Should You Leave Your Child Alone With A Doctor? | Dr. Scott Hadland

0:00Doctor Mike: Some parents hate when the doctor asks them to leave the room. I think that the best care is delivered when the doctor asks the parent to step out and the parent obliges. There's talk I've heard on some specific news stations worrying that children are being groomed into different sexual orientations, gender identities. It's not possible for a clinician to convince a young person that they're a gender different from the one that they walked into that room thinking that they were. It's just not possible. I can't remember how this family found out that I was gay, but they asked me not to examine their child because they were worried about someone who was LGBTQ plus examining their male baby.

0:45Doctor Mike: How did you feel when they said that? Oh, it was enormously upsetting. That would have been 17 years ago and I still remember it. Parents naturally want to protect their children from drugs, alcohol, vaping, and the harm they can cause. But the harder adults push, the more teenager may shut down. So how do you intervene without losing their trust? Today's guest is Dr. Scott Hadlin, Chief of Adolescent and Young Adult Medicine at Mass General for Children and an Associate Professor of Pediatrics at Harvard Medical School. Sadly, one of his most valuable tools has become the center of controversy.

1:20Doctor Mike: asking parents to step out so he can speak privately with their child. Some parents fear that confidential time excludes them or even gives a doctor an opportunity to influence or groom their child. Dr. Hadlan explains why that conversation absolutely needs to exist and why attacks on it would only lead to worse outcomes for teens. We touched on so many valuable topics on this episode from the failure of America's DARE program, the status of marijuana and nicotine use amongst teens, the drug kids are using now more than ever, and whether young people today actually might not be experimenting enough.

1:56Doctor Mike: Please help me in welcoming Dr. Scott Hadlin to the Checkup Podcast. You know, I think one of the tougher vaccines, you know, historically has been the HPV vaccine, you know, with families and teens, because there's this perception that if you give a teenager a vaccine that protects against a sexually transmitted infection, HPV, that you're going to contribute to them having more sex. And of course, like data doesn't support that. But how do you talk to a family about this? I've got my approach, but I'm kind of curious what you do. Honestly, my approach is full on listening before giving any kind of feedback.

2:33Doctor Mike: Because for me to understand where I should guide the conversation, it's not, I don't actually guide patients to making a specific decision. I am almost a bit laissez-faire in my approach where I believe that I want to do the best for their child. I have certain data points in mind. I can make certain recommendations based on here are the risks, here are the benefits, but ultimately they have to make that choice. So I need to learn what's driving their decision to do it or not do it. And then if their reason for making choice A or choice B is not based in science or data or it's lacking science or data, I can give that information and then allow them to come to the conclusion.

3:19Doctor Mike: And the reason why I like that approach a lot is, A, doesn't feel like you're ever forcing anyone to do anything because you're actually not. B, you're leading with curiosity. So you make them feel like a human. You allow people to feel seen because that's what should happen during a visit. And then the final point is that it allows you to create a team-based mentality. And when someone from a motivational interviewing standpoint feels like they're making the decision and they're guiding it based on your expertise, suddenly they're way more likely to buy in. So that's my strategy. And again, it's gonna be so different depending on what concern someone has.

3:55Yeah, yeah, I completely agree. I think the one other thing that I'll add on is I do put a cell in there. So I'll say, we'll have the conversation, actually, I think really similar to what you just described. And then at the end, I'll say, this is a vaccine I do recommend for folks. And here's why, and I'll provide the health benefit information if that hasn't already come up. And now that I'm a dad, I'll say, you know, if it's true, I've got my kids fully up to date on all their vaccines up to the ages that they are. So, you know, they're almost nine and almost six. So they've gotten their vaccines up to those stages of life.

4:28But I'll say, you know, this is a vaccine that I made sure my own kid got. And here's why. And I think that that's helpful. Very helpful. Yeah. Because I think it's putting sort of my words where my actions are and my actions where my words are. And I think families appreciate that.

4:45Doctor Mike: I was gonna say it's valuable that you're able to do that and why it's so important to have a variety of different providers in a practice, parents, non-parents, different religions, different backgrounds, different appearances, because the more likely that you are to see eye to eye with somebody could be based on where you're from, what religion you follow. So being able to share that you're a parent can create buy-in. I see that a lot with patients of mine who are athletes. And before, when I was a resident and I wasn't performing in professional sports, it was a different type of conversation than if they're aware that you're a professional athlete or a semi-professional athlete because they go, oh, this person gets it.

5:27Doctor Mike: Right. And there's a little bit more camaraderie there. Right, right. Yeah. To your point about having a team that's got lots of different representation, it is sometimes the case that a family has said no to me as the white male doctor who has talked to them about vaccines. And then either a nurse or an MA comes in who has a different background, who is a woman, maybe not white. And the family connects with them. And actually it's that other healthcare provider who sort of helps to talk to a family about a vaccine in a way that builds trust and the family decides to go forward with it. That's happened more than once.

5:59Doctor Mike: Yeah. It's an interesting conversation to have because I never expect results on the first conversation. I think it's a lot of times unreasonable that, oh, I'm so good at this, that in a 15-minute encounter, I can change someone's mind. And I think that's where the elitist stance from us comes in. And I disagree that it's elitist. I think what is happening is we want to be effective because we actually want to do right by the patient. So it's less elitist and more we care so much, but it comes off as elitist. And it's like a good intention creating a bad outcome. So a big thing that I have to slow my residents down during their visits is explaining that they're not going to solve every problem.

6:41Doctor Mike: They're not going to change everyone's mind. They're not going to get optimal every visit. And they have to get rid of this hyper optimization mentality, not because it's not good to optimize someone's health. It's great, but it's also not practical. It's not realistic. Starting multiple medications at once is usually not a great thing because then you can't see where the side effects are coming from. It also can be confusing to be able to manage starting three different treatment plans at once. So I frequently have to pump their brakes a lot because they're just excited to deliver care. Do you ever see that play out?

7:12Yeah, I completely agree. I mean, I think on the vaccine question, I think historically we're used to families coming in and saying, okay, you know, we're ready for our vaccines today. Let's go ahead. And so this actually has become an area where we have had to slow roll a little bit because families have concerns based on the things that they hear. And I think having these conversations over time can bring families in, in the way that you described. And I think we're also helped by the fact that families don't have to get their vaccines from our clinics, right? They can take time to think about it and then go to CVS or, you know, somewhere else out in the community.

7:43And so I've started to take the same approach with vaccines as well, where I have a lot more sort of flexibility around figuring out the right approach for the family in front of me to make sure that that vaccine gets in, because I think that that's really important and that's my recommendation, but allowing for a different path that may be a little bit slower than the one historically where a family just comes in and gets it. But I think to your point about talking to residents and trainees about slowing their role a little bit, I think that's really important, especially in my own area of adolescent.

8:15I do a lot of adolescent addiction treatment, but a lot of adolescent mental health. And sometimes the only goal that I've got from a visit is just trying to get the adolescent on board to come back and talk to me again. I think there's a lot of teens who are brought into my practice, dragged in by the scruff of their neck by a parent who says, my son is vaping, my daughter is using cannabis, I need you to help me get them to stop. And that's an unrealistic goal for a single visit with a doctor.

8:45Doctor Mike: You mean you can't just wave a magic wand? I wish, I wish, right? But it's an unrealistic goal for a single visit where the teen's been dragged in and isn't on board and has a lot of ambivalence about stopping their substance use. But if I make it my goal to just build the rapport to get them to come back and talk again, in my mind, that's often a win. How do you make sure that you getting them to come back for another conversation and marking it as a win doesn't come off as manipulative to them? What do you mean by that? So for example, I am an adolescent in this hypothetical, and I'm listening to this podcast, and I go, oh, so basically, this first conversation is just them trying to win me over.

9:28Doctor Mike: So this isn't even who they are. They don't actually care about me. They just want me to come back for visit two. So I'm going to be wise here and see this thing play out. So what is the purpose of bringing them back for visit two? What are you trying to achieve? Well, that's a really good point. I mean, the first visit, yes, sometimes my own personal goal is to get them to come back so that we can talk some more. But the rapport building is really focused on finding out what are their goals, right? So, you know, if you take a motivational interviewing approach where you're trying to find out, you know, what are the things that are bringing this adolescent into the behavior that their parent has brought them in for, right?

10:04So take the example of vaping. You know, if you dive deeper and find out from the young person, like, why is it that you vape every day? What is it that you're getting out of it, right? I think teens are used to hearing all the negative consequences of what they do. But a few people stop to actually ask them, what are the positive things that you're getting from it, right?

10:24Doctor Mike: Do you think they've already had that answer in their minds, or are they shocked by that question? In some cases, it's a surprise. In other cases, they know. So I'm thinking, for example, teens who use cannabis and use it to help themselves sleep, right? They might be able to say out loud, like, oh, actually, now that I think about it, I'm using it all the time to help myself sleep. And that's not a surprise to them. But it might be that they sort of light bulb. A light bulb goes off when they're talking to you, and they realize that, oh, you know what? The main reason I vape is because if I didn't vape around the group of folks that I'm hanging out with, I would feel like I don't fit in.

10:59And I just really want to fit in. Yeah.

11:01Doctor Mike: Go to that level. Yeah. Self-analysis. Yeah, exactly. But I think that that takes a deep conversation, right? And so the idea here is to understand what are the motivations and then as a pivot from that to then find out, do they have some goals of their own? I think often I find if I dive deeper, even a young person who comes in and says, my mom brought me in because I'm using cannabis. I smoke it every day. I don't want to stop. If we dive a little bit deeper, sometimes I'll find that actually, you know what? Cannabis is costing them a lot of money. And it would be great if they could cut back a little bit because if they cut their cannabis use in half, they could save maybe a couple hundred bucks a month and that would be a big deal.

11:38And so they get to sort of continue the cannabis use that in their minds is positive. But we also get to have a clinical win as we start to identify things that we can ally together on. So that's the goal of these first few visits is to figure out some of those goals together.

11:57Doctor Mike: I've run into issues in dealing with this evasiveness, perhaps apathy at times from the adolescent population. Do you ever struggle with that? Yeah, yeah, it can be really challenging. I think the toughest parts or toughest times are when somebody comes in and just doesn't want to talk at all. And that's hard because then you don't have a ton to work with. So I do the best I can. I show up, I try to come across as a friendly doctor. And even if they aren't able or willing to say a lot back to me, I can still send the messaging that's really important to me to have them here. And that includes things like, look, I'm here as a doctor.

12:34I think a lot of people are used to the idea of drug treatment as being a place where it's very prescriptive and people tell you what to do and they're going to tell you to stop. Look, my goal, obviously, is to help you cut back or stop. Otherwise, we wouldn't be here. And yet, I think that there's probably ways that we can partner together on this. There are probably some things that you're finding about your substance use that you don't like and that we can partner together on, on, you know, reducing that harm or cut back on the amount that you're taking in a way that will benefit you and will leave you happy.

13:09Doctor Mike: Do you ever have scenarios where the parent comes in, they go, my son's daughter vaping, want them to stop. You bring them out for an encounter, the kid in for the encounter, and you realize you're not going to be able to do it in one visit, two visits. You're getting a lot of pushback. They're not interested in stopping. The parent gets mad at you. Does that happen? Yeah, I think there can be a misalignment. Unfortunately, I think a lot of parents, because they're really struggling, right? Like they're watching as their teen is using substances heavily. Well, because they're not doctors and seeing numerous patients and not knowing how hard it is to get someone to change your behavior, they might assume, what do you mean?

13:49Doctor Mike: I brought them to the doctor. They should stop. Right. Yeah, exactly. And it's distressing for a parent to watch their kid use substances and to not be able to stop it. And I think that's the place where we sometimes run into problems is that if parents have expectations that we'll be able to solve this in one visit or even two or three visits, often that's not a realistic expectation. Got it. So how do you set those? Just being upfront, clear? Yeah, I mean, they come on board over time. I think it is really important for me to sometimes say out loud that, you know, this is really a long game here, that we'll continue to work at this.

14:21And one of the most important things that I want to do is build a relationship with your son or your daughter so that we can move the needle over time.

14:28Doctor Mike: What substance has been in the last 10 years most difficult to get an adolescent, a teen to stop using? Yeah, I mean, in our program, we care for teens and young adults between the ages of 13, all the way up to age 29. So we see a big age range. We see a lot of different substances. We see nicotine. We see cannabis, alcohol, stimulants, opioids. I think the most distressing for me over the years has been opioid use because I've had patients die of overdoses, incredibly tragic and heart-wrenching. And those have been the hardest parts of my practice. But interestingly, opioid use disorder or opioid addiction has evidence-based medications, has FDA approved medications that we can use to treat it.

15:10And so there's often a lot of opportunity for hope to keep people safe and help people enter into recovery. Cannabis use has probably been the single most challenging because we live in a world in which cannabis is often - It's just a little weed. It's natural, it's green, it comes from the earth. You can't get addicted to cannabis. Is that true? You certainly can have a cannabis use disorder, which is the sort of like clinical term that we use for cannabis addiction, right? And so in that sense, yes, cannabis is addictive and probably not in the same sense that a lot of people think about it.

15:45I think people think of like, oh, I need to use again, I need to use again, I need to use again. Most people who use cannabis -

15:51Doctor Mike: So it's less of a physical dependence or is that like nomenclature thrown out already? Yeah, I mean, we tend to move away from using the term dependence, but I think it's still a helpful concept to be thinking about, right? Like you stop using opioids and you will feel miserable, right? You'll break out into sweats and you'll have goosebumps and you'll feel just, you know, diffuse pain and terrible, right? You stop using cannabis. Many people will get anxious or have difficulty sleeping, but it's a milder withdrawal. And so I think a lot of people think that that means cannabis isn't addictive, right?

16:24But the way that we think about cannabis, when I use that sort of like, you know, overly clinical term, cannabis use disorder, what I'm thinking is cannabis use that results in negative consequences for a young person and whose use can spiral out of control.

16:37Doctor Mike: Can't that be any substance? Sure. Even like something super benign, soda can become sugar dependence, use disorder. Sure, yeah. So like we can technically replace that. So how does a problematic use disorder of whatever substance become addiction or not become addiction? Like where is the line there? Yeah, I think if you want sort of like a line or a litmus test, for me, it's all about function, right? So we were just talking before we came on here about how much caffeine I drink a day. I tend to have two or three cups of coffee. I try to limit my caffeine intake, but I struggle without it. And so you could say, does Dr.

17:18Hadlin have a caffeine use disorder? Not a cannabis use disorder, a caffeine use disorder. And you can make the argument for it. But actually, interestingly, caffeine helps me to function. There's a way in which I function better when I've got caffeine. And so I would say probably I don't have a caffeine use disorder because my functionality is improving. And so a young person who is using cannabis and starts to have difficulties with grades at school or their relationships are starting to deteriorate or they're spending lots of money on it or they're driving using cannabis and putting themselves at risk, those are negative consequences and use that's starting to get out of control.

17:56Doctor Mike: So then what do you say to folks who say, I use nicotine and it helps me be sharper, regulates my emotions? I feel like it's only a net benefit. Yeah. I mean, there are a lot of people who would say that, right? I think the first question to ask is, is the use spiraling out of control? Because some people who use nicotine find that, oh, they need to use more and more and more in order to sort of get the same sort of feeling from it that they used to and they experience really bad withdrawal symptoms if they stop and they may be spending more money on cigarettes or e-cigarettes or nicotine pouches or whatever it may be than they intended.

18:36So I think that's thing number one. Thing number two is, is that nicotine use starting to cause harm to their body? We would consider that to be part of an addiction. And so if somebody who, for example, was heavily smoking cigarettes and couldn't stop, we would view that harm that the cigarettes are doing to their body as a sign of a problem.

18:55Doctor Mike: But what about non-combustible nicotine use? So pouches, patches, et cetera. Yeah. So this is the interesting era that we're in right now is that there's new delivery modes of nicotine. And that's hot on the podcast world. Much less, much less harmful, right? Yeah. And so actually like one of the harm reduction approaches that I will sometimes take with my patients, particularly young adults, is if they are using e-cigarettes or cigarettes really heavily and they're looking to reduce the harm, because we know that e-cigarettes probably do have some harm, much less harm than traditional cigarettes, but switching to a nicotine pouch, probably a safer switch to that.

19:30Yeah. Yeah.

19:30Doctor Mike: From a risk reduction standpoint, for sure. Do you see that being as successful as the producers are making it out to be? Because they essentially are saying any regulation of these products, removing the bubblegum flavors, the colorings to make the packaging fun, that is harming our ability to risk reduce versus the argument on the flip side is, well, by making it attractive to teens, are you getting them into the nicotine gateway? Yeah, where do you stand on that? For me, I think that if they believe their products to be truly a risk reduction modality, it needs to be treated like a risk reduction modality and regulate it as such through trials, through FDA, as opposed to, oh, this is just something we sell at the pharmacy to help people quit.

20:22Doctor Mike: Well, no, if you're gonna make that claim about it, it needs to have the data behind it to make that claim. Therefore, you treat it more seriously and you're not putting in bubblegum flavors and you're creating a little bit of a barrier so that it doesn't reach the community where they can get addicted and now escalate as opposed to deescalate. Yeah, yeah, I think that's right. We have this balance that you've talked about on the one hand, initiating young people into nicotine use because the flavors are attractive versus helping people who have been using nicotine for a long time quit or cut back by using a less harmful mortality.

20:59Doctor Mike: And then there's this third world where people are just saying, well, I'm just using nicotine because I think it helps me be more functional. And that may be okay, right? I mean, that's certainly the way that people have traditionally viewed alcohol, right? Not necessarily more functional, but a glass of red wine with dinner is something that many people enjoy, right? I think this is a sort of argument potentially in favor of everything in moderation. I think if we're talking about adults who are making choices that aren't causing severe harm to themselves, then sort of my libertarian view is that that may be okay.

21:29Doctor Mike: Yeah, no, I think absolutely that's normal because nicotine products, once you reach a certain age, you're an adult. You make your choices, you can go buy Nicorette or whatever over the counter. but the problem is when it is accessible to kids, just like with kids drinking, et cetera, it changes the way that they make their decisions. It makes them become more highly addictive in their personality and seeking highs, experiencing lows, et cetera. So I feel like it's a slippery slope going down that pathway. Yeah, I mean, I think what has been helpful for me as somebody who helps a lot of young people cut back or quit nicotine is to have other options, right?

22:11So I view the FDA sort of like acceptance of nicotine pouches and flavored e-cigarettes as potentially tools that can be harnessed to help young people cut back or quit or reduce harm. And that for me is important. But I do share the very same concern that, you know, having flavored products, we know that the vast majority of young people who use e-cigarettes are looking for flavors. They do it because they like the flavors, right? So that is a slippery slope, and I do worry a lot about that.

22:39Doctor Mike: Do you have any patients who use nicotine successfully? I think it's probably the case that I do. I think what is really tricky about substance use is that there's often a lot of layers to it, right? What you view on the surface as somebody who says, oh, I'm using this in a way that's safe and that's benefiting me, you know in the case of say nicotine right um in sort of you know moderation um i think often there's a lot more going on beneath the surface that i may not ever know about as a doctor so i'm a little bit skeptical uh when somebody um that i'm seeing is it feels that they're fully in control i really want to i really want to explore that and understand um and try to figure out if things may be going in the wrong direction i actually find by the way that like one of the most effective things that I can ask as a doctor, you know, I'll have young people come in and say, oh, I smoke cannabis every day, but I don't have a problem.

23:35I could quit any time, right? And again, you know, different for teens. I think teens should not, well, I know teens should not be using cannabis because the studies show us that it's unhealthy. But for an adult who's using cannabis intermittently, again, in the safety of their own home, not causing anybody harm, not causing themselves harm, it's probably okay, right? So where do you sort of like, where do you draw the line here? And I think one thing that's really helpful for me is if somebody tells me, hey, I don't have a problem, I'll spend a little bit of time exploring that. And I'll say, what would it look like for you if you had a problem?

24:09What is the line you would have to cross to know that you're starting to slip? And then I'll take stock of that. I'll write it down. I'll put it in my note and I'll revisit that in the future because I think that the natural history of addiction in a person is that it gets worse. Is the barometer keeps shifting. Yeah, exactly. It gets worse over time, right? And you will cross that line and I can reflect that back to a patient.

24:30Doctor Mike: Yeah, it's interesting because I do that sometimes in other ways in helping with mental health counseling where if they have a social phobia or just generalized anxiety disorder and they're worried about something that's about to happen, we ask them to put a number on it and then it plays out and then they put a number on it after it's played out and they see that their worry was asymmetrical in what actually happened, that gives them courage for the next time to reflect on that moment and on those numbers. You're doing it on the opposite end, the scales. Yeah, yeah, I do think these scales can be really helpful, right?

25:04Like I think the whole point of motivational interviewing is really to identify that discrepancy, right? When there's a difference between somebody's perception of what's going on and what is actually going on, that discrepancy can be really powerful to highlight.

25:16Doctor Mike: I remember in my childhood, I grew up in Brooklyn, New York, went to a public school system, first eighth grade, moved to Staten Island High School, dare. That was the program that I had every single day. Last I heard, this program phenomenally failed us. Is that true? Yeah, yeah, that's true. Because it was like, just say no, hyper simplified. Where did they go wrong? Yeah, focusing just on refusal skills has not been effective, right? So the idea that you can just tell people how to say no or to say no, and that that's enough isn't accurate. Actually, one of the most helpful messages, if you look across all the different preventive programs that have been studied and looked at sort of what are the key ingredients of those studies, one of the single most important things, and I think this is actually really helpful for all pediatricians, family medicine docs, and folks who are talking, teachers, parents, folks who are talking to teens to understand, one of the single most important key ingredients of a good prevention program is helping a young person understand that substance use isn't inevitable, that not everybody uses drugs and alcohol, and that in fact most people don't use drugs and alcohol.

26:26And there's actually been an enormous public health success, not because of D.A.R.E., but in the last two decades, we've seen as drug and alcohol use rates among teenagers have actually hit all-time lows. And in fact, the National Survey on Drug Use, which is one of our major national surveys of drug use in teens and adults, just came out yesterday, the latest 2025. results. They lag by about a year. And again, this historic decline in use of nicotine through vaping, alcohol, cannabis, other illicit drugs have all been at historic lows. And in fact, like two thirds of high school seniors at the time that they're graduating from high school have not used any drugs or alcohol in the last month.

27:09Doctor Mike: Some would say that's a bad thing. You mean that that number isn't high enough? Yeah. Yeah. Well, I think - What's your take on that? Well, I think it probably doesn't match up to many people's perceptions, right? I think a really common trope in our society is that every kid is going to use drugs or alcohol, right? And that may be true that the majority of young people will have tried, most commonly alcohol, but like a drug or alcohol by the time they graduate high school. But it's certainly not the case that they're using frequently or even recently at the time that we do these surveys in young people.

27:40And I think, again, the idea that if we can help young people understand that it's actually kind of normative for them not to be using substances, that's actually one of the strongest things that prevention can do.

27:51Doctor Mike: I kind of meant it more from a standpoint where people say teens aren't experimenting enough and learning about themselves and are not getting into trouble as often. They're spending more times in this closed, controlled environment at home, digitally encompassed from the third spaces of the real world. Do you feel like declining drug experimentation is a reflection of that? It might be a reflection of it, but I might sort of leave that outside because I think we know that drugs and alcohol are harmful for the developing teen brain. And so if rates have gone down in drug and alcohol use, I'll take it as a win.

28:30Yeah, exactly. But I think you're getting to a deeper and more fundamental and pervasive issue. And that is that by behavior, young people's health right now is really in a better place than it's ever been. And not just when it comes to use of drugs or alcohol, but also, for example, like sex and pregnancy rates in teens. And there's all these different risk behaviors that are actually going down in young people. And yet we actually have one of the most psychologically distressed generations that we've had in a while, right? At the same time, anxiety rates are really quite high. Rates of depressive episodes are really high.

29:07Again, this all came up in this new National Survey on Drug Use of Health Report that came out yesterday, that actually one in five adolescents has moderate to severe anxiety. About one in seven has had a depressive episode in the past year. And those are really high percentages, right? These are things that we need to be worried about. So in many ways, the behaviors have gotten safer, but the well-being of young people has actually seemingly gotten worse.

29:32Doctor Mike: Do you believe that to be a correlation that two things are happening simultaneously or does the fact that there's less risky behavior somehow negatively impact mental health? I don't think we know. I don't think we have the studies to know. My best guess is that all of these things are changing at the same time and some things are influencing others and it's pretty complex. I think that it's entirely possible that risk behaviors affect mental health and mental health absolutely affect risk behaviors. But it is interesting to me that they seem to be going in opposite directions. Because I think about the numbers of kids using drugs going down and I go, win, right?

30:11Doctor Mike: But I also know that if I trap a kid in a room, that kid's chances of using drugs will also be zero, but that doesn't necessarily mean we're making their life better. So I just think about all these trade-offs of at the cost of what, Right. That's what I, whenever I hear someone make a video that like veganism is the best diet, paleo is the best diet, or this is the healthiest food. It's like in replacing what? At what cost? What are you missing? What are you losing? I try and zoom out and be as holistic as possible in understanding what recommendation I'm actually giving. So I'm always like, oh, are we like locking our kids in a room because we're so worried about drug use that then we're decreasing drug use, but we're making them actually less healthy.

30:54Yeah, yeah. I think it's a good point. I will say that there are some other things that have gone in the other direction. So energy drinks, for example, have absolutely taken off in young people, especially like the high caffeine energy drinks that have anywhere from 200 to 300 milligrams of caffeine. And use of those has actually gone up a lot in young people. So it's not necessarily the case that everything has gone down. Some things do spike, which suggests that there's still some risk going on there. So I think it's entirely possible that we've had kind of a a public health win on the drug and alcohol front.

31:27I don't think it was DARE. What do you think led to that? Well, I think that our public health messaging has gotten more effective.

31:34Doctor Mike: You think so, though? Yeah, I think so. I think also, especially in the case of, for example, opioids, young people watched as overdoses just kind of rampaged the youth population, peaking in 2022, and they've actually declined in the last few years since. And I think part of that is just a public awareness of drugs and alcohol as a problem. I hear you skeptical. I'm just a little skeptical from a public health win because I've never seen a unified front on that outside of the opioid Narcan being everywhere or something. I also, when we say opioid overdoses, I don't even know if that's the right term in many of these instances because they almost feel like poisonings.

32:13Doctor Mike: You know, kids are going in or teens are going in and using what they think to be Xanax or shrooms or cannabis and it's laced with fentanyl and they have an overdose. So like, is that really an overdose or is that, should that be counted differently? I don't know. What is happening actually on the - Yeah, I mean, that's a really good point. I talked to a lot of parents who have lost a kid to overdose and they'll tell me, you know, it wasn't an overdose. It was a poisoning. You know, he or she thought that they were taking one thing and it ended up being fentanyl, something completely different.

32:41Doctor Mike: And that's what happened. And so I think you're right to be sensitive to this idea of is it an overdose or is it poisoning? Because I think that language matters to families. We hit an all-time high for overdoses in 2022 among adolescents and young adults in this country. And it was really bad. I mean, the equivalent of a high school classroom of teenagers was dying every week across the country in 2022. Those numbers have gone down. I would love to think that it's because we had really strong public health messaging. So did we have really bad public health messaging prior to 2022? What was driving the numbers going up?

33:18Doctor Mike: Obviously, pandemic played a role here. Yeah, I worry that as much as we are doing all the right things, we're trying to get the messaging out about the dangers of the drug supply. We're making sure that people have access to naloxone to reverse an overdose, that they know how to intervene in an overdose, identify the signs of an overdose, call 911, those sorts of things. They were doing a better job, although still not a great job, of getting people into treatment when they have addiction, even though we're doing all the right things. I am humbled by the fact that I think it is probably related to the illicit drug market and the changes that take place in it.

33:50And so those spikes that we saw leading up to 2022 in young people's deaths were largely driven by illicit fentanyl getting into the drug market. You know, illicit drug manufacturers making products that looked like real opioid tablets, right? Real oxycodone, but actually contained fentanyl at a lethal dose. And that was contributing to overdose deaths. And I worry that part of the quote unquote win that we've had with rates of overdose going down in recent years is actually related to drugs in the illicit drug supply being less lethal than before. Wow.

34:25Doctor Mike: So you're saying the drug dealers have cleaned up their behavior somewhat and it's actually improved their health? That's a unique thing to think about, right? I mean, it's like. Well, you know, the decline is one that so few people have a great explanation for. And I do not have one. And I know that we're doing better, that we are doing the right things. But I don't know that we're doing enough of that to really explain the decline that we're seeing. I think that is part of it. We're always thinking about supply versus demand, right? So when we think about drugs, the supply side is the drug manufacturers and the illicit drug markets that people buy drugs on.

34:59The demand side is people who are using drugs or alcohol and are purchasing it, in this case, on the illicit market. So when we're doing all the things that we know are important, like preventing drug use in the first place, getting people into treatment when they have addiction, making sure that we are supporting social determinants of health, that people have good housing and good health, generally speaking, we're focused on that demand side. We're trying to make it so that there are fewer people that need drugs or are buying drugs. The supply side is where law enforcement comes in and where interdiction comes in.

35:33And I think in this country, we've had a pendulum swing back and forth where so much of our drug policy for decades was unsuccessful, really focused on the supply side, law enforcement side with almost nothing on the demand side to reduce people's need for drugs. The pendulum has swung a lot, and we've done a lot more on the demand side. I think there are some people who think the war on drugs was a complete failure, and by and large, it was. and then the next logical thought for many people is therefore law enforcement and sort of interdiction has been completely unsuccessful i think we have to be a little bit humble and sort of acknowledge that probably both these sides of the equation are important i personally as a doctor focus my efforts on the demand side and that's of course the part i really care about

36:24Doctor Mike: from an evidence-based perspective impacts demand side clearly well we know that prevention likely prevents people from using drugs in the first place. And that's probably one of the cheapest things that we can do. So prevention, how would you define that in your mind? Yeah, I'm thinking about good old fashioned drug prevention in high school, for example, and even before that in middle school, but not dare. Only because dare is focused on the wrong skills, right? So what skills are the good programs teaching? So actually the good programs often aren't focused on, and we're talking about here, middle school programs and high school programs for the most part, drug prevention programs, often aren't wholly focused on drugs.

37:03They're often focused on teen mental health and well-being. And so more important than telling a teen to say no to drugs is actually making sure that that teen has healthy coping skills, that they know how to manage stress appropriately, that they are building good interpersonal relationships and communication with their peers and with trusted adults, that all of these things. How do they teach that? Well, so a lot of this is around sort of like thinking about skills like mindfulness, for example, that when you impart mindfulness skills on a young person, they are more likely to focus on healthy ways to cope with stress than to turn to a drug or alcohol.

37:40And we know that a lot of drug and alcohol use in young people is actually driven by feelings of hopelessness, by feelings of anxiety, in some cases like impulsivity.

37:51Doctor Mike: So this is interesting because mindfulness as an adult, more developed, mature mind can find their way to peace away from anxiety. I could see someone drawing the connection and saying, okay, you taught teens and kids mindfulness. You got them from using drugs, but now their mindfulness is super mindful of their insecurities, anxieties, and now you've created this anxious generation. Is that happening or is that I'm reaching here? Well, it's interesting, right? Like I think one possible underlying explanation for why rates of depression and anxiety are high right now is that the stigma associated with reporting those symptoms has probably gone down, right?

38:29I think we've become a society that still has a long way to go, but it's gotten friendlier and less stigmatizing towards people reporting their mental health symptoms, right? And so some of this might just be people being more comfortable reporting what they didn't use to feel comfortable reporting, right? Makes sense. So I think that that's a piece of it. I think it is important for people to have mindfulness about what it is that they're feeling and how it is that they're going to respond to that. Because we, again, we just know that the links between mental health problems and drug and alcohol use are so strong.

39:02And we really want to disrupt that link, right? We want to make it so that if somebody is feeling distress, they are doing the healthy things, the evidence-based things, and not turning to drugs and alcohol.

39:13Doctor Mike: It's interesting for me, growing up with a Soviet father, very strict, very just focused on school mentality. I'm thinking about what he would say in thinking about mindfulness and whether or not he would, because he's also a physician, family medicine physician, very much towards the tail end of his career. Also educated in two countries, interestingly enough, in medicine. So he went to medical school in Russia and the United States and in residency in both. So interesting perspective from him. His stance would largely be that puberty, teenage years is a time where you go through phases so often.

39:50Doctor Mike: And if you spend so much time checking in and thinking about all these anxieties, it might lead to more confusion rather than less. Do you ever see that play out? Well, I do think that, I think having a healthy self-awareness about what you're feeling is really critical and important. I think a lot of people don't have that even as adults. And I think adolescence is a good and important time to really start to learn that about yourself so that you can learn the right ways to deal with life stressors, right? So I do stand by that. I do think we can over-focus on it, right? I think that when it comes to anything mental health related, there's an aspect of it that really does need to be immersive.

40:31You need to understand what your symptoms are. You need to understand how you respond to those symptoms. What are your thoughts and emotions? That that's a really important part of mental health. But so to are all the other aspects of your life, right? Like getting out of the house, getting a little bit of exercise, engaging with people, going to school, going to work. And some of that, and you know, your patients and my patients will tell us this, that actually like distractions are helpful. If you're experiencing anxiety or you're experiencing depression, the distractions are helpful. So I think there are elements of both, but I do stand by it's important for people to understand what they're feeling.

41:05Doctor Mike: Right. Do you give any credence to this social contagion conversation that's happening across social media where folks say, you know, it's almost become in to discuss you going through a hard time, that you're going through a generalized anxiety disorder diagnosis, where it starts almost impacting kids who are experiencing normal physiologic feelings, like anxiety, like feeling down for reasonable situations. Their friend just died and they feel sad and they self-diagnose with a depressive disorder. Or they have a test coming up that they didn't do well in the previous one. They're feeling nervous.

41:44Doctor Mike: They self-diagnose with an anxiety disorder. Do you see any of this social contagion being discussed in a meaningful way? Yeah. I mean, I do think it's important for us to, for you and me, when we're talking to young people, to be thoughtful about our language and how we talk about this stuff, right? Because I think it is easy, especially in a place or in a time when we are so open about talking about mental health, which I think by and large is a good thing. I think some people can be a little quick to sort of self-diagnose, right? And that's, I think, the role of doctors is to help sort of cinch that diagnosis for them, right?

42:19I think we'll be in business for a great many years to come with some of these issues. But I think it's really important in my work to make sure that a young person understands that not every stressor equates to them having anxiety, right? Not every heartbreak equates to them having depression, that not every bad thing that happens to them requires a fatalistic response. Because I think that that's where we can over pathologize. I think we want to be friendly and thoughtful and welcoming to people who have mental health problems. And yet at the same time, help people understand when some of the strong feelings that they're having aren't necessarily part of a mental health diagnosis, but are a part of the human experience.

43:03Right. Right.

43:03Doctor Mike: Do you ever get, you say that to a kid, you say, this is part of the normal living experience. It's actually valuable to feel sadness, anxiety, and they then feel written off as if you just don't see what they're going through. Yeah. And for exactly that reason, I probably wouldn't take that approach. What would be important for me is to understand the ways in which the feelings of sadness they're having, the feelings of anxiety they're having is impacting their life. and so once I have that information, I can reflect it back, right? Like a diagnosis of generalized anxiety disorder just really causes chaos in a person's life, right?

43:41It makes it so that they can't go out, they can't do things, right? If a young person is otherwise, you know, largely functional but is experiencing stress around, say, you know, final exams or stress around like a friendship that they're having a problem with, I can often help reflect back to them like, you know, it sounds like you're really struggling in this one domain of your life. I'm also seeing that other parts of your life are still intact and working well. So that to me suggests that, and I think this is hopeful for me, that if we can help address this one specific aspect of your life, then things will get better.

44:15Yeah. I struggle with that a lot because it feels like there's been this shift on social media where it used to be that if you said someone was,

44:29Doctor Mike: and I'm gonna take anything that's triggering out of this equation. So if you used to call someone a diabetic patient, it would be viewed as potentially stigmatizing. But now folks are wearing their diagnoses as a proud label, and it's empowering to be a diabetic patient. And again, I'm using diabetes specifically, So it's not taking anyone who is diagnosed with autism. That's a frequent one. How dare you call that child an autistic child versus some with autism love and own the label of being autistic and neurodivergent. So how does that play out in an adolescent encounter? Well, I think I'll first preface this by saying I'm supportive of the moves that we've made.

45:15I think we, you know, so many pendula tend to swing so far to either side, right? I'm appreciative of this pendulum swinging in a direction that I think has been really helpful and meaningful, that people, rather than feeling stigmatized for having a disease or having a mental health condition, actually feel like they can speak openly about it, including on social media, which 10, 15, 20 years ago would be a huge risk for a person to make. right now, it's certainly much more accepted. And we have online communities that help support people. So I, I'm appreciative of that move. But I, I also understand where you're coming from, that I think we also need to ensure that communities of people that are living with conditions don't feel that their community is sort of being affected or changed or altered by people coming in who may not have that diagnosis or, or maybe sort of sharing their own story about that diagnosis and generalizing it to everybody and saying this is the uniform lived experience of everybody.

46:17I think we have a lot of work to do to help support people in building these communities and keeping them medically accurate and making sure that folks are getting the support they need.

46:26Doctor Mike: Where do you think the most common breakdown is for an adolescent discussing mental health with a provider these days? What do you think we're doing wrong if we're not as trained as you are with as much experience as you have? Yeah, I mean, I am not, I am not perfect. In fact, if anything, I think the two things I have on my side is that I've done this a lot now. Sure. And I have a little bit more time. I work in a practice where we've made sure that everybody has 30-minute visits with teens, which is a lot of time for us to spend time confidentially with a teen, asking them questions where we're trying to get at their mental health, potentially with a parent out of the room, if that helps to elicit better answers.

47:07And so I think I have the right setup to be able to do this. But I'm not perfect. I think that probably the single most important thing that clinicians can do if they're not already doing it is actually less on the detection side. Because I think that many practices are doing a good job of screening for mental health conditions. We're not perfect, but we've gotten better. Many parents are good at bringing in a teen if they're struggling with mental health problems. The thing I worry about more is that when a problem is identified, does that young person get connected to good services? And those good services can be a counselor or a therapist.

47:40We know that that's helpful. It can be that clinician themselves providing a medication, like an SSRI that's evidence-based to treat adolescent depression or anxiety. It's that link that I worry more about.

47:54Doctor Mike: What's your take on an Elon Musk, for example, who's very anti kids being over-medicated with SSRIs or just medications in general that are mentally active? Well, the studies don't support it, right? So if you look at the science, we know that SSRIs, medications like fluoxetine or sertraline, which go by the brand names Prozac or Zoloft, are effective. We just know this. There have been dozens of studies looking at this, high-quality, effective clinical trials, observational studies that just all point to the same answer. And then, I mean, I'd love to hear your response to this because I see them help in my patients.

48:31Doctor Mike: Yeah. Obviously, I see them help as well. I also am not naive to the idea that there's many practices where they don't have half an hour. They don't have the training to actually tease out whether or not this is a child who is going through a normal down moment, puberty moment, anxiety-provoking moment, and reflexively prescribed because they checked a few boxes on the PHQ-9 or what have you. So I don't believe that every prescription has been adequately assessed. But that doesn't mean you throw out all the prescriptions that are adequately assessed and are following guidelines and are appropriately used and backed by science.

49:15Doctor Mike: So I feel like there might be a personal experience that's driving that decision for him or that statement for him. Yeah, yeah. I completely agree that the challenges of medical practice where we are all rushed and don't have enough time to gather information to the extent that we would all like leaves us limited and can put us at risk of doing exactly what you described. I guess the other thing I would say, and here I'm admitting a little bit of fault in our medical system, is that there are, to me, elements of truth in the push right now to, the push is sort of like deprescribe, right? The idea that people who are on SSRIs need to have them stopped, that the data have never really fully supported people being on them for the long periods of time that they are on.

50:06For sure.

50:07Doctor Mike: We've definitely talked a lot about that on this channel. Yeah, I bet. I bet, right? And so I feel very strongly that most doctors are engaging in good clinical practice, that they are thinking about this, that they are reassessing with their patients whether they should be on a medication. We routinely do decrease prescription doses and discontinue medications altogether and do it in a safe, monitored way. This happens all the time. So I don't want people to think nobody's ever discontinuing an SSRI prescription once it started. But I do think we as a medical field and as a research field have work to do on this front to understand like when is the right time and what does that dose reduction and discontinuation look like?

50:50Doctor Mike: Yeah. I don't oftentimes use vocabulary, medical lingo vocabulary when discussing a lot of these topics because we're talking to people who are perhaps not in the medical field. And in this one instance, I'm trying to find the right word so we can get a little bit of academic backing for this theory that I've had. Maybe you can help me brainstorm live on this. So you're obviously very familiar with survivorship bias. The classic example for the audience at home is a World War two plane comes home, multiple of them come home, they have bullets, holes across specific sections of their plane. And people say, well, if that's the place the plane is most likely to get hit, we should put armor there.

51:37Doctor Mike: And the actual survivorship bias would teach us the opposite. Where they don't have bullet holes teaches us that that's where you put protection because otherwise they don't come home. So it's like what you see is actually the opposite of what's happening. So on social media, we see basically an example of survivorship bias, the worst health outcomes where doctors don't spend enough time, patients are hurt, you have parents that are like, the doctor didn't even examine my child properly to know if they have a mental health condition before prescribing SSRIs. And then it creates this distorted view of what's happening in healthcare that is largely disconnected from your accurate, what I think is accurate view, that most doctors are doing the right thing.

52:21Doctor Mike: Because if you look at social media, it looks the exact opposite. But that's because patients who are getting good care are not on social media talking about getting good care. So it's this social media distortion bias or something, but it's terrible. Do you have a good term that we can use for it? But the other issue is that good care is often kind of boring. Yeah, and quiet. It's quiet. It doesn't result in a really dramatic story that lends itself to a social media post that gets picked up by the algorithms. Yeah, it's like a posting bias or a viewership bias. Algorithm bias. But I want it to be better and we can claim it as our baby.

53:03Doctor Mike: But I haven't yet come up with it. Tragedy bias. Error bias. Like Shakespearean bias or some interesting term. Yeah, I'm going to keep working on this. But it's an interesting thought because it feels like that's what's leading a lot of our healthcare decisions these days. That exact bias. Yes, yes. Because it's what's driving Elon Musk to say that everyone is over-prescribed SSRIs. It's leading Secretary Kennedy to say school shooters are caused by SSRIs. It's like this distortion that they get from a twisted view of what's happening by only seeing the negative. Honestly, it's a good description for it is what President Trump called fake news.

53:40Doctor Mike: because fake news used to mean truly fake news. And then it got co-opted and is all a messy term now. But if you watch the news, it's doom and gloom at night. It's like, oh my God, there's only shootings going on and car accidents. But if you live in real life, you realize that no, none of your friends are getting shot. No one's getting into a car accident most days. So it's a twisted view of reality. So it's kind of some like media distortion. Yeah, it's a form of anecdotal bias, isn't it? It's that the anecdotes of the very small percentage of people for whom a thing went wrong or didn't go in an ideal way and gets highlighted and gets amplified really is out of proportion to the much, much, much, much larger percentage of people who got good care and for whom the outcomes were good.

54:26Doctor Mike: Yeah, it's like a TikTok bias or something. I'd love to throw a TikTok under the bus. Yeah, you really need to get this and then trademark it because this could be yours. No, I think this is something that society needs because once you have a definition that is publicly accessible, all of a sudden it becomes common sense. Almost how in order for you to force yourself every day to go to the gym is tough in the beginning, but once it's a habit, it's kind of like what you do and it doesn't require a lot of energy. So if we can mentally implant this thought that it becomes common knowledge, all of a sudden it's like, oh yeah, when I see this, I know that there's a distortion.

55:01Doctor Mike: That's one of those posts. Yeah. Yeah, yeah, yeah. And then someone will weaponize it like when people say fake news all the time. When they hear a story they don't like. And there'll be a new challenge after we solve this one too. Exactly. It's always a thing. There's more to come. So I want to ask you, if you're a parent, what substances should you be most afraid of for your kids to try? What should you talk to your kids about? or is this something that you should entrust your primary care provider to have the conversation with them on? I think the best outcomes are probably when everybody is taking this on, right?

55:39So parents are talking to teens about substances. So how should they do that? Teachers are doctors. So I think it really depends on the age of the child, right? So my kids are, as I said, five and eight. And so we're starting to have the conversations and have for a few years now about, you know, what it is that I'm drinking, right? I'll have a glass of wine and the kids will see the really nice looking glass with a different colored liquid and be like, oh, can I have some, right? And so we've started to distinguish that there are some drinks that alcohol, that adults will have, that have alcohol in them that are not appropriate for kids because, you know, your brains are still developing.

56:15And we'll say that out loud. And, and, and I think they understand that, that this isn't sort of an adult only drink and that's, what's age appropriate for them. You know, as teens get older, I think it's actually really important for parents to make a clear recommendation that they don't want their teen to drink or to use drugs. I think a lot of parents fall into a trap of thinking that introducing a young person to drugs or alcohol in the safety of their own home is what's best for a teen.

56:41Doctor Mike: So being a cool parent is not a thing. Turns out it's not a thing. This has actually been studied. There's a huge study, in fact, has been a large cohort study happening overseas. When you look at parents who supply alcohol to their teens, those teens are actually much more likely to go on to drink heavily and to have a problem with substance use disorders down the road. So prohibition, all is terrible, is not great? Right. Oh, you can have it as long as it's here, also not great. Right, right. So like somewhere in the middle. The healthy middle ground is to say, like, this stuff is out there.

57:15You might even come across it at school or your friends may use it. I really recommend as your parent for your health, for your well-being, that you stay away from it. And I also want you to feel like you can talk to me about this, right? So parents, I think, you know, the other end of the spectrum, you know, on one end of the spectrum, there's the, like, here's the case of beer, go to the basement, like, learn how to drink, which is not good. On the other end of the spectrum, there is, and quite frankly, I get a little bit of this when I was growing up in the 90s, like, don't ever do drugs or alcohol.

57:45They're bad for you, like full stop.

57:47Doctor Mike: Yeah, so the term gateway drug, has that been disproven? That's complex. That's complex. So gateway drug is the idea that like if you use cannabis, you're going to be more likely to then go on to use heroin, right, for example. So you use one drug and then you go on to use harder drugs. The studies that have teased this apart have really shown that the same people who were always more likely to go on to use heroin because they may have had challenges with impulsivity or they may have had other mental health problems. High A scores. Yeah, exactly. They just have sort of like a different set of risk factors that put them at greater risk for using both cannabis and heroin are sort of the common underlying issue here.

58:28There's also the very practical point that, you know, back when you would buy drugs on the illicit market, like when you would buy cannabis on the illicit market because there was no dispensary, that often the same person who sold you cannabis could sell you other drugs, right?

58:40Doctor Mike: Which is not usually the case these days. Right. Yeah, so it's not that one drug is causing you to use another. It's that you have the same sort of common set of risk factors. But back to what I was saying before about sort of - Where is it, though, that it's the opposite? You said that sometimes it is true because you said it's complicated. Is there a gateway? So it is a little bit complicated in that neuroimaging studies, particularly of young people who use nicotine, show that there may be brain structure and function changes that happen when somebody uses nicotine that may place them at risk for downstream use of substances.

59:15Yeah, yeah. And we also know that the earlier somebody starts using substances, the higher their risk of having a lifetime problem with addiction. And so there's got to be something going on in the brain. But whether a drug is itself a gateway drug is probably not the case. Okay.

59:31Doctor Mike: Anyway, so I was talking about that sort of like healthy middle ground, right, between those two extremes. I think the key take-homes for parents are to be curious. So don't lead with no, but actually lead with questions like, you know, Joey, what are you seeing at school? Have you ever been asked to drink alcohol? Do your friends drink alcohol at parties? Do people you know at school vape nicotine? Like what are you seeing, right? That approaching from a place of curiosity gives a parent an understanding for them to tailor their conversations with the young person. And ultimately, they do need to make that recommendation.

1:00:07Like, look, I recommend you don't use, right? It's different from saying don't ever use because that shuts the conversation down. A young person is not going to come back and talk to their parents.

1:00:17Doctor Mike: And I'm sure just like with most behaviors, leading by example is important. Right, yeah, yeah, very important. So that's probably going to be the biggest driver of their decisions. Not the sole one, obviously, but a big one. Yeah, I mean, one of the most challenging scenarios that comes up for me in clinic is if I have a young person who's using substances heavily, maybe using cannabis every day, and then their parent is also using cannabis every day. Part of the intervention in my mind needs to be helping the parent come back or quit too. What role does punishment play in this? Caught your child doing X, Y, Z.

1:00:51Doctor Mike: Do you punish? Do you thank them for being forthcoming? What's the - This is tricky. This is probably the hardest part for parents and a thing that comes up all the time for us. so uh limits and consequences are important right so one thing that comes up all the time for me is that parents will come in they'll brought their teen in dragged him in by the scruff and said like you know he's drinking i want you to help me to get him to stop and then i learned that the parents are um you know continuing to provide cash to the young person continuing to let you know their their child stay out late without a curfew letting them take the car and i think it's important for parents to remember that they have a lot of leverage and that they have limits that they can set, right?

1:01:32They can have the expectation that their child be home by a certain time, that their child not take the car if they're going to be drinking, that even if like their child is using their cell phone to connect with friends to buy drugs or connecting on social media to buy drugs, that parents can take a cell phone away, right? That I think there need to be, and the studies have shown, that there need to be limits and consequences that parents act on. Punishment is trickier, right? I mean, there are times where you need to take a thing away and you need to sort of have consequences for a young person's action.

1:02:02But I think where you were going is, you know, what if a teen calls up their parent and says, I'm at a party. I've been drinking. I need a safe ride home.

1:02:10Doctor Mike: Well, yeah, that's a no-brainer in that moment. Right. But what is the follow-up after? Well, so I think if you want your child to continue to call you for a safe ride, you probably don't want to come down too hard on the consequence, right? I think you can actually provide praise to your child and say, thank you so much for calling me. As we've said many times before, I really don't want you drinking. And yet I'm so glad that you called me so I can make sure that you got home safely. So the nuance needs to be there. The nuance needs to be there. It's so hard because, okay, we started this conversation on vaccines.

1:02:45Doctor Mike: And I was like, you have to be curious. You have to ask questions. And now we're doing that same thing. It's like, man, if you're an adult in this world, you're just curious all the time. You never have any like held in beliefs that you can just reflexively go out and act. It's always adapt to this situation and to everyone else. It's pretty overwhelming. It is. But, you know, this is what we have to do as doctors too, right? We've learned that over the years that prescriptive care where we just tell patients what to do, like lose weight, take blood pressure medication, that that prescriptive approach doesn't always work.

1:03:19In fact, often it doesn't work, right? But when we are curious and we find out why is it that you've struggled in your weight loss approaches, why is it that you don't take your blood pressure medication every day, that that curiosity actually helps us to tailor the intervention?

1:03:36Doctor Mike: I have an answer to this question, but I don't think I'm the right person to answer this question. Philosophically speaking. Is being a doctor similar to being a parent? Oh, interesting. Well, I want to hear your answer. I want to hear your answer. My answer is yes. You're a family medicine doctor. You absolutely have to consider this. But meaning I'm not a dad, right? So I don't have kids. So can I really answer this question accurately? I don't know. But it feels like yes, because you're always trying to be curious. You're always trying to learn more. You're not being prescriptive. You're trying to lead by an example.

1:04:14Doctor Mike: But like, there's so many things that check a box that if you're a good parent, you do these things. But also if you're a good doctor, you do these things. So to me, it's yes. But I'm curious if that holds true as someone who actually has the experience of doing that. Yeah, I would say there are elements, right? I think everything you said is true. And I completely agree. What elements that is not? Well, I think the dynamic is very different between a parent and a child than between a family medicine physician and his adult patient, right? Adults have the choice to go out and do what they want so long as it's not harming themselves or other people, right?

1:04:46Kids, we have to be, we have to stop them from harming themselves. We have to stop them from harming other people, right? So there is a stronger sort of paternalism or maternalism that's required when we're talking about a true parent and child relationship.

1:05:00Doctor Mike: I meant more so from the skillset required to be a good parent. Well, I think that that's a really good point that there is a lot of commonality between them. It involves often more listening, something you're very good at on this podcast. Something that involves often more listening than speaking, right? Yeah, that's true. Okay, so we have this good balance of helping parents have the conversation. Not all no, not all yes. Nuance in consequences.

1:05:31Doctor Mike: We know that the sensitivity of catching those issues is quite high already from either child pointing out, the doctor pointing it out, the parent figuring it out. what should they expect in a visit with you when they do bring up an issue? What's an expectation that they can have of, if I get my doctor on board, here's what I can expect to happen. Yeah, if we're talking about drugs and alcohol and young people struggling with addiction, that visit, that first visit, I think, again, will be really focused on the rapport building. A lot of information gathering, again, being curious and trying to find out what's the young person using, What's the range of substances that they've been using?

1:06:15How long have they been using for? Has that trajectory intensified? Are they at risk of overdose? Are they mixing stuff together? Really sort of getting that full set of information. And I will say that often what we learn suggests that a person's problem is often deeper and more fundamental than they or a parent or you as the doctor on first meeting a patient may realize. So that curiosity and information gathering becomes really critical.

1:06:44Doctor Mike: Speaking of curiosity, and this is a triggering point for patients, this is a triggering point for parents because not all feel the same. And when they do feel, they feel strongly. Some parents hate when the doctor asks them to leave the room. Is this a good thing or a bad thing when a doctor does this? Well, I think that the best care is delivered when the doctor asks the parent to step out and the parent obliges and gives that doctor one-on-one time with the teen. And this is the standard of care in pediatric care. This is what has long been the standard of care, that the expectation is that there are certain conversations that are better had without a parent in the room, right?

1:07:29We've been talking about drugs, alcohol. We talked about sex. We talked about pregnancy. There's a whole other range of issues like sexually transmitted infections or other risk behaviors like driving well under the influence that a young person is just not going to bring up in front of a parent. And so we do this. It's the gold standard. And it's the gold standard because there actually are clinical trial data randomizing young people to different clinical scenarios. And it is the case that when they have confidentiality assured and a parent isn't in the room, they will share more information with their doctor, and they're more likely to come back and talk to their doctor again about these things.

1:08:07So there's an evidence base here.

1:08:09Doctor Mike: I'm a parent. Yeah. Doctor, you want me to believe that my child will trust you, a stranger, more than they trust their own family, and that you will know better for them than me? I'm another ear. I am another ear. And I think what's really important is for us to normalize this as part of the encounter, to tell parents, you know, I start this at about age 11 or 12 when I'm seeing younger kids, I will say to parents, you know, starting in a year or two, we're going to routinely spend part of the visit with the young person alone in the room with me and you stepping out. And actually, by far and away, parents are agreeable to that.

1:08:52That is actually really a very small percentage. I can think of, you know, on my patient panel, it's really just like one hand's worth of families for whom they've elected not to do this. And I honor that request. I understand that some parents just don't feel comfortable with this. And I want a family to feel comfortable in my exam room, right? So I honor that request.

1:09:11Doctor Mike: During that confidential portion, is this a true confidentiality from a HIPAA perspective where what's said is there between you and the teen? And at what point do you involve the parent? Do you have to get signed up from the teen to involve the parent? How do you judge that? Yeah, there's a lot of layers to this. because there's the patient encounter and then there's like the health system stuff, which is really complex. And we can talk about that in a second. But for me, it's really important that I talk in front of the teen and the parent about what the expectations are here. And I will say, we're going to spend part of the visit right now where actually I'm going to ask your parent to leave.

1:09:47And you, Joey, and I are going to sit here and we're going to have a conversation one-on-one together. And during that time, this conversation is really meant to be an open space where you can be open and honest because we're going to keep things confidential. What that means is that I'm not going to share the information that you tell me with a parent or anybody else that stays here at your clinic. I will only share that information if I have concerns about your safety or somebody else's safety. But even then, when I do it, I'm going to talk to you about the best way to deliver that information to a trusted parent first so that we can strategize together on the best way to do it.

1:10:22Doctor Mike: And that holds true for any portion of the conversation? Yeah, so the way that it ends up boiling down is that generally when we're talking about substance use that doesn't rise to a level of a young person being in harm's way, and I will say young people who use opioids who are at risk of overdose is a tricky kind of gray area because what might feel like casual substance use puts them at enormous risk for death. So that's a gray area. But by and large, alcohol use, cannabis use, nicotine use that doesn't rise to the level of, say, drinking and driving where they're in bodily harm's way. Sexual activity.

1:11:00Doctor Mike: Sexual activity. That all of that is really meant to be confidential. Now, I think it's also really important for us to engage parents in this stuff, right? So we are using that confidential encounter to gather that information and to help support the health of the young person in front of us. But it is really common that I'll say to the young person, like, you know, you're having sex and I know that you haven't told your parent that. I actually think it could be really helpful and important for your parent to understand that. Is there a world in which you could tell them or I could tell them or you could tell them with me in the room so we can do it in a safe way?

1:11:35Because I think that if they knew this, they'd be able to help support your health and safety. And so you take something that, strictly speaking, isn't something that we would normally break confidentiality for, but you do want to link to the parent.

1:11:49Doctor Mike: Yeah, this sounds very clean. Has this ever gone bad for you? Yeah, absolutely. This is tricky stuff. We're talking about teenagers and parenting and sex, right? So do they start yelling at you? What's a thing that sticks out in your mind? Well, by far and away, people tend to be very well behaved in the exam room. I think the times that it has gone off the rails has been probably exactly the same situation that you're thinking of in your mind when you ask the question. And that is young person having sex. I've said like, you know, I think it'd be helpful for your family to know young person decides to share that information, decides to share that information with me in the room.

1:12:27And we have what I think is, you know, the groundwork for a really nice conversation between a young person and a parent and a health care provider talking about sexual health. And it goes off the rails because the parent gets really angry. I've definitely seen that. I've had yelling in my exam room. Do you schedule follow-ups?

1:12:45Doctor Mike: What's your strategy for that? And do they usually come back? Sure. Usually it's not. It is anger born out of shock and surprise. I've seen religious issues come up here as well where folks say, you're not allowed to do this. And then it becomes very close-minded. And then the patient goes, see what I have to deal with? And I go, oh no, I do see. I do see. But then at the same time, you want to be respectful of the religion. So it really puts you in a tough predicament. But again, curiosity is the path forward because we have a lot of patients who, for whatever reason, there's huge disagreement between the parent and the young person about what's going on.

1:13:27And if you find out where that disagreement is, what it's born out of, what are the parents' worries? You can often address them.

1:13:35Doctor Mike: And you, in preparing for our conversation, mentioned that you believe this personal time is under attack. This confidentiality is under attack. Tell me how that - Well, we know it's under attack because there have been governments in North Carolina, Arizona, Idaho, Iowa. There's one other I'm not thinking of, Louisiana, that have all introduced measures in their state houses to limit this confidential time, to not allow young people to receive confidential care. And I understand parents' concerns, right? I understand that Parents are thinking, if my child is having sex, I need to know about it.

1:14:13If my child is using drugs or alcohol, I need to know about it. But the problem is nobody's ever going to get that information if the young person doesn't feel safe to share it. They need a safe place to share it. Fortunately, these bills have not, by and large, moved forward. But it's a real concern of mine that this is under attack.

1:14:33Doctor Mike: There's talk I've heard on some specific news stations, I'll refrain from mentioning them, worrying that children are being groomed into different sexual orientations, different sexualities, gender identities. Where is that concern coming from? Does it hold any water? Has this ever been an issue? Is that something that you've seen parents get worried about? I've seen parents worry about it, but the data are clear that a clinician's conversation with a young person can't cause them to become something that they weren't before. So I think parents are often worried, especially about gender-affirming care.

1:15:15It's not possible for a clinician to convince a young person that they're a gender different from the one that they walked into that room thinking that they were. It's just not possible. What is possible is to create a safe space for a young person to have that conversation with a clinician. And I understand parents' concerns, and I'm actually very sympathetic to it. And that's why part of me is always making sure at these visits to figure out ways to engage the parent in the conversation. That I need to have that confidential time to gather the information to help develop a plan. But the parent ideally is part of that plan because care always goes better when the parent's involved.

1:15:54Doctor Mike: Right, you're not trying to exclude them. But if the child refuses to share the information unless they're excluded, no one's going to get that information. Exactly. It's a very rational approach. Do you feel the way these conversations are being held by teachers in accordance to a child's development is valuable these days? Because parents are also very, in much the same way that they want control of what's happening in the doctor's visit, they're also feeling the same way about what's going on in schools. do you feel that parents are having those concerns? And how do you feel teachers are doing with them?

1:16:32Yeah, I think that this may get to your sort of earlier phenomenon of a certain type of bias, right? That we only ever hear about the cases that have gone off the rails, right? That like some very, very small point percentage of people experience a situation in which they're made to feel uncomfortable by a teacher asking them questions or a parent is worried about what the teacher was asking. We have to remember that pediatricians, family medicine physicians, teachers are all trained and have enormous experience when it comes to what's developmentally appropriate for a child. And so when conversations are happening, we have to remember that by and large, the vast majority of cases, they're happening in a totally appropriate and meaningful way for a young person.

1:17:14That it's really sort of a very small percentage where something has gone awry here.

1:17:18Doctor Mike: what point in the child's development is the introduction of drugs sexuality sex when should that be happening ideally i think sooner rather than later right if we introduce these topics sooner then we minimize the stigma of them we make it so that a young person feels like they can talk to a parent about it and you're sort of laying the groundwork for the conversations that you want to be having over a long period of time. So with my own kids, I mean, this isn't a thing that we talk about all the time. Don't get me wrong. We're not talking about drugs and alcohol and sex all the time, but we have had conversations about what is a cigarette and why is it that I don't want my kids to start using cigarettes?

1:18:02Because I recommend that they don't for their health and well-being. My kids are like, again, eight and five. And some people would say that's too young. You're going to make them want to use cigarettes. But we're having this in a really thoughtful way. I'm talking to them about what are the concerns that I have about cigarettes and have they ever seen anybody smoke a cigarette and what did it smell like? And just understanding what their experience is so that I can tailor my recommendation.

1:18:25Doctor Mike: So when you say sooner rather than later, what is in your mind sooner? Well, the truth is this stuff happens all the time, right? Think about like the Thanksgiving dinner table. There are glasses of wine all around. So kids are going to be exposed not just to wine, but also to the uncle who has too much, right? And so there are opportunities to be having these conversations and it's best to have these conversations as soon as possible, right? So should you have the conversation, say with a three-year-old? No, it's probably beyond their neurocognitive abilities. But my five-year-old is understanding some of the stuff.

1:18:58My eight-year-old is absolutely understanding some of this stuff. And it's much better we start the dialogue early.

1:19:04Doctor Mike: And then when it comes to sex, sexual identity, Should that be later or also five and eight is? Well, I think that it may depend on the child in front of you, right? So have I had complex conversations about sex with my kids? No, I haven't. Have I had some conversations? Have we talked about, for example, what goes into reproduction and where - And I don't want this to feel like I'm asking you about your kids. I'm sort of saying like, what does the evidence say that we should be doing in terms of age demographics? Yeah, well, I mean, the truth is that the studies would support that we should be having these conversations sooner rather than later.

1:19:39But there's not a magic age and there's not a magic age because each kid differs, right?

1:19:43Doctor Mike: We have developmental milestones. So are there developmental milestones by which we should aim to have a range even of when should the conversation about what sexes happen, childbirth happen, gender identity happen? Or is that going to be so varied that it's impossible to set guidelines? Yeah, I mean, I think that we don't have clear guidelines on them because it hasn't been so extensively studied as to like identify clear cutoffs. But I think that you can have developmentally appropriate conversations about all of these things at really any age. Right. And so for, you know, a five year old, you can have conversations about not about you may not have the conversation about the act of sex itself.

1:20:27but they talk about like what are the parts that come together to make a child right um that it takes you know uh parts from what we call a man and parts from what we call a woman and and uh that someone needs to carry that pregnancy right you can talk about sort of the ingredients that come together to create a child right um even if you're not talking about sex itself you might save that for a later age um uh alcohol again is something that we've had age appropriate conversations about it at a young age in our household.

1:20:56Doctor Mike: You're very proud being a gay dad. How does that impact your children's upbringing, your patients? Does that give you an advantage, disadvantage? How do you feel it? Well, I live in a neighborhood in Boston, Massachusetts, that is one of the most open-minded LGBTQ plus friendly neighborhoods in the city, which is one of the most affirming cities in the country in one of the most affirming states, right? So I think their experience has been kind of like, meh, you know? They've got lots of parents with, or lots of families that they know with same-sex parents and LGBTQ plus families. And do they give any question to this?

1:21:34Doctor Mike: Is this, how do you discuss it? How do you bring that into the conversation? Yeah, well, this is actually what has forced us to have some of these conversations about sex and where a baby comes from at a younger age, right? Because I think they pretty quickly detect that most families have a mom and a dad, right? And that ours looks different. And I think it's kids talk and they share what they know about sex. They're gonna be the first ones to point out when something doesn't fit their pattern. Yeah, exactly. So we've had to have those conversations because of this, right? I don't think our kids experience much in the way of stigma in our neighborhood, but I'm very mindful of the fact that families like mine struggle in other parts of the country.

1:22:16And globally, my God, it could be even deadly in some areas. But I will say it has been, whereas it hasn't impacted my personal life all that much because it is kind of, man, you know, it's just not, it's old news in Boston. It has impacted my professional life. Really? There are absolutely young people and families that seek me out precisely because of who I am. And I think sometimes this representation of me as an out LGBTQ plus doctor is as important to them as the care that I provide them.

1:22:48Doctor Mike: And how was that in your experience going through residency? Were you open about this? Were you worried about what professional consequences, if any, you'd face? Yeah, I've got an answer to that. I wonder, what do you feel like you observed as somebody who's not presumably a member of the LGBTQ plus community? what do you think somebody like me would have experienced i'm kind of curious um what stage of your training uh let's start at med school yes and at that point you were out or not out uh i was out in med school yeah you were out in med school um and framework wise what time was that uh so this would have been like uh 2004 2005 that i started and i i went to med school inst louis missouri that changes things I think your concern would be about judgment facing judgment from your peers about judgment from your patients

1:23:51Doctor Mike: finding a partner would have been trickier I don't know based on the time frame obviously if this was 40 years before or I don't know Missouri actually demographically wise in terms of how conservative the area is. But if you're in a different area, different timeframe, your fear could be much more scary. I mean, from a criminal standpoint. Right, right. So I don't think you had those concerns if I'm right. Yeah. You know, I've reflected on this with other people who are in their early to mid forties, like I am, who are gay and sort of were just young enough to not experience the loss of like friends and loved ones to the HIV crisis.

1:24:33And yet also to have grown up in a time where stigma was much more than it is now, very thankfully. Things have gotten a lot better. I think you actually totally nailed it. So I was out. I often didn't experience much stigma at all from my classmates. I felt very comfortable with my classmates. But as soon as I entered those clerkship years, I found myself not telling people I was gay, at least until I felt comfortable on the rotation because I didn't want it to impact my grade. And I remember when I was applying for residency, getting the advice from some people, oh, don't come out to people during the residency application process because you might not get into the residency.

1:25:12Really? Yeah. Wow. And that would have been 2009 that I was matching.

1:25:16Doctor Mike: I'm assuming, but correct me if I'm wrong, was that the same reason that you had the concern about your grades being impacted if you came out? Yeah. Yeah, it was this idea that if people knew this thing about me, I wouldn't do as well. And going through it now, let's do that before and after scoring system. Was that concern appropriate? I can say it turned out fine. So it so happened that the program that I wanted to do in Boston that I matched into was a program where I felt enormously comfortable with the program director in the application process coming out to him. So it was prudent then? Yeah.

1:25:56And sharing with him like, hey, I'm also trying to figure out how do we get my partner in the same place because, you know, we want to settle down together. And him being the program director being enormously open and thoughtful about this. And I was so glad that I chose the program that I did because the program selected me not despite who I was, but in fact, in some ways because of who I was. And I've been incredibly happy. Now, I was matching in Boston in pediatrics. I was not matching in a more conservative part of the country in a more conservative specialty.

1:26:28Doctor Mike: Yeah, that would have been trickier. Oh, what is a conservative specialty? That's a great question. Yeah, I was about to say, you said that and I caught my eye. I mean, I think we would historically say probably like surgery and the surgical subspecialties. But I think that that's probably a trope. Yeah, I was going to say, I mean, things have changed and I feel like it's more geographic. and partisan than it is specialty-driven. Because even I remember them doing demographics of physicians where it's like more physicians are Republican than not. I don't know. I think all those from where I learned in residency have shifted so greatly that even demographics, more women are in med school than men are in med school, I think now.

1:27:11Doctor Mike: So the numbers have shifted. So that's interesting. And you said you didn't face much stigma. Did you face any stigma? Were there any situations where you're like, wow, this is still happening in medical training, whether it's for patients or colleagues? I think a lot of it was in my head. And I think that's the case for a lot of LGBTQ plus people that we have our own internalized stigma, right? So the thing that I probably encountered the most was not people treating me differently, but me modifying my behavior or modifying who I was or who I presented because of who I perceived to be the person in front of me.

1:27:45So the example that I think comes immediately to mind is when I was an intern in pediatrics in my continuity clinic in Boston, again, open, affirming city, I wouldn't tell families that I was gay because I was worried about the old tropes and stereotypes that gay people are trying to groom your kids or gay people are trying to turn your kids gay, right? Gay people are some of the really terrible, horrible tropes that have really affected my community for decades.

1:28:19Doctor Mike: What do you think was the biggest driving factor of these beliefs? Do you think it's this term that we were trying to name earlier, algorithmic TikTok bias, or is it something else? Well, I think when you grow up LGBTQ +, and you realize who you are, you are constantly thinking about how you present yourself. and I think some people worry less about how they present. I was always very mindful and overly cautious about who I presented myself to be to other people. For fear of what? I was just worried about how people would react. I mean, I was worried that a parent would say, you can't be the doctor for my child because you're gay.

1:29:00And I mean, there was an instance where in the newborn nursery, I can't remember how this family found out that I was gay, but they asked me not to examine their child because they were worried about someone who was LGBTQ plus examining their male baby. So it wasn't born out of nothing, although I will say it is exceptionally rare. How did you feel when they said that? Oh, it was enormously upsetting. And on the other hand, I was really busy and moved on. You know, those are busy notes.

1:29:30Doctor Mike: Yeah, but you're allowed to have both of those thoughts. Yeah, yeah. I'm thinking - Well, I clearly remember it to this day, right? That would have been 17 years ago and I still remember it. Yeah. I get patients, and this is not exclusive to me, but male trainees get turned down to deliver care to women. This happens a lot, whether by the partner or the patients themselves. Do you feel like that in general is a problem or was it specifically because this is a pediatric population? Yeah, no, I think people should be cared for and examined by the people that they feel comfortable with. I think for me, it is the utmost important that people feel comfortable in my exam room, right?

1:30:14So if I have a patient who doesn't want a male clinician, that to me is really important to know and I want to honor that request. So I do want families to have a say in who sees their child.

1:30:27Doctor Mike: So are you saying that if they make that decision based on the fact that you're male is one thing, but if they make it because you're gay, it's a different thing? So that's it. So when it is born out of stigma, that upsets me. Tell me about the stigma that upsets you. Well, the idea that because I am gay, I shouldn't be able to examine their child or I shouldn't be able to have a confidential conversation with their child, that I can't be trusted with their child is enormously upsetting to me. The idea that, you know, let's say a female patient says, who needs a sensitive exam, you know, because they may have, you know, they may need a breast exam or something.

1:31:02The idea that they would prefer it not be a male provider is very different. I think that's a question of comfort. If the comfort is born in stigma, though, that's a problem.

1:31:13Doctor Mike: I see. It's very unique that you had this training experience in such an accepting place, because I could easily see that if you ended up in a different state, in a different demographic, this could go completely sideways and you'd feel totally different. Have you had friends or colleagues that have experienced working in a less than accepting place? Yeah, absolutely. And what's probably more common is colleagues that I know who perceive that they can't leave the place that they are now, which is safe to go to another place, really feeling like, if not for the fact that I was LGBTQ +, I could go to this particular state or this hospital or this city, but I would worry about what that would mean for me to practice there.

1:31:57And I think that's where stigma starts to impact health is when you have people who want to deliver good care everywhere in this country feeling that they can't go to certain places. And whether that's a real correct perception or not, it may be up for debate, but it's certainly a perception that people have. Yeah.

1:32:15Doctor Mike: How do you have a conversation with a child, a teen who wants to come out or is questioning their sexuality? Do you help guide them? Do you ask them questions? What's the usual approach there? Curiosity, find out where they are, where they are in the process, how they've been thinking about this, what conversations they may have had with their family, how they think their family will react to that information, how they think their friends would react to that information. It's a lot of information gathering. And the truth is, here's a place where it's actually, I don't think appropriate for me to be prescriptive, right?

1:32:49There is no right time for somebody to come out, at least like for my choosing, right? They have their own right time. It's not up to me to...

1:32:59Doctor Mike: There's no medical evidence-based answer for that one. There's no clear cutoff, right? We have to remind people in that moment that the lowest form of evidence is expert. Yes, exactly. Exactly. Exactly. So, so, you know, I think it's really about gathering information so you can be a source of support for that young person, answer their questions. And if they want that support, if they want advice on how to have that conversation with the parent, I've actually had young people come out to their parent in front of me because they wanted to have me present for the conversation because they thought it would go better if I was there when they told their parents.

1:33:35So I have been a part of that.

1:33:36Doctor Mike: Did it go better? Yes. I've been a part of that really incredible, magical, special moment for a young person who really wanted to do that. And I think they just wanted sort of a witness, an arbiter, right? Somebody else who was present. An objective. An objective. And then a safe, neutral space in which to do it, right? And when that conversation does happen, do oftentimes the parents have questions for you? Oh, yeah. Are they questions for you as a doctor or as a gay man? Or both? It's interesting you say that. Often the same families for whom there may be some hesitation about whether it's okay or comfortable for their child to come out to them are the same families where we may not have actually had an open conversation about who I am.

1:34:21I mean, probably much like you, I'd be curious to know how much personal information you divulge with the families you care for. I'm pretty open, but that doesn't always come up.

1:34:31Doctor Mike: Yeah, I get a lot of the, oh, I have someone I want to set you up with conversation. I'm sure that happens across the board in the medical field in general. Yes, it does. But that's part of it, right? Is that your patients, when they look you up online, are seeing this highly approachable, really communicative, wonderful, warm person that they probably feel like they can share whatever they want with and ask whatever they want. Right. That's an interesting point. Like early on in doing the social media thing, people said, like, how has it changed your care? And some people assume that there would be a lot of negatives.

1:35:05Doctor Mike: And while there's certainly risks, I don't see a lot of clear negatives if you do it respectfully, of course. Because mostly when people become more familiar with you because of your presence online, they become more trusting. and not as much as people reflexively TikTok bias think that they're gonna become overwhelming. Most people just feel more comfortable. Yes, there's gonna be a person who goes too far. I had a patient come in and tell me she spoke to my dead mother and she fixed her way onto my schedule even though she wasn't supposed to be there. So like, yes, do those things happen? Sure.

1:35:43Doctor Mike: But by and large, it creates an air of comfort where they can share certain things. they're actively seeking out my care because they've seen that I am an athlete and they feel like there's more camaraderie there or understanding there. Just like I'm sure if you're a black patient and you want to see a black physician, you understand what that's like. So there's all these types of traits that folks look for when they're looking for a provider. Yeah, I mean, if you right now need to go find yourself a new doctor, chances are you are either Googling or going to the health insurance website and seeing who takes your insurance and you just get a name, right?

1:36:20You often don't even get a picture of the person on many of these directories, right? So it is a big leap of faith to just show up to a doctor's appointment where you know nothing about that doctor. And I do appreciate that social media allows patients to kind of self-select for me. I'm a relative open book on social media. They know who I am. They know what some of my ideas are about health based on reels that I may have put on Instagram. So there's fewer surprises when they walk in the door. And I think that helps them feel more comfortable.

1:36:50Doctor Mike: I've struggled on social media sometimes. You are not struggling on social media. Poor choice of words. I've struggled in certain encounters on social media where people who are activist focused sometimes will see a certain interpretation of your actions in a way that is less favorable. and it's done so at your expense and at their benefit of notoriety, attention clicks, what have you. So even recently I had Dr. Ali Mattu on the podcast who's a psychologist, used to work at Columbia, now is on the West Coast, does fantastic work with adolescent health, like really someone I trust and I admire in the way that they approach things, his humility on subjects.

1:37:41Doctor Mike: And he was talking about in his circle, which he found to be very liberal being on the West Coast, San Francisco area, right? Sam, I'm getting that right? In the San Francisco area. And he says that whenever he talks about masculinity and how to have healthy masculinity, everyone gets annoyed at the subject and that there is less discussion of how to be healthy in your masculine approach than what he would like. And we posted a clip of it and it got really twisted out of proportion where certain activists started coming out and saying, hey, you are completely missing this conversation when you say no one's doing this, we're doing it.

1:38:25Doctor Mike: And the fact that you don't know this and the fact that you're straight means that you don't care about our opinion. And all these things were inferred in a very pathologic way. Pathologic not for either one of us being on the podcast, but pathologic for the actual improvement of the discussion. And I try to figure out a way how to move that conversation to something productive, but I failed. And I'm curious if you have a strategy that has worked well for you in this regard, where it feels like it's going off the rails and you want to bring people in. Yeah, well, I'm certainly not the one to be telling you anything about how to manage oneself on social media.

1:39:04But I agree with you that some of the hardest challenges are with people with whom you agree 97 or 98 percent of the time but that last two to three percent you go to the mat over um and i i am somebody who really tries to keep the big picture in mind that we have enormous challenges out here and many of us are on the same side here and and sort of this infighting or this again going to the mat on that last two to three percent on which like we have a minor disagreement in my mind is just not worth it and actually is puts us at risk when we're trying to take on the bigger challenges. Yeah. And I feel like when I point this out, it's somehow more

1:39:43Doctor Mike: igniting of controversy. Yeah. It doesn't help. It doesn't help. Yeah. It's like, oh, so you are minimizing this difference between us. So I struggle with that. And I'm still figuring out how to bring people into the fold as opposed to creating barriers. And then people say, by you doing this and trying to bring people in and be so polite and charitable in your approach, that's something that was weaponized for so many years against certain populations that it feels repetitive to them and i understand where that's coming from because if it was weaponized against you oh be polite when we're being assholes to you it can bring those feelings back that's a natural approach yeah so i'm trying to figure out how to tailor my approach to be better yeah i mean some people want to fight right and and so they're they're just going to keep going until they get that fight.

1:40:31I mean, I think that there are a lot of people who may take issue with something that I post on social media. I DM them. I have sort of a side conversation and we're able to come actually to a nice agreement, right? And sort of sort it out. Some people don't want that. I think that's the struggle is that some people just want the fight to continue in the DMs, right? And in those cases, I think it's probably not worth the time or mental energy.

1:40:54Doctor Mike: What's been your most controversial post that you think you ever had? Hmm. I'm almost afraid to say it out loud because it might draw people to it. I may not it may not even exist anymore. But early on in just topic wise, early on in COVID, I posted in support of masking in schools. OK, which is a whole other topic that we talk about. And it was, you know, with an eye to their safety. I was a pediatrician who actually I was called as a pediatrician to go work in the adult hospital caring for older adults dying of COVID because the internists and the family medicine docs and all the other folks who normally take care of adults have been depleted.

1:41:35They were all out sick. And so they were dipping into the next pool of physicians. And I was just horrified by what I saw.

1:41:40Doctor Mike: What was that like being a pediatrician caring for adults? Well, the funny thing was that I was often the attending physician of record with residents who did have more immediate experience caring for adults reporting to me. So there was a lot of, yep, if that's what's evidence-based, let's do it. Well, look, it's you asking for evidence or proof or whatever. That's the check, right? So you're able to process that information being an attending. because a lot of what being a doctor is these days is communication, curiosity, triage, connection, because anything can be looked up. I mean, it was already that way when I was in medical school 12, 13 years ago, now even more so.

1:42:31Doctor Mike: And people ask me, are you threatened by AI? It's like, no, because you could look up anything you wanted 15 years ago and it's not doctors became less valuable 15 years ago. It's, yeah, information's always around. What do you do with that information? How does it apply to you as an individual? Do you trust the person giving you the information? Because what I feel was always an inequity in my practice was, because I work at a community health center, is health literacy, right? So how well people understood science, their own health, their cultural beliefs, et cetera, would impact how well they would interact with the healthcare system.

1:43:10Doctor Mike: I feel health literacy in the AI age is shifting in a unique way. I'm sure you use some AI chatbot, right? Whether personal or professional, basically using it as a Google search. That's like the base use for most people these days. You can ask it and get an instant response, or you can pay for the really high-end pro version. And I feel like this health literacy imbalance in equity is going to happen when there's going to be information inequality, where if you ask it a medical question about your care and it gives you the instant answer, which does a cursory search across Reddit threads and recent YouTube videos or TikToks versus the pro version that's gonna go and look at, you know, Elsevier journals, et cetera.

1:43:58Doctor Mike: So that scares me how people will interact with it. But ultimately at the end of the day, they're gonna want a person who's lived it, who's an expert. What do you do with this information? How does it apply to me? why is what I'm feeling different than what's being said in the textbook and I don't know I'm curious about your thoughts on AI yeah I mean I use it all the time and it's been enormously helpful I think for me you're right it's about the speed of gathering information right my visit I can spend so much more time focused on a conversation with a patient and a family now because I can look up information so much more quickly than when you had to like type it into say up to date as a Google search even now up to date has a good AI that will point you right to the article.

1:44:40Doctor Mike: Get you the information quickly, right? Or now we have ambient scribes where you put your phone down, it listens in on your conversation, it turns it into a documentation note so that I can talk to the family instead of spending half of the time writing the note about the things that we talked about, right? So that has been a huge, huge, huge key. You said your partner was trying to match in the same area as you. Did that ever end up happening? Yeah, yeah, he did. Now, we were a little out of sync. He actually had already started residency and was two years in and living in Philadelphia at the time that I moved to Boston.

1:45:12Doctor Mike: So still Northeast. Yeah. Yeah. But that, you know, I don't know if you notice, but New York City is in the way if ever you try to drive between those two cities. And New York is uniquely huge. Like I still don't have the grasp of how big New York is. Yeah. And very traffic-y. And not to throw shade at Connecticut because it is a beautiful state. I just took the train along its coastline this morning and loved it. but it is a state with a disproportionate amount of traffic. So, uh, so as much as Philly and Boston were close, um, uh, it was, it was far and we were bootstrapped at the time. We didn't have a lot of money, so we couldn't always pay for flights.

1:45:47Um, so he, he toyed with the idea of actually leaving his residency program and doing his final year in Boston. We ultimately didn't do that, but then we also pediatrician. No, he's a, he's a internal medicine doc.

1:45:59Doctor Mike: Okay, cool. Yeah. So both primary care. Both primary care, yeah. Do you ever have debates about taking care of patients or medical stuff? Yeah, I mean, I think we internally in our home probably overstep, meaning that we probably should stay within the lines a little bit more. I think sometimes he thinks that he's capable of pediatric practice because he knows a thing or two about medicine, not recognizing, of course, that kids aren't little adults, and then vice versa. I have all these things in internal medicine and adult medicine that I think I know because I went to med school 15, 20 years ago.

1:46:35I see that happen a lot.

1:46:36Doctor Mike: Usually more on social media, less in households, but I'm sure it happens in households. I also never really dated someone in my field. I've always dated outside of healthcare, so I've always been curious, what's it like having a relationship with another doctor? Is that a topic of conversation, or do you both are never talking about this because we just got home permit? Well, I think we try not to talk too much about work, but we speak the same lingo. We speak the same language that we can talk about work and the other one sort of immediately knows what you're talking about. So you go coffee stat?

1:47:07Doctor Mike: Yeah, exactly. Exactly. I think the hardest part, so we started dating in 2005. So it's been 21 years since we started dating. We've been married since 2010. So it's been, you know, we're coming up on our 16 year anniversary. The hardest times were actually when we were in school together. And I think there was like a lot of kind of like angst about doing well. And I was following in his footsteps. He's a brilliant, brilliant person, was a brilliant student, got great grades. And I felt a lot of pressure to do as well as he did. Okay. Yeah. So it was a motivating factor. Yeah, it was, it was. And I'm obviously aware, but I'd love for the audience to hear your wisdom of same-sex parents, what is the evidence show?

1:47:51Oh, yeah. Well, you know, shows that kids of same sex parents have the same outcomes, if not in some domains, even better outcomes than other families. Now, to put an asterisk on that, you know, the studies that have been done have sometimes come from other countries, sometimes been small samples. But when you stitch together the available evidence, it is clear that to the extent that this is looked at in a thoughtful and more recent way where families have been able to live in a country that recognizes their marriage and allows them to be parents, that kids do really well. To the extent that there are, in some studies, a smaller number of studies, poorer outcomes of kids in LGBTQ plus families, it's often from older times when those families were probably experiencing a lot of stigma.

1:48:34Doctor Mike: Yeah. The interesting part is a lot of people forget how important it is to have two. Right. And they think it's about certain defined roles or characteristics, but in reality, it's just the presence, the attention that's necessary to split a load of raising a human. Yeah. And there's been so many interesting studies that I've looked at about even the number of children couples have, irrespective of gay or not, but each progressive child splits attention further and potentially makes it more difficult to give more attention to that child. Have you seen that research? Yeah, yeah, yeah. I, for a time, wanted a third child.

1:49:11We've got two. We're not going to have a third. But there was part of me that thought the ratio is going to be off if we have a third. And then also, I didn't want to, you know, I just talked about our Subaru. I didn't want to have to get a bigger vehicle. I didn't want to have to get a bigger home. Practical concerns. Yeah, yeah. There were all those two. So I think that's the case. But you're Right. It's two parents, right? It is the fact that when our kids are off the rails and one of us is about to lose their cool and just needs to step away, that there's another parent who often has reserve to be able to step in and be the parent.

1:49:42Doctor Mike: Yeah. What's the future hold for you? For me personally? And professionally. Well, I'm going to keep doing what I'm doing. So I'm really happy in my job. Growing these new platforms? Yeah. Yeah. So we, so yeah, I haven't talked a little, haven't talked much about what I do professionally, but I work at Mass General where I'm the chief of adolescent and young adult medicine. And so we lead a group of 30 interdisciplinary staff. We've got 11 doctors. We've got a mix of nurses and social workers and clinical psychologists and dieticians and researchers and front desk staff, you know, the whole gamut.

1:50:16And so I get to lead this group of folks that are just really passionate about caring for young people, which is really exciting. And I love the job, so I'm going to keep doing it. Yeah.

1:50:26Doctor Mike: What's the field of research within that field that you're most excited about? Yeah, my work really focuses, and it's NIH funded to do this, to look at addiction treatment for young people. I'm trying to understand what are the gaps in addiction treatment for young people, particularly people who are on Medicaid in this country, and where do we need to improve those gaps. So I'm excited about continuing to do that work and being a dad while I do it. That's an important identity in time. Yeah, yeah. The other thing that's really exciting is we were just approved to start our own adolescent medicine fellowship.

1:50:59And so we're actually going to be training new fellows. This is brand new. We're going to be recruiting. So apply now. Apply now. Link down below. Yeah, link below. Applications are in. We've started to get some. We've got some amazing candidates and I'm really excited for this next phase. All right.

1:51:13Doctor Mike: This is a fun little segue here. What is something you look for when you get applications for this spot or residency, et cetera? Well, I'll tell you what I actually don't look for, and that is I am not terribly interested in board scores. That I have sat on selection committees for residency programs for many years and seen many, many, many instances of individuals who have failed step one, who have needed to take exams multiple times or gotten scores that were just borderline, quote unquote, and have gone on to have amazing careers, been incredibly wonderful physicians. And so board scores are not terribly important.

1:51:55I de-emphasize them. For me, what is really important is to understand the relationships that people are forming. And that really rises out of letters of recommendation for candidates. You'll see that there will be anecdotes in there talking about the wonderful interaction that was observed between this trainee and a family or the ways in which that trainee went above and beyond.

1:52:17Doctor Mike: Those are the kinds of people. Are these being co-opted by AI in any way? Oh, well, that's a great question. I'm just entering this field of sort of like fellowship applicant assessments right now. And we're definitely going to be on the lookout for it. I do think letters of recommendation are clearly now increasingly being written by AI. Yeah. I suspect that just because everyone's strapped for time. Takes time. Yeah. I'm sure you write no end of them. Actually, I don't write many of them, which is interesting. I've written a few, but because I'm precepting not every day of the week and because we have 21 residents, I'm not spending a unique amount of time with every single resident.

1:52:59Doctor Mike: So uniquely, I'm not writing a lot. But the ones that I have written, I've obviously been very passionate about in supporting those candidates. So yeah, that's really interesting because I used to interview a lot of candidates And a lot of them will do this performance of what they think someone in a selection committee would want. And what was special about where I did my residency was they allowed the residents to also participate in the interview process. And all the residents. Every resident gets to take out a group. They would also interview and also take out a group of applicants for lunch.

1:53:43Doctor Mike: and it would be really interesting to see the process because you're almost like a colleague of theirs, not so much competitive with them. And you would see how some people would put on a show and it became so obvious very quickly where you almost want them to be like, just be yourself, like just act what you would define as normal so that we could see if this is a good fit as opposed to you thinking what is a good fit, which might not be a good fit at all. Yeah, no, I'm sensitive to it. And I'm somebody who takes a little while to warm up when I'm in a new setting. And so I'm sensitive to the fact that it's gonna take some people to, some time to sort of settle in and feel like they can be themselves and sort of remove that veneer.

1:54:23But this is where, you know, when med students ask me and they say like, I wanna match at a particular program, I wanna go here for pediatrics, what should I do? My number one answer is do an away rotation there. Let people see the wonderful.

1:54:35Doctor Mike: I was just about to ask you about spotlight rotations or second looks, et cetera. Yeah, exactly. It gives you the opportunity to be seen by that place and to be seen in a very real way. And also you'll learn if you actually want to be there. I've been to some places where I'm like, oh, I love this place. Then I go there and I go, whoa, the culture here is so toxic. I am out. Or actually too chill. I spent some time interviewing at a place down South where I was like, oh, this is a good environment in terms of location where maybe I'd like to live. And I spent a couple of days with them. And I'm like, it's one o 'clock and you guys are done?

1:55:12Doctor Mike: And they're like, yeah, we're going to go to the beach. I'm like, that's cool, but when do you learn to be a doctor? And that scared me. Because the last thing I wanted to do was go through residence. Obviously, no one wants to work their behind off to the point where they're sleep deprived and making mistakes. But at the same time, I don't want to be equally unprepared to finish residency. Like, all right, now go practice. Right, right, right. Are they taking doctors down there now? Because that sounds like a great job at this stage of my life. Yeah, that's a good question. Now that I've done the hard training, I'd be happy to go surfing all afternoon.

1:55:43Doctor Mike: So I don't know if their actual doctors were working that lightly, but the residents sure were. And I was like, okay, not for me. For someone who wants that lifestyle, great. But I don't feel like that was adequate. So you need to learn is basically. Yeah, yeah. And that immersive experience of going to the place that you think you might want to go helps everybody learn whether it's the right match. Sure. I very vividly remember doing a second look where I did my residency and I continue to work to this day. And I did my second look on Christmas or Christmas Eve, whatever, it was a holiday where no one should be there.

1:56:17Doctor Mike: And I assumed when I got that date given to me as my time to come in, I was like, I'm not gonna see anything. I'm gonna see the worst part of it. They're gonna hate that I'm even there. And it was exact opposite. It was like holiday camaraderie of being on the shift together. And I was like, if this is what they're like during the most stressful moment, That means everything else is going to be awesome. Right, right. And that actually turned out to be the case. That is a really good point, right? Is that actually the moments that we cherish most about residency are sometimes those exact moments, right?

1:56:47Like the 11 a.m. like Jell-O party that you have in the break room, right? That these moments that are not scripted, that are really like, I mean, who would imagine that, you know, you would want to go to a residency program because of who you ate Jell-O with and the fact that you ate Jell-O. But that is sometimes the moment where you see the true personality of a place.

1:57:08Doctor Mike: Those human moments are why I tell very early pre-meds. I'll speak at high school sometimes, and they'll say, what should I do to get accepted into school, like they ask you? I say, go to Egypt and see the mummies. And they're like, what is that so arbitrary? It's like, yes, because if you love mummies, and that's part of your dynamic and your human interest, and you share that with another human who also gets fascinated by it, you've made a connection that's real. Yeah, yeah. As opposed to you said that you want to be a doctor because your mom's a doctor. Yeah, yeah. It's like, oh, okay. And you've also lived your life a little before.

1:57:42You're about to lose a big chunk of your life, right? You're about to lose your youth. So you got to enjoy it while you can. Very true.

1:57:49Doctor Mike: Well, thank you so much for spending the time sharing your wisdom. I've definitely learned a lot. I know the audience certainly has. And where can people follow along the journey? At Dr. Scott Hadland on Instagram, on TikTok. Yeah, the new TikTok account. Cool. And we're still going to, I'm going to hold you to it that we're going to have to figure out what this word is and we're going to have to go on through something on that. I'm going to go ask AI actually. Good point. Cool. Well, thank you so much. That's awesome. Today's teenagers are members of Gen Z and soon Gen Alpha. I recently spoke to clinical psychologist, Dr.

1:58:20Doctor Mike: Ali Matu about how today's young people are receiving way too much criticism and are actually struggling with real life problems that the generations before had never faced. So scroll on back to find that episode. And if you like this one with Dr. Hadlan, I think you'll really like that one as well. Plus, if you enjoyed this episode, if you could give us a five-star review, drop a comment, perhaps share the episode with a loved one, that'd mean the world to us as it helps us find new listeners and viewers. And as always, stay happy and healthy.