Beyond the Prescription

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Suneel Gupta on Finding Your Dharma Sep 18, 2023

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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 thei…

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Monica Gandhi on What's Next with COVID Sep 04, 2023

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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…

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The Healing Power of Psychedelic Medicine Aug 14, 2023

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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, MDManish 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, MDPaul 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 th…

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Let’s Talk About Sex Jul 31, 2023

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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…

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Should You Take Hormone Replacement Therapy? Jul 17, 2023

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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 antid…

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Jessica Lahey on Talking to Teens about Alcohol Jul 03, 2023

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You can also listen to this episode on Spotify!Did you know that all children, regardless of genetics, are at risk for substance abuse?Jessica Lahey is a New York Times bestselling author, mother, and parent educator on teen substance use. Her most recent book, The Addiction Inoculation, is a practical guide to help children grow up to be healthy and addiction-free. On this episode, Jessica sits down with Dr. McBride to discuss her own path to sobriety, the myths about substance abuse in adolescents, and how to help kids feel comfortable setting healthy boundaries. This is a must listen if you’re looking for ways to talk with your kids, grandkids—or yourself—about alcohol. Feel free to share this episode with others who may be, too.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!Transcript of the podcast 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 for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at https://lucymcbride.substack.com/subscribeand to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.[00:01:01] My guest on the podcast today is Jessica Lahey. Jessica is a New York Times bestselling author, mother, longtime teacher and educator for parents and teens on the subject of substance use and overuse. Her most recent book, the Addiction Inoculation, is a crucial resource for anyone who plays a vital role in children's lives, from parents and teachers to coaches and pediatricians. Helping raise kids who will grow up healthy, happy, and addiction free. Jessica, welcome to the podcast.[00:01:35] Jessica: You are so welcome. I'm so happy to be here.[00:01:38] Dr. McBride: I'm really happy to be here too because you and I were talking before the show started recording about how medicine in the current landscape is failing people. It treats people like a set of boxes to check, like humans are a bag of organs. We cattle herd, we box check, we move people along the conveyor belt, when health to me, and I'm sure to your husband, who's also a doctor, is rooted in the relationship with a patient, is founded on trust. And particularly when we're talking about complex issues like substance use and overuse, it requires time to get to know the patient and then unlock those complicated stories.[00:02:25] So, this is why I'm thrilled to have you here because it's clear to me that this is not just your job, but this is who you are. So I'd love to talk first about your story and how you became interested in substance use.[00:02:39] Jessica: I couldn't avoid it because I was raised in a home with someone with substance use disorder. One of my parents and one of my parents was raised with a person with substance use disorder and so on and so on, and so on and so on. And when I first got sober, On June 7th, 2013. Not coincidentally, my mother's birthday, I got blackout drunk at her birthday party.[00:03:03] My very first thought was, okay, well hold on. If I'm part of this long legacy, and by the way, my husband is part of a very long legacy of substance use disorder, how on earth do I make this stop for my kids? I mean am I just, are they just destined to carry? And I had so many questions about genetics and risk factors and all that stuff.[00:03:27] And more than that, I had also been a teacher for 20 years. And after I got sober, I started teaching in an inpatient recovery center for adolescents. And I wanted to understand very specifically, how those kids ended up there, what could we could have done differently, both from a parenting, from a social, from an educational perspective, how those kids ended up there.[00:03:50] And then looking at my own kids, I got sober when they were nine and 14. And I really just needed some answers. And I was hearing, most of the information I had in my head was myth. It was magical thinking. It was myth, it was rumor. I needed to understand, if we give kids sips when they're younger, does that do anything about helping them learn moderation or should we be aspiring to be like those European families that we talk about so much?[00:04:19] And anyway, so all of that stuff, I needed answers. I have the coolest job in the world, which is to get curious about topics and then get paid to research the heck out of them, and then translate that research for people who don't wanna dive in and research for two years to get the answer to a topic.[00:04:36] So my job is not just… I'm a writer, but I'm at heart, a teacher. I mean, not just to kids, but now I get to go out into the world and translate all of this stuff. And if there's nothing I love more, it's helping people think about topics that freak them out. Whether that's letting your kids fail with Gift of Failure, whether that's substance use prevention stuff.[00:04:59] It's the reason that I've stuck with this substance use prevention stuff, because it’s just so hard to get people over the shame, the guilt, the fear, the denial in order to talk about this stuff. So that's one reason that I make daily videos about this stuff. I'm out there speaking to lots and lots of people, and sometimes it's an uphill battle, but it's really, really fun.[00:05:23] Dr. McBride: I can tell you're enjoying it and you're so effective at communication. I'm the same way. I love complicated patients. I love the layered kind of kernels of people's interiority and how their thoughts, feelings, and behaviors are interrelated and then explaining it to people. I also love tackling topics that tend to freak people out, like death and dying, delivering bad news, like somehow that's like my Super Bowl. And I think one of the reasons is because, at least for me, I see the fear in people's eyes and I see the shame that they carry and then being able to kind of convey a message to people that is, that they can wrap their arms around is really gratifying. When it comes to substance use disorder, I think a lot of parents are freaked out.[00:06:12] I think they read the headlines. They see how pre pandemic, we had an epidemic of diseases of despair, including substance use disorder that is only accelerated during the pandemic and they don’t know what to do. And they know their kids in their adolescent years are trying alcohol, drinking in kids' basements.[00:06:30] They're kind of looking at what other parents are doing and not knowing who to trust. And so I'd love to hear from you what are the common myths that parents tend to hold in their minds about substance use disorder in adolescence?[00:06:47] Jessica: Yeah, I think this is really important because it's also the myths that get translated to their children. And the big ones are things like, first of all it's a fait accompli—kids are going to drink anyway, so I might as well teach them how to do it responsibly, either because I have beer at my house and I take away everyone's keys, and at least they'll be safe.[00:07:06] That sort of just fatalistic, it's going to happen anyway because that's simply not true. The numbers are so much lower than people understand, and I get into that. In the book, there's this thing called pluralistic ignorance, which is we tend to overestimate in the case of alcohol, for example, how much people tend to drink, the people around us and how invested they are in having alcohol around.[00:07:28] And we all tend to overestimate that. So that sort of fatalistic thing, the whole, you know, I really want my kids to be like those European kids. So therefore if I let my kids have sips at home, let them have their own beer, a little bit of wine, that kind of thing, it'll somehow teach them to be moderate drinkers and not freak out when suddenly alcohol is available to them at college or whatever.[00:07:51] And that's wrong for so many reasons. I mean, the European Union as a whole, based on data from the World Health Organization and specifically World Health Organization Europe has the highest level of alcohol consumption in the entire world, and the highest level of deaths and illness attributable to alcohol.[00:08:10] Yes, there are exceptions, and that's a fantastic conversation to have as well, because that's about outliers based on the fact that those countries tend to have very particular community standards around public drunkenness. So the outliers tend to have to do with community pressures, and that leads to a great conversation of family culture, school culture, city culture, all those kinds of things.[00:08:33] And then, the idea that our kids don't listen to us because that's just not true. Even as kids get into college, they report that their parents tend to be their preferred and most trusted source of information for especially health, personal health, that kind of stuff, that kind of information. And finally, I want to also, I think it's really important to remember that substance use disorder and substance use are two different things. Lots of kids can try substances and not go on to have a problem with substances over the long run. And it's important to understand from an objective perspective what those risk factors are so that you can say, oh, my kids are at higher risk, or this puts my kid at higher risk, so what do I do specifically to deal with that. And then finally, I think it's also important to remember that yes, substance use disorder, we're having a crisis right now with mental health and stuff like that. And substance use disorder or substance use can be one way to cope with that. But prevention works. Effective prevention works.[00:09:31] And we're at, we've seen a 10 year decline really now 15 year decline in most aspects of substance use in adolescence. And that's because prevention works. And in order to do that really great prevention work, we have to be objective about risk factors, and we need to realize that adolescent brains are different from adult brains. I don't talk about adult substance use that often, except for when I talk about whether or not you should do it in front of your kids and what your messaging should be, because the adolescent brain is just different from the adult brain.[00:10:06] Dr. McBride: Okay. I wanna talk a lot about the adolescent brain, having three of them in my own house. I welcome your insights. Actually, two are in college, but they do inhabit my house every now and then. But let's go back to the first myth for a second. The myth that parents, I think, believe quite often, and I have believed in some ways, which is that it's inevitable they're going to use alcohol, trying to stop them from drinking alcohol or experimenting with it in high school is kind of like stopping a 747. I think a lot of parents think, as long as we've had the conversation, then this is, this is the best we can do. What data is out there, Jess, to show that delaying your exposure helps prevent the likelihood of substance use disorder?[00:10:56] Jessica: So first it's just important to remember that there are two periods of brain development that are the most important. They're just these massive periods of brain plasticity, and that's zero to two and puberty to around 25-ish, depending on the kid. So what we need to remember is that that development, that cognitive development that's going on, and that brain development that's going on from puberty to 25-ish, we don't fully understand all of it, it is massive. It's happening all over the brain. It's happening with lots of different centers. The executive function part of the brain, the upper brain is connecting to the lower brain, and anyway, that needs to happen as unimpeded as possible. What we do know is that the younger a kid is when they first initiate their substance use, the more likely they are to have substance use disorder during their lifetime.[00:11:46] So for example, if a kid starts in eighth grade, it approaches a 50% chance of developing substance use disorder over their lifetime. If they start in 10th grade, it goes down to around 20%, a little bit less than 20%. And if you can get them to 18, we get so darn close to 10%. It’s important to delay, delay, delay. So that's one reason. Not only are we lowering their statistical risk of substance use disorder over their lifetime, and yes, there are some confounders in that data. There are confounders. I mean 90% of people who develop substance use as an adult report that they started before the age of 18.[00:12:26] And of course there are issues in there that we can't control for—the social determinants and all that kind of stuff. Families that have more alcohol around are gonna have kids that are more likely. So there's all of that as well. But this is what I'm dealing with in terms of the statistics.[00:12:42] Also remembering that the development, the longer a kid goes without ingesting anything that messes, whether it's with your dopamine cycle or fills up receptors in your brain that are, should otherwise have naturally occurring neurotransmitters in those receptors, because we're introducing them through drugs and alcohol. The brain just needs to develop as unimpeded as possible for as long as possible. So we're protecting their brains and we're lowering their risk of substance use disorder over their lifetime.[00:13:11] Dr. McBride: It makes sense in a lot of ways. The way I think about it is that the longer you give adolescent brains to ripen on the vine, and the longer you give kids who are dealing with a lot of complex thoughts, feelings and emotions and genetic predispositions, the more chance you give them to find and practice coping with hard thoughts and feelings. You just give them more opportunities to realize that they like drawing, they like being outside to play sports, they like laughing with their friends, they've realized who their intimate friendships are and where they can go to put a lot of thoughts and feelings instead of the default mode to alcohol, which for some kids, as we both know, is a occupational hazard for our kids who are in distress.[00:14:02] Jessica: And that's really apparent when you see what happens to a kid who has substance use disorder. They come to rehab. We remove the substance they're using as their coping mechanism. Suddenly you have kids with unresolved trauma. I mean so much. When we talk risk factors, you know, trauma is a big part of it.[00:14:21] So suddenly we have these kids that have been using this one and only coping mechanism for so long that they. Not only don't have coping mechanisms for that trauma, but they don't have coping mechanisms for interpersonal disputes, for just feeling anxious. All of their coping has been through using the substance instead of actually learning a real coping mechanism, which is why we often…

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Nedra Tawwab on The Freedom (and Health) of Self-Expression Jun 19, 2023

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You can also check out this episode on Spotify!Juneteenth is a celebration of freedom and liberation. I can’t think of a better person to speak to the importance of self-expression, autonomy, and living without oppression than Nedra Glover Tawwab.Nedra is a practicing therapist, relationship expert, and two-time bestselling author. She understands that health begins with individual freedom—and that healthy relationships require supporting each other's freedom, growth, and self-identity while maintaining mutual respect and healthy boundaries. Her books, Set Boundaries, Find Peace: A Guide to Reclaiming Yourself and Drama Free are born out of her philosophy that a lack of boundaries and assertiveness underlie most relationship issues. Today, Nedra sits down with me to discuss the physical and emotional health consequences of relationship drama—and the importance of self-awareness and acceptance in order to have agency over our life and health.I hope you enjoy this very special podcast episode. Listen above! 👆🏼👆🏼👆🏼Together we are helping redefine what it means to be healthy. To join this community—and for lots of fun extras—consider a paid subscription!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!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 for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story, to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at https://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.[00:00:58] Okay. Buckle your seatbelts. I am thrilled to be speaking today with two-time bestselling author, licensed clinical therapist, and relationship expert Nedra Glover Tawwab. Every single day, whether it's counseling patients in her therapy practice, or talking to her 1.8 million Instagram followers. Nedra is helping people create healthy relationships by teaching them how to implement boundaries.[00:01:29] She has written two books Set Boundaries Find Peace and her most recent book, Drama Free, both of which are born out of her philosophy that it's a lack of boundaries and assertiveness that underlie most relationship issues. Nedra, I cannot tell you how happy I am for you to be here today. Thank you so much for joining me.[00:02:02] Nedra: You're welcome. Thank you very much.[00:02:04] Dr. McBride: As patient-facing providers, you and I both know that relationship stress, relationship drama, can affect people’s health. During the pandemic I witnessed patients coming into my office with headaches, migraines, back pain, high blood pressure, weight gain, alcohol use increasing as a result of a spotlight being shined on a troublesome relationship, or until they had to make hard decisions about parenting, caregiving, living through a trauma. And so when I saw you on Instagram I knew I loved you at first sight, because you were there talking straight to the audience your 1.8 million followers about the relevance of relationships to our health and then you were dispensing practical guidance to this the drama and lean into the joys of relationships. And so thank you for doing that and thank you for being here.[00:03:26] Nedra: You're welcome. The only time that, well, one of the only times I'll said, there's two times the only, one of the only times where I felt, oh my gosh, I think I'm having a panic attack, is when I was put in the situation of seeing a person who made me very uncomfortable. I was like, I'm about to have a panic attack… this is how much I don't want to see this person.[00:03:54] My nervous system is on fire. My body is like run, hi, go. And it's not always, oh my gosh, I need to trust this, but I need to consider it. Right, because sometimes our bodies, our minds could be pushing us away from things we need to do, but there are other times where it's like warning, warning and we're like, okay, I'm going to do this anyway because I have to do it. And for me, in that situation, it was a warning to stay far away from a situation that was unhealthy because of past events.[00:04:31] Dr. McBride: Another reason I knew we were kindred spirits, if you will, was that I saw you talk about adverse childhood experiences. So ACEs, as many people know, are events or situations or even relationships in childhood that have lasting effects on our health. In fact, there's no shortage of data to show that people who experience childhood trauma, whether it's physical, emotional trauma, experience higher rates of binge eating disorder, depression, anxiety, post-traumatic stress, and even cardiovascular disease.[00:05:12] And so when I see someone like you who's helping people address the experience head on instead of meeting me when they're 50 and having heart disease, I think this is health, this is prevention. So could you talk to me, Nedra, about how you became a therapist and how the ACEs in your life perhaps informed that decision?[00:05:36] Nedra: I was trained to be a listener. I listened a lot to my father in particular, talk about very adult topics, complain or, you know, ruminate or you know, do all, and I would just uh huh. I took it on as something that I had to do. I didn't know that this was a profession. I didn't even know this was something I was drawn towards, but it really shaped me into a person who. Was a good listener because with your parent, you're not really allowed to cut them off or stop them from talking. It was just like, oh, I have to listen to this person. And so it became a part of me with my peers, with other people in the grocery store who wanted to tell me random things.[00:06:22] I'm like, “Uh huh.” And when I went to college, I thought I wanted to be a social worker who worked with children and you know, I got an internship and it was. In a therapy setting. And I realized that I actually like the side of listening where people actually want help. Not just people complaining, not just people ruminating or you know, saying, “Oh, woe is me.”[00:06:47] It was people who wanted help with their situations. Now they may not all be at the same level of readiness, but they were certainly in the place of seeking. And for me that was a light bulb moment of, “Well, I have the training. I have the parent to fight training to do this. Perhaps this is an opportunity where I can really get into something that feels good to me.[00:07:14] I felt really good being that person, that hope, [to help] someone think about things differently, because that's really what it is. I never had the opportunity to give insight. I was only a listener up until that point. But then when I was able to give the insight with that and they were like, oh, I never thought about it.[00:07:31] I was like, “What did I say? I said that. I said that. Yeah, that was really good.” But I just think therapy is a wonderful thing for all people. And I don't just say that because I'm a therapist. I say that because I'm a person that goes to therapy and there is nothing like having a person who does not tell you about themselves for one whole hour a week. [00:08:00] Dr. McBride: Amen. And I'm a believer as well, and I love that story that you had this firsthand experience of being an empath and listening and observing. I think I agree with you that therapy is a wonderful way of having that space and time to download our thoughts, feelings, and talk about our behaviors and relationships.[00:08:26] I do think, however, there is a difference between therapy that is simply chewing over the day's news and the data dump in therapy that is, I think, what you do, which is helping people affect change. And having the courage and tolerance for distress, they need to affect change. And I actually, I just talked to a patient today who's been in therapy for about a year, and you and I can agree that it takes sometimes years to make changes, but I asked her because she isn't feeling better vis-a-vis some things in her life.[00:09:07] Do you think it's possible you're not bringing the whole story to your therapist? I think we all have parts of our lives that are so vulnerable that it's hard to even bring up to ourselves, not to mention to another person. And I said maybe it's like at the museum when you kind of rope off a part of your story that you're not accessing.[00:09:29] And I don't know if you have thoughts about that, but I'm guessing you do. But I just think that I said to her, I would, I would love to challenge you to bring more out and maybe think about other issues in the relationship with your therapist that make it harder to do that. I push people.[00:09:46] Nedra: Yeah. I'm excited for the people that I work with who are brave enough to be deeply honest. It requires some honesty to admit the things that don't make you look good. Everybody loves to tell the story of, I can't believe they did this to me, or Can you believe this person did blank? Not many people acknowledge I did this to this person and it wasn't very nice.[00:10:15] I've recently thought of a story only because something happened to a person in my life where they had this friendship sort of situation where someone did not honor a commitment. And I said, oh, I remember one time, I think I was like 20. I did not honor a commitment and I ghosted that friend after because I could not address it.[00:10:42] And they were like, “Really?” I was like, yes. I'm like, put it in my obituary that I apologize to this person today.[00:10:52] Dr. McBride: Yes.[00:10:54] Nedra: I even tried to Google them. I was like, “let me email them.” I'm like,[00:10:58] Dr. McBride: That's hilarious.[00:10:59] Nedra: I've done one bad thing in life. That's it. No, probably tons, but this is the one that is sticking out. And they were really shocked. They were like, “I can't believe you did that.” I'm like, “I didn't want to do it.” I didn't know how to end the relationship. And in my immaturity, I did it in a very explosive and probably damaging to the person way is not something I'm proud of. I would never do anything like that today, but I did do that and it does not make me look good.[00:11:32] Dr. McBride: Well, I think it makes you human, Nedra, and it's like just the process of being human and sort of sharpening our tools for managing relationships and honoring our needs and honoring the other person's needs. I'd love to talk about acceptance for a minute. So you wrote on your Instagram recently, and I screenshot it—a little secret from a therapist.[00:11:56] “In relationships, we often think the other person is the problem. If they changed this or that, your life would be better. Sometimes the problem is you not accepting that you can't change the other person and you have to change for the situation to improve.” And then you wrote in bold repeat after me, and this is where I thought, oh my gosh, this is so good.[00:12:19] “I am not in control of others. I am in control of myself.” One of the things I was telling a patient today or not telling, one of one of the things I was talking to a patient of mine today who is a middle-aged woman, mother of three, and a born sensitive empathic pleaser who is coming in not feeling well emotionally and physically asking me if she should be on more Zoloft when we drill down to the issue is really that she's not erecting appropriate boundaries with her family. They have expected her to jump through hoops in every department of her life to please and satiate their thirst for whatever she's offering, and as a result, she's feeling exhausted and burnt out and resentful. So there's no amount of Zoloft that can help her tolerate that. What I talked to her about is I said, first of all, buy Nedra Tawwab’s book, And she said, which one?[00:13:20] I said, well buy both because they're both really good. And then I said, let's think about retraining your family and rehonoring your needs in the relationships. And, and I'm gonna make this a question, accepting that painful acceptance of realizing your parents and your siblings may not change. They may not want to ask less of you, but you can hold the line.[00:13:47] Nedra: You can do less. They can ask whatever they want to, and you can do less. Take it from a person who gets countless amount of dms,[00:13:58] Dr. McBride: Oh my gosh. I'm sure. [00:14:00] Nedra: All so many requests. I meant, here's my question for you. Here's this thing I need. I can't respond to all those things and show up in my life. It's not possible in a healthy way. I'm not gonna say it's impossible. It's not possible in a healthy way. It's not possible to fulfill many commitments the way that we do sometimes in a healthy way. We do it while other things are suffering. Can you imagine that here it is, you haven't even had a glass of water and you're doing all these things for other people. You haven't even had your yearly checkup and you're doing all these other things for people. You are last on your list. Your health is suffering. You have things that you need that aren't being honored, and your concern is, “oh my gosh, they’re gonna be so upset at me.” You may not be here at the rate you're going.[00:15:00] They're gonna be upset at a ghost. They're not gonna be upset at you because you're not gonna be here, you're not gonna be, well, you're not gonna be able to keep this up long term. So stop it now. Stop it before it gets to a point where you know, the migraine is actually really a issue now. It's not, it's no longer just, oh, I'm having the occasional headache.[00:15:22] You've worked yourself into hypertension, now you have hypertension. Because you're doing these things at this high capacity that is not sustainable. And I think about people who have to take things to be able to get through the day. So there are some people who will take a painkiller every day just to get through the day.[00:15:43] I have a headache every single day. I have a whatever. Every single day I've watched Dr. Pimple Popper. Oh my gosh. And those people, they'll have this growth on them for 20 years, and I often think, what have you been doing that long that you couldn't get yourself to the doctor? 20 years? That looks like something that should have been removed after two months. But there's all of these other places, all of these other things that we have to do other than taking care of ourselves, which is the most important thing in life for us to show up in these other spaces.[00:16:24] Dr. McBride: Why do you think it's so hard for women in particular? I think it's true for men as well. Why do you think it's so hard for humans to center their own needs? I mean, what are the themes you see in your practice that people come up wit…

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Dr. Rachel Zoffness on Re-Conceptualizing Pain & Pain Management Jun 05, 2023

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You can also check out this episode on Spotify!Pain is an inevitable part of life. But did you know that pain is not just about body parts?Dr. Rachel Zoffness is an Assistant Clinical Professor at UCSF and leading global pain expert who is revolutionizing the way we conceptualize pain. She explains that hurt (pain) and harm (damage) are not the same—and that pain is never purely biological. Similarly, treating pain is never just about pills. It’s about addressing the social-emotional context around it. On this episode, Dr. Zoffness sits down with Dr. McBride to discuss how thoughts and feelings inform the experience of pain. And how treating pain must include treating the brain. 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, review — and enjoy — the show!Transcript of the podcast 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 for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at 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] I'm delighted to welcome to the podcast my friend Rachel Zoffness. Dr. Zoffness is a PhD, pain psychologist, assistant clinical professor at UCSF, and an author of a new book called The Pain Management Workbook. She believes like I do, that our bodies and minds are inseparable and that we need to think about pain in a much more nuanced way.[00:01:25] In other words, when I was trained in medical school, we thought pain was about the body part and that pills were the solution. When actually, as doctors, we describe pain as a biopsychosocial phenomenon. Rachel, I am so happy you're here today. Thank you for joining me.[00:01:42] Dr. Zoffness: Thank you for inviting me on, Dr. McBride.[00:01:45] Dr. McBride: What I love about you is that we agree that mental and physical health are inseparable. When I was training in medical school in the 1990s and early 2000s, we were taught that pain was about the body part itself, and that we used medicines to treat pain. We used Tylenol, Advil, opiates, and we were taught to get ahead of the pain and to get people more opiates than we thought they might need because it was cruel to deprive people of pain meds, which of course it is in many ways.[00:02:16] But we now know just how addicting these medications are, and we also know that pain is about more than the limb that is hurting. So could you describe for me how you talk about pain, this bio psychosocial model? Because it's a big word and I'd love to break it down.[00:02:34] Dr. Zoffness: Yeah, it's sort of frustrating for people who have been living with pain and also for healthcare providers who treat pain because medicine, as you know, has been rooted in this antiquated, dinosaur era biomedical model, which teaches people that everything to do with pain is just anatomy and physiology.[00:02:54] But neuroscience has known for many decades that that's not actually true when it comes to pain. And one of the reasons we know this is because of this syndrome called phantom limb pain. And phantom limb pain is when someone loses a limb and arm or a leg, and they continue to have terrible pain in the missing body part.[00:03:14] Now, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain does not just live in your leg, and it does not just live in your back. And what science says is that, of course the body is involved in pain production, but ultimately pain is constructed by the brain. [00:03:38] And the reason that's so profound, at least for me as someone who treats pain and has lived with pain as many of us have, and all of us will because everybody, everybody is gonna have pain at some point, is that there's lots of parts of the central nervous system that process pain. It's not just there's one pain center, and that's how that goes.[00:03:56] There's lots of parts of the brain that contribute to the pain experience including the brain's emotion centers contribute to the pain experience, and what that means is how you're feeling emotionally in any given moment, whether you're stressed or anxious or depressed affects intimately the pain that you feel.[00:04:15] So we know from neuroscience that pain messages are amplified during periods of anxiety or during a global pandemic. That's not gonna surprise anybody, and we all know this. We all know that our bodies feel worse during times of duress. So it's really not that shocking. And we also know that, say if you stub your toe at work on the day you get fired, that exact injury feels completely different than if you stub your toe on a day at the beach when you're hanging out with your friends in the sun. So context matters, emotions matter, thoughts matter. Everything matters to the brain when it's deciding whether or not to make pain and how much, and that's always true.[00:04:54] Dr. McBride That's a great example and the phantom limb pain is, is, I'd love to talk more about the phantom limb pain because I mean there couldn't be a better example of the construct that pain is—not to say it's not real— it's to say that it's more than just about the limb. So take that example for a second. How do you treat someone who has phantom limb pain? If it's not about the limb?[00:05:18] Dr. Zoffness: So there is this frustrating thing that happens in medicine where people with chronic pain are often told it's all in their head. Especially if there's no known etiology for the pain. If you've had a lot of scans and tests and you know, people just aren't sure, the doctors are like, we don't know.[00:05:31] We can't find a thing. So people get told often that pain is all in their head, and that is not what I'm saying. So I want to be very clear. Pain is never all in your head. If you have pain, your pain is real. The important thing to know about pain is that it's the brain in conjunction with the body always working together.[00:05:47] The interesting thing about phantom limb pain, again, we've said you can have pain in a leg that's no longer attached to your body. And we've said that's because your brain is implicated in the processing of pain in your brain. You have what's called homunculus, and a homunculus is literally a map of your entire body that lives in your brain.[00:06:06] So if I said to you, Lucy, without doing anything or moving, sense into your foot, can you feel your foot on the ground? Notice if your foot is warm or cold. Can you feel if your foot is moving or… you can do that. And the reason you can do that is because you have a map of your whole body that lives in your brain, your homunculus. [00:06:23] So sometimes if you lose a limb, you've lost the limb, but you haven't lost the leg part in your brain map. So with mirror therapy, what we do is. We hold a mirror up to people who have phantom limb pain and they go through a series of activities and structured exercises to help the brain become unconfused and realize that pain, which is your body's danger detection system, doesn't need to send you any more danger or warning systems because the damage has already occurred and there's no warning signals that need to continue. So that's one of the treatments for phantom pain.[00:06:58] Dr. McBride: It's such a great example and I love the way you described it because I think for a lot of people, doctors included, we have a hard time wrapping our arms around this concept of suffering you can't measure or you can't see it, but everybody who's listening right now can think about their toe or their foot and know that you're directing your attention to it, and there's a reason for it's in our brain. So that is great. That's a beautiful way of opening this conversation about pain being more than just physiological.[00:07:31] Dr. Zoffness: Exactly right.[00:07:32] Dr. McBride: Talk to me about—breakdown biopsychosocial, because when someone hears pain is biopsychosocial they may think, oh wow, it's more complicated than I thought, but they don't necessarily know what that means. So what is it?[00:07:45] Dr. Zoffness: Right. So I happen to really love big words, and this big word in particular has helped me make sense of a lot of different things, not just pain, because it turns out anxiety is biopsychosocial, and depression is biopsychosocial and diabetes. So I'm going say what this word means. So biopsychosocial, what we know now about pain, is that it is never a purely biological thing. It's never just to do with your bad knee or your aching back. Never. It is more complicated than that. Of course it is. And so with this word, biopsychosocial means, and we know that that's what pain is. It means that there, of course, are biological components or triggers for pain contributors [00:08:25] So the bio components of pain are genetics and tissue damage and system dysfunction and inflammation, and things like diet and sleep and exercise. Those all are biological contributors to pain. They're very, very, very important. However, what we know about pain is that there's other things that contribute to your experience too, and they're just as important.[00:08:48] It's not that they're less important. So in the psych, we have bio, we have psych, and we have social or sociological. And the psych domain of pain has so much stigma around that. And I am a pain psychologist, and let me just tell you all day long, all I do is try and explode the stigma around these quote unquote psychological contributors to pain.[00:09:08] So I want to very clearly say, When you say that pain has psychological components, that's not, again, that it's all in your head. What it means is neuroscience shows that emotions intimately affect the pain we feel, and that negative emotions are going to amplify pain volume and positive emotions and feelings of calm and relaxation are going lower pain volume, turn pain volume down so that lives in that psych bubble.[00:09:35] Also, in that psych bubble, we know that thoughts and beliefs intimately change the pain we feel. This is supported by many decades of science, for example. We've all heard of the placebo effect. The placebo effect means, Lucy, I'm gonna give you a sugar pill. I'm going to tell you as a pain doctor that this is gonna lower your pain volume, and low and behold, you actually feel better.[00:09:59] That happens a lot of the time, and the reason that happens is not that the placebo pill is nothing, rather the placebo means you change your beliefs and your brain understands that these danger messages are not needed anymore. So your pain volume is lowered. Beliefs and thoughts change the pain you feel.[00:10:19] That doesn't mean you can think your way out of pain. It's more complicated than that. But thoughts and beliefs matter. We also have in this bubble coping behaviors. What do I mean by that? People with pain often, understandably believe that they need to stay home, stay inside, not move, not go outside, stop going to work, stop their activities, stop moving.[00:10:40] Reasonable. However, what science shows is that that ultimately is also going to amplify pain volume and that to treat chronic pain, we have to get out of bed and back to life very slowly and in a structured way, and I'm not telling people to go outside and do things, but behaviors, how we act, how we handle our pain also changes the pain experience.[00:11:01] Then I said, we have this third domain of pain. It's the social or the sociological domain of pain and what science says is that social factors matter all the time. When it comes to pain and health, humans are social animals. We know that the worst punishment you can give a human being is not Thanksgiving traffic, and it's not your in-laws, it's actually solitary confinement. And what happens when we are lonely and isolated and alone, which happened during the pandemic to a lot of people, our brain amplifies pain volume because a lot of brain chemicals change. So in the presence of others, our brains produce all these chemicals that literally make us feel good.[00:11:42] Dopamine, serotonin, oxytocin, and endorphins. Endorphins are our brains’ natural painkillers. They are our endogenous opioids. So in the presence of other people, brains produce painkillers. There's other sociological factors that matter also. It's community, it's context, it's environment, it's even race and race and ethnicity, and even racism.[00:12:07] It's poverty and it's access to care, it's trauma. There's so many, so many things that live in this sociological domain, so, All of it together contributes to the thing, this experience that we call pain. And what's happened in medicine is that we’ve distilled it down to just the biological, the bio bubble. And what that means is that what we've been doing in medicine is missing two thirds of the pain problem. And part of the reason I do things like this and come on podcasts, is to try and change the way we're thinking about pain so that we can change the way we treat pain.[00:12:41] Dr. McBride: It is so important, Rachel, because as you just said, we have reduced the patient to a set of lab tests, a set of complaints, and because doctors don't have time and they aren't trained—we are not trained in pain management like we should be—People who are in chronic pain are often thought to be nuisances, thought to be malingering or thought to be making it up, because we don't have sophisticated ways of treating pain and because it takes time to access the 360 degree version of the person we prescribe pills. Now, I love Advil for a headache. I love Tylenol when I have a fever. But I think what you're saying is that we need to look at the whole person. We need to look at their emotional health, their mental health, their physical health, their story, and address the various complex parts of this person because they're integrated and they show up in pain.[00:13:40] Dr. Zoffness: That's exactly right.[00:13:41] Dr. McBride: Can you give me an example, Rachel, of a patient who had intractable pain, who was treated inappropriately by the medical establishment and then got better with this model.[00:13:52] Dr. Zoffness: It's really interesting. I'm in private practice and I see people with chronic pain and I happen to love working with teenagers in particular. They're sort of forgotten in medicine, especially in the world of pain. We have pediatric pain and we have a lot of adult pain and older adult pain work. It's not being done right in my humble opinion. But we do have a lot of attention and money being thrown at it. And then we have teenagers who are sort of in this messy middle, like…

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Health is a Process, Not an Outcome May 22, 2023

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You can also check out this episode on Spotify! If you’re anything like Dr. McBride or her patients, you want to live a long life. You want to be healthy! Yet when you try to execute on your best intentions—whether it’s cutting back on alcohol, starting an exercise routine, or taming your phone addiction—you end up defaulting to factory settings.Well, you are not alone.The pandemic laid bare how wired and tired we are—and how desperate we are to feel better. We scroll endlessly online for wellness advice and health hacks. We grab quick hits of dopamine through sugar, shopping, booze, or whatever gizmo social media is offering up. We are sleepless and irritable and don’t know what’s wrong.The U.S. medical industrial complex is failing people. The wellness industry is fleecing people. How do we get ourselves “unstuck” when we don’t know what questions to ask or who to trust?Dr. McBride argues that first, we must first redefine “health” as more than a set of laboratory tests or a single visit to the doctor. To her, health is a process, not an outcome. Health is about having awareness of our medical data, acceptance of the things we cannot control, and agency over the things we can control.She calls this the “Three As.” She argues that articulating our Three As allows us to more accurately tell our story. An honest reckoning with the Three As can put us back in the driver’s seat of our health. In this week’s (short!) solo podcast, she explains this in more detail. She defines each “A” and suggests a way to move through this process on your own. Spoiler alert: getting healthier isn’t particularly sexy. It’s often not very fun. It usually isn’t usually quick, and it never involves a “fix.” In reality, staring down the facts, accepting hard truths, and then challenging our beliefs and our everyday behaviors is arguably the deepest and hardest work we do. Our stories live in our bodies. What’s yours?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, review — and enjoy — the show!The full transcript of the show is here!Dr. McBride: Hello, and welcome to my home office. I'm Dr. Lucy McBride, and this is Beyond the Prescription. Today, it's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as a process of self-awareness, acceptance, and agency.[00:00:28] In clinical practice for over 20 years, I have found that patients generally want the same things. A framework to evaluate their risks, access to the truth and data, and tools and actionable information to be healthy, mentally and physically. We all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today. Let's go.[00:00:55] So today it's just you and me. I am pretty excited, because I get to talk to you the way I talk to my patients. Specifically today, we're going to talk about how we might approach the process of getting healthier. If you're anything like me or my patients, you want to live a long life, right? You want to be healthy, you want to feel good, and you probably know that there's some things you could do to be healthier, but you find them hard to do, and you default to factory settings on a day-to-day basis.[00:01:30] Well, you're not alone. Many of us aspire to get more exercise, to eat better, to get more sleep, to manage stress. In other words, we all want to do what our doctor tells us to do, but when the rubber meets the road, it's actually pretty darn hard. So how do we actually get healthier? How do we mind that gap between our best intentions and the execution part?[00:01:53]So let's first talk about definitions like, the definition of health. Unfortunately in the US, we kind of think of health as the sum total of our lab tests. If we have normal cholesterol and a normal weight, we're healthy. But health is not just an outcome. It's not just about the absence of disease or pain, it's also not about pleasing the doctor or winning your annual checkup.[00:02:19] After all, as humans, we're not just a set of boxes to check, a bag of organs to fix. We are the integrated sum of complex parts, and the US healthcare system just does not do a good job of countenancing the whole person. There's such a focus on extending life, which is of course good, but at the expense of thinking about our quality of life.[00:02:41] And unfortunately in this country, by the time most people are seniors, they have a doctor for every body part, a pill for every symptom, and no one is talking to each other. No one is talking to the patient and asking them simple questions like, how are you, Mr. Roberts? What is your story? Are you okay?[00:03:00] What are your goals? What's your North Star? What gets you out of bed in the morning? What do you live for? And by the way, how do you define health yourself and how can I as your doctor help you get there? In fact, a lot of people, regardless of age, are walking around feeling completely disenfranchised from the medical system and disenfranchised even from their own bodies.[00:03:26] In fact, 80 million Americans don't even have a primary care doctor. So what is health? How do we define it? Health, to me, is a process. Health is about our everyday thoughts, feelings, and behaviors. It's not just about that single point in time in your doctor's office standing on the scale in a gown. It is about the 364 days a year you're not in the doctor's office. [00:03:53] This is where I get really excited, this is why I'm here, and I can't wait to tell you about what I call the three A's. The process of becoming healthier from the inside out. It's not easy, but it's necessary for health. In my opinion, health is a process of laddering up from awareness to acceptance to agency.[00:04:19] So I'm going to say that again and then we're gonna break it down. Health is the process of laddering up from awareness to acceptance to agency. So what do I mean by that? First, let's start with awareness. Awareness is step one. Awareness specifically is of the facts, awareness of the facts and data. When I say facts and data, I mean metrics, physical, quantifiable information that we can measure and see.[00:04:50] I'm talking about your cholesterol levels, your blood sugar, and your diabetes testing, your weight. I'm talking about the results of your mammogram, your colonoscopy, the PSA test if you're a man, your genetic testing when you went to the geneticist because of your family history of breast cancer. These are the things that we can hold onto because these are the things that we can see, that we can quantify and that we can measure. And this kind of traditional medical data is essential to know for our health.[00:05:19] But guess what, it's not sufficient and there's actually more data we need to collect. Quantifiable information that often gets missed in the doctor's office. Things like, what is your family structure? Are you a middle child? How were you raised? Were you raised in an urban or rural setting? What were your environmental exposures as a kid?[00:05:40] Were you raised in poverty? What was your socioeconomic status? What about your job? What are the facts of your employment situation? What are the facts about your children, your parents, and your family's system? What is your cultural background? What are your religious beliefs? What about your educational status?[00:05:58] How many pets do you have? What we need to gather are facts about you historically and currently that are unequivocally true. So this is step one, gathering facts and data, finding out what is true and putting these facts in a box. Now modern medicine is happy for you to stay here, for you to measure your health as the result of your lab data.[00:06:22] Medicine is happy not to consider the other contextualized facts I just went over about who you are, what happened to you, and what are the realities, factual realities, of your life. In fact, modern medicine is delighted for you not to climb the ladder any further and to keep you stuck in the lobby.[00:06:42] But let's not stay stuck. Let's do it. Let's ladder up and let's talk about acceptance as the next rung of the ladder. So this is where it gets hard. This is where people push back. This is the common sticking point where people have a hard time, and this is where we get into some of that magical or even delusional thinking that guess what, we all do.[00:07:05] This is where the rubber meets the road, and it's where we have to acknowledge facts that are unpleasant, that are ugly, but are true. And this is where we have to cope, or else we get stuck on the first rung of the ladder. When I am talking about acceptance, I mean making peace with the things we cannot control, accepting the things we cannot change, and that is hard. For example, let's talk about your biometric data.[00:07:36] You might have high cholesterol readings despite being an avid runner, eating vegetables and a vegan diet, you have no body fat. Yet your cholesterol levels just won't budge. And you may be really ticked off that you can't exercise your way out of this fixed reality. You might even have to take Lipitor because of your family history of premature heart disease.[00:07:59] And in the meantime, you might be like one of my patients who's trying to exercise their way out of this fixed genetic reality. Running yourself ragged, blowing out your knees on the running trail, popping a bunch of Advil, when what you really need for health is less running, some physical therapy for those knees, and a dose of acceptance about your genetics.[00:08:23] So the first part of acceptance is really looking at all that data and the awareness box. Shining a light on those dark corners, looking at things we don't necessarily want to see but that are true, and we have to cringe and we have to swallow our pride, and we have to recognize that we do not have control over every aspect of our bodies, minds, health and life.[00:08:48] We just don't. There are things that were given to us like genes. There are things that happen to us like trauma or neglect or bad breakups or hard times. And then there are environmental factors, family dynamics, birth order, special needs kids, aging parents, things that we are exposed to that we cannot change and we cannot control.[00:09:11] And it's when we start to accept the things that make us human and the sometimes unpleasant realities of our lives—that is the birthplace of health. So here's where I want to say very clearly that acceptance is not about giving up. Acceptance is not about throwing in the towel. It's about making peace with the things we cannot alter and change in our lives.[00:09:36] Acceptance is not about being passive. It's about taking active control over the finite resources of our body, mind, and spirit. And so whether it's things that are innate, that are biologically fixed or that are emotional, behavioral, social, or even structural in nature, acceptance is about reclaiming the energy and brain space that is occupied by trying to change the things we cannot change, and then moving that energy into a more positive, productive place.[00:10:12] It's about taking charge. It's about being in the driver's seat of our health. Now, no one is saying that acceptance is easy. In fact, like I said earlier, this is where most people get stuck. And we don't often even know that we're stuck. But this is where we all get stalled out. Accepting things that we don't want to accept and that we desperately want to change, whether it's about ourselves or what happened to us or about other people or our environment is an extremely hard thing to do.[00:10:46] It's a process. It can be painful, and we're also never really done with the process of acceptance. But I will say it again, that acceptance is a necessary process of becoming healthier from the inside out. It's essential for minding the gap between our best intentions and the execution of them.[00:11:08] Acceptance is also part of this laddering up process to be able to more accurately tell our story to ourselves, to the people around us and then to our doctors. All right, so let's move up to agency. Agency is the next rung of the ladder. Agency is where it gets fun. It's a little sexier. It's where the action is, there's movement, there's momentum. [00:11:31] But remember, we can't get to agency before we have worked on acceptance. Why? Because we've jammed up all of this real estate in our brains by trying to control the things we cannot control. So here's the cool thing. Once you have put all of those facts and data into the box and you've accepted the things you cannot control, everything else is fair game.[00:11:53] Everything else is changeable. You can actually change the way you think, the way you feel, the way you behave. You can actually rewrite your story. You can tell a more accurate version of your story that is rooted in facts with all the junk and waste cleared out of the way. So what is agency? Agency refers to our capacity to exert control over our thoughts, feelings, and behaviors.[00:12:21] We all wanna live in that agency space. We all wanna make changes, be better. New Year's Day is a perfect example of aspirational, almost delusional agency at its finest. It's when people newly sign up for the gym, they drop the booze, they commit to yoga, I'm gonna start meditating we all say to ourselves. We're trying to get from point A to point B.[00:12:43] We're trying to make changes to be healthier. But if we haven't taken the time to understand the facts, the realities of our lives. And the medical data that is actually part of our health makeup, and if we haven't gone through the exercise of separating fact from fiction and accepting unpleasant parts of ourselves that we cannot change, then agency is gonna be uniquely challenging.[00:13:07] We are going to set ourselves up for failure, and by the time February rolls around the wheels come off the bus. And despite our best intentions, we default to factory settings, trying to get things done, and we're wondering why the hell don't we feel well? So that's normal. That is human, and this is what I see every day.[00:13:24] This is what I do myself. Instead of being intentional all the time, I'm reacting to what's happening in my external and internal world, and I spend a lot of wasted energy trying to control the stuff I can't control instead of leaning into the parts where I do have control and understanding where I have agency.[00:13:41] Let me give you an example of a patient I recently saw, and I'll tell you how we walked through the three A's. So, this patient is a middle-aged woman who's overweight, she has an arthritic painful hip, and she comes in to see me and she says to me, “Dr. McBride, I really wanna lose weight, but I can't. I can't exercise.[00:13:58] It's driving me nuts and I don’t know what to do.” So we go through her data. She has high cholesterol, she has pre-diabetes. Her BMI is in the obese range. On her x-ray, she has bone on bone arthritis. Some of her data is favorable. She has healthy lungs, she has a healthy heart. She has a stable job, a supportive spouse, and really good health insurance…

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Jessica Grose on the State of American Motherhood May 15, 2023

Show notes

Why are expectations about being a woman—specifically a mother—so unrealistic? Mother, author, and New York Times opinion writer Jessica Grose has a lot to say on this subject. Her latest book, Screaming on the Inside: The Unsustainability of American Motherhood, is inspired by her own shortcomings as a mother. She interviewed hundreds of women as part of the research process while writing the book. In it, Jessica shines a light on the current state of motherhood, and the historical context around the impossible standards for American mothers. In honor of Mother’s Day, Jessica and I sit down to discuss the narrative and messaging to parents that “they’re doing it wrong.” Jessica urges parents to learn to trust their instincts and to show up to parenting as their authentic, imperfect selves. Join me 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, review — and enjoy — the show!Transcript of the podcast 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 to 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 for more than 20 years, I’ve realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies. I’m here to help people tell their story, to find out, are they okay, and for you to imagine, and potentially get healthier from the inside out. [00:00:45] You can subscribe to my weekly newsletter at lucymcbride.substack.com and to the show at Apple Podcasts, Spotify, or wherever you find your podcasts. So let’s get into it and go beyond the prescription. [00:01:01] Dr. McBride: Today I'm interviewing Jessica Grose. She is a mother, she is an author, and she is a New York Times opinion writer who writes a lot about parenting. Her most recent book is called Screaming on the Inside: The Unsustainability of American Motherhood. I was immediately drawn to this book because it was inspired by Jess's own perceived shortcomings as a mother, something I think a lot of us women can relate to. The book combines in-depth interviews with mothers and a historical context on motherhood to help explain why our expectations about being a mom are so unrealistic.[00:01:37] I think there's a narrative that a lot of us women and mothers absorb that if we only read the right book, if we only had the right parenting expert on speed dial, that we could be the perfect mother when it's not that simple, and frankly, we need to be better able to trust our instincts to know that by showing up, by being a good person and by leading with empathy and curiosity about who our kids are that we are good enough. Jess, I'm thrilled to have you today. Thank you so much for joining me.[00:02:07] Jess: Thank you for having me. I just wanted to mention, we actually recently dropped the on parenting. I will still talk about parenting. I think my last column was about parenting related issues, but I wanted to have a chance to broaden my aperture a little bit, write about all sorts of issues, mostly cultural, but it's been exciting and I'm really looking forward to this year.[00:02:30] I mean, an example of that was I just did a big piece about midlife and millennials at midlife. I am one. I am an ancient millennial. I just turned 41.[00:02:39] Dr. McBride: What's the newsletter called now?[00:02:41] Jess: It's just my name, just Jessica Grose.[00:02:43] Dr. McBride: Okay, awesome. How cool is that though, Jessica, that you got to move from being a reporter, which I know you loved to giving your Opinion. I mean, anyone who knows me will tell you that. I love data. I love analysis. I love pouring through primary sources. I also have a few opinions and I love delivering them.[00:03:04] Jess: Well, I don't think that my approach has actually changed really radically. I do what I like to think of as reported opinion. It's unusual for me to just riff on an idea without including data or including interviews. Occasionally I will actually, my next column is just about Brook Shields' new documentary. And so that's more just thoughts about what it’s like to grow up in the public eye for a kid. And it’s unsurprisingly not great. It was really difficult for her to develop a sense of an identity. But typically I still do a lot of reporting. What it allows me to do is draw more aggressive conclusions from that reporting. And anyone who knows me in real life knows I have a lot of opinions, so it feels really nice to share them.[00:02:52] Dr. McBride: Well, I think that's right. It's the same thing in medicine. I have a lot of opinions, but it's rooted in my understanding of the medical literature and the understanding of the patient in front of me. So I'm never going to just say, do this because I said so. The fun is taking the data and the data in your case on motherhood and the historical context around it, and then giving parents and mothers permission to be less perfect than their Instagram highlights might suggest they should be.[00:04:23] Jess: Yeah, I mean I had just the genesis of the book was really just in having so many questions about where ideas that I had about motherhood came from. Because when you start to unpack them, they sound crazy. So one example that I often give is I was very sick during my first pregnancy. I had hyperemesis, so I was throwing up constantly. I could not keep food down. I got incredibly depressed and anxious. I honestly think in large part because I had hyperemesis, just as you cover, the body mind connection is very deep. Not being able to nourish yourself, it's tough to feel good in any way. And I had the question, why is there even the expectation that one should feel good during pregnancy?[00:05:16] Because I've known a lot of pregnant people in my life, and most of them do not feel great. Maybe they have moments where, during the second trimester, they're not enormous yet. They're feeling a baby kick. They're not sick anymore. Maybe you’ve got like two months of feeling pretty good, but often, there are many ways in which you can feel not your best self, and so every chapter of the book started with a question about an ideal that when you think about it for more than five minutes, makes absolutely no sense.[00:05:49] Dr. McBride: Yeah, it's interesting about the hyperemesis, and I heard you say in an interview that you leaned into the toilet, that was your lean in. So I had a patient recently in my office who is pregnant with her second child. She's in her second trimester, and so, so sick, like on her knees, in her bedroom. She's a congressional staffer and can't even really go to work most days because she's so sick. And she went to her gynecologist and she was explaining how sick she was to her gynecologist, her obstetrician, and my patient asked the question, “can I take Zofran or something for this nausea?” And the doctor said to her, and the patient's crying telling me this story, she said, “well, if you really can't function, I guess you can take some Zofran.”[00:06:31] That's a tough standard to hold ourselves to. If you're in the fetal position, then you can treat yourself to a medication that's exceedingly safe, particularly in the second trimester. Why are women so conditioned to suffering and why are we depriving them of the permission to experience highs and lows of pregnancy and motherhood, I don’t know.[00:06:55] Jess: Well, we're working against thousands of years of conditioning, right? I mean, the idea that mothers shouldn't be martyrs and sacrifice themselves, put themselves last in every situation. That is in all of our in some ways all of our religious texts of the major religions, it is there if you want to pick it up. I mean, in terms of pregnancy and the benefit risk analysis, I think particularly in the United States, and Emily Oster is obviously the guru on this topic, we have just over-rotated on risks and perceived risks because statistically speaking, many of the things we think of as scary and we shouldn't do them, are not damaging really at all, except in extremely unusual circumstances. [00:07:45] And so I think medication is one of those things, and particularly things that are seen to be non-essential. And it's always a question, well, it's like, well, non-essential for whom, and one of the big mental health related medications, it's even more for, where it's like Prozac in particular is that there's so many studies on SSRIs in pregnancy. So, so, so many and perinatal psychiatrists will tell you that the risk profile for those drugs is pretty good. Everybody needs to make that calculation for themselves. I am not pro or anti-drug. I'm pro making an accurate risk benefit assessment in every individual[00:08:31] Dr. McBride: You sound like my friend Emily Oster, and you sound like, and you sound like me, because Emily's a good friend and she was on the podcast and we've talked extensively about the level of scrutiny that we expect women to look at these risks with is exceedingly high. Eating blue vein cheese during pregnancy, having a thimble full of wine. Those carry risks, but so do being anxious and being depressed.[00:08:59] Jess: So does getting in your car every day, which [00:08:00] is probably the most dangerous thing that you do as a pregnant woman. That's typical. But we don't think of it that way because of complicated reasons. And I do think it's affecting not just how we feel in our own bodies and how we experience the pregnancy and postpartum period, but I think it's affecting how we parent and it's making us more anxious parents than we need to be. And to me, the joy of being a mother is watching my kids become who they are and watching them go out into the world and navigate it. And excessive anxiety about things that have risks but low risks really impedes relationship building that joy of watching them become their own people.[00:09:50] And that just makes me incredibly sad because it should be joyful. Not all the time. That's a big part of my book. Parenting is not joyful all the time, but there are parts that are incredibly joyful and validating. And so I think having too aggressive a feeling about risks and a scary world out there impedes the joy that we could feel.[00:10:15] Dr. McBride: Yeah, I think we learned in Covid that people in general do a pretty bad job of assessing risk. And then thinking about risk benefit ratios, we tend to overestimate risk when we're thinking about our children and we think about women.[00:10:31] Jess: Yes, and I don't blame anyone because the avalanche of information that all of us are getting all of the time, no one can parse that. You don't know who to trust. I feel lucky that I gave birth to my older daughter in 2012 when the social media ecosystem was not—I guess I would describe it as broken today. There were problems with it, but it wasn't, there just was less social media. There were no Instagram stories. TikTok didn't exist. It was not what it is today, and I made a concerted effort knowing myself that I tried and really didn't look for parenting information online. I did not follow any parenting as much as I could. I had one book, and the only book was the Mayo Clinic's Guide to Your Baby's First Year. And if I had a question, I would ask my pediatrician or I would ask my mom, and that's unfair to expect everybody to do because my mom is also a retired physician.[00:11:31] Dr. McBride: You have an advantage.[00:11:33] Jess: I have a home court advantage in terms of trustworthy, you know, people in my life. But I think paring down that is one thing I tell parents all the time. Pick a few trusted sources and just try to block everything else out because otherwise you're gonna drive yourself bananas.[00:11:53] Dr. McBride: I think it's great advice, because of all the information coming at us like a open fire hose, and because there's so much fear-based messaging and because we're predisposed to being more anxious about our children and society has made women more anxious about themselves for whatever reason. How do you guide people on deciding who to trust and who not to trust? What's the anatomy of trust in your mind?[00:12:16] Jess: So, I mean, number one, and again, expertise does not always equal trust, but always look at the credentials. Look at their credentials. See as much as you can. If they have a particular narrative on any topic that they are trying to push, see if they have any conflicts of interest in terms of payment through a certain company. All of the things that… it's sort of a journalistic way to look at the sources that you trust. And then the sort of X-factor is more just vibes. Are they making you feel bad about yourself? That's huge. So many advice givers on social media are invested in negativity.[00:13:01] Actually, there was just a great article in Vox about this, not specifically targeted at mothers, but saying, because negativity plays better in the algorithms telling you that you're doing it wrong will rise to the top and that's just not how I wanna be talked to about my parenting. Like, “you're doing it wrong and this is the right way to do it.” Well, piss off! My spirit is very contrarian. And so if anyone is telling me like, you're doing it wrong, I have just an immediate gut [reaction]—I'll do what I want. I've talked to so many people through my reporting days that they have the opposite reaction, which is like, I must be doing it wrong and I feel terrible. So if something's making you feel terrible, listen to that voice.[00:13:45] Dr. McBride: I think women walk around with that narrative on their own. They don't need help in many cases. I think so much of our messaging to women the historical context around this is about you're doing it wrong. You could be better. You're not enough. Your kids are messy, your kids are loud, your kids are emotional, your kids are this. And then of course we feel anxious. Of course we feel like we're not good enough. And so we have this narrative often that is, we are not doing it right, we're doing it wrong. And that is a narrative that dies hard for so many people and does inform the way they show up in my office as patients with insomnia, alcohol overuse, distress and malaise. The pressures we put on the American mother are enormous, and it's not like it is in other countries. Other wealthy countries don't have the level of scrutiny on mothers like we do in this country.[00:14:41] Jess: And I think there's been cross-cultural studies done on this, and parents in our peer nations actually look to experts less for advice because they feel more supported in their own communities and they feel more confident in their own instincts. And I think that there's a lot of complicated reasons why that is. [00:15:01] Dr. McBride: Could you talk about why you think that is?[00:15:03] Jess: Well, I mean, I think, you know, they orient their entire societies around children being more part of the day-to-day and having children behave as children do is just understood. It's not demonized. It's not, you're not worried all the time, that's everybody's gonna give you nasty looks in a restaurant.[00:15:29] It's like…

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