've just gone through menopause myself. I'm on hormone replacement therapy. Woohoo. It's fantastic. I mean, my symptoms weren't that dramatic, but I think what happened was when I went on hormone replacement therapy, I just felt like myself.
[00:32:54] It wasn't like I could name what it was. I mean, I had some hot flashes, night sweats weren't bad, but I don't know, I just slept better. I felt like myself again. But nutrition, so patients commonly come into me around perimenopause in their late forties, early fifties saying, my belly fat has increased. I've never had belly fat there. And they're just, their body composition has changed and they find it harder to…
[00:33:20] It's true that estrogen in the absence of estrogen makes it easier to accumulate weight in our middles typically, and then it increases our risk for insulin resistance or pre-diabetes or diabetes.
[00:33:33] So what are you counseling patients? I know it's not a one size fits all prescription, but what are you counseling patients in general about how to combat that metabolic shift and the weight distribution?
[00:33:44] Dr. Haver: So there are certain behaviors and patterns of eating that we know through studies that for women in their menopausal journey, are going to lead to less accumulation of visceral or belly fat. When we say visceral fat, I want to be clear. So we have the fat, we've known our whole lives, subcutaneous fat.
[00:34:03] It gives us our breasts, our butts, our curves, our cellulite. We don't like it. It's cosmetically distressing, but in, in usual physiologic amounts, it's not dangerous. Okay, visceral fat is different. That's the fat inside of our abdomens and our wrapping around our organs. That at a level, at a certain level starts leading to inflammation.
[00:34:21] It produces cytokines, it's linked to cardiovascular disease, stroke, diabetes, et cetera. And we see a rapid accumulation of this fat in the menopause transition due to multiple factors, but leading off with decreasing estrogen levels. So, what can we do about it? So number one, women who have 25 grams or more of fiber in their diet per day have a much lower risk of visceral fat, and there's probably several reasons for this. It slows down the absorption of glucose into our bloodstreams, which lowers our insulin levels. It keeps us full longer. You're less likely to overeat or make different choices.
[00:34:55] Number two, having a diet that has less than 25 grams of added sugar in your diet per day—less visceral fat and added sugars are the sugars in cooking and processing. And I'm not talking about keto, so I'm talking about the sugars that are found naturally in fruits, vegetables, dairy, they come in a package with fiber, with other micronutrients, with other things that keep you healthy and slow down their absorption.
[00:35:21] It’s Very different from drinking a soda, and that's the number one source of added sugar in the United States in women's diets is beverages that sugar is instantly absorbed. It instantly goes into the bloodstream, causes a spike in glucose, and the concomitant rise in insulin levels, which then drives fat to the abdomen.
[00:35:37] The whole thing happens so fast before you even realize it drives your blood sugar down. Boom, you're hungry again. And so keeping those added sugars less than 25 grams per day. Not to say you can never sip on a soda or have a cookie, but you have a budget. And if you can keep it less than 25 a day, you're going to have less visceral fat and less ensuing health risks because of it. Third, there are some supplements done, checked on, menopausal women that seem like they were helpful. Number one is eating something rich in probiotics every day. So that could be yogurt, kimchi, miso, tempe, whatever… chinese pickles, there's lots of options, but the study that was done in menopausal women was actually done on supplementation, because that's easier to control and study is give someone a pill versus have them eat a tub of yogurt.
[00:36:25] So, when the study was done on obese, menopausal women with hypertension, so the weight loss was the same. They put them both on calorie restricted diets, but added in a probiotic supplement for Group B, and the supplement group had less visceral fat, so they did their visceral fat measurements, and they also had lower blood pressure.
[00:36:44] So keeping the gut microbiome healthy, both through fiber, which we talked about earlier and with probiotics, restocking the pond, as I call it, can be really helpful. Turmeric supplementation or eating diets rich in turmeric, not so typical in the US. People are now drinking turmeric teas or adding it to certain things, but turmeric supplementation, especially if you add a black pepper extract, can be really helpful.
[00:37:06] Zone two training. It's getting real with Peter's book, Peter Attia's book. It's getting really popular right now. Zone two training is training below the level that you can talk through, so like when you're a little bit breathless and so there's multiple, you can google different ways to calculate what that is.
[00:37:22] 220 minus your age, 60 to 70% of that is one thing that patients use. I wear a heart rate monitor usually, and so I know what my maximum heart rates are and I can do the calculation from there, but 150 minutes a week of zone two training is really helpful in that, and resistance training is important as well.
[00:37:40] Dr. McBride: Okay, so to summarize these pearls of wisdom we're talking about ideally getting at least 25 grams of fiber a day. Ideally less than 25 grams of added sugar a day. We're talking about supplements based on your unique profile and health issues, and we're talking about resistance training and 150 minutes of exercise a week, building that muscle mass, keeping that motor running. In addition, we talked about sleep stress management. I mean, that's a good kit. I mean, it's a lot to do. You know, when I talk to patients about these kind of lifestyle modifications, they often aspire to these things. They aspire to sleep more or drink less alcohol.
[00:38:19] Eat less sugar. One of the challenges is minding the gap between our best intentions and the execution, as I say to patients all the time,even walking around your block for five minutes after work is better than nothing. While you're on the phone, maybe do a couple squats or wall sits.
[00:38:38] Notice how you feel if you take a week off of alcohol. I decided to take May off of alcohol, not because I have an alcohol problem per se, but just because I feel better without it. And it really does take at least a week in my mind to kind of notice the effect. One night's not gonna do it. So my advice to patients is just small, incremental bite-sized changes. Don't try to make wholesale changes in every aspect of your everyday health because you just won't do it.
[00:39:08] Dr. Haver: Exactly. I say, we have the rest of your life to figure this out. Let's take this one step at a time. Here's the ultimate plan. We're building a house here, so first we have to lay the foundation, then we're gonna put up the studs. Then we're gonna, you know, like we have to take this step-by-step. We don't want you to be overwhelmed. We don't want you to feel like these are new habits. We're building one habit at a time.
[00:39:29] Dr. McBride: That's right. That's right. Mary Claire, thank you so much for joining me today. How can people find you on the internet? In your clinic, like how can people find your wisdom and expertise?
[00:39:41] Dr. Haver: So we have tons of blogs packed with information on how to advocate for yourself at your doctor's visit and you know what tests to ask for. There’s lots of nutrition information at our website at galvestondiet.com. You can also find me on my biggest social media channels on Instagram and TikTok.
[00:40:06] Dr. McBride: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected].
[00:40:28] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.
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