387. Beyond the Prescription with Dr. McBride

0:03Welcome to You Are Not Broken, the podcast that challenges everything we've been taught about midlife, hormones, and sexuality. I'm Dr. Kelly Kasperson, board-certified urologist, author, and a leading voice in women's sexual and hormone health. Enjoy the show. Hey, everybody. Welcome back to the You Are Not Broken podcast. Today, we're going to talk to Dr. Lucy McBride, who's out with her new book, Beyond the Prescription, A Doctor's Guide to Taking Charge of Your Health. Welcome to the podcast. Kelly, thanks for having me. I feel like we met in like a fever dream of COVID. Yep. Because I don't remember.

0:34Like we met, you're friends with Rachel Rubin, so obviously. And then we had a long conversation about podcasting. And now that was like six years ago. It was a fever dream. I think, I don't even remember when it was, Kelly, but I remember thinking that you were a kindred spirit because you, like I, like Rachel Rubin, believe in the radical concept of addressing the whole person. thinking about sexual health as health, and taking away this narrative that if you have sexual health problems or mental health problems, that you are not broken, a la your podcast title. I know, which I named because of my patients saying that all the time.

1:14And I was like, knock it off. It's amazing how many people fight for their brokenness, getting immediately into mindset and health. People are like, no, but I am because one, two, and three. And I'm like, okay, well, that could be hurting you. I would say the most, I mean, we're going to just jump right in. I think, but I would say the most important moment in my office with a patient is not me writing a prescription. It's when patients realize I'm paying attention. And when I am allowing them to say the things that they're embarrassed to say out loud that make them feel broken. I mean, how many patients have you seen, Kelly, who have sexual dysfunction they've never talked about with their partner, not to mention a doctor?

1:52Oh my God. The amount of men with erectile dysfunction who's never have told their partner that they're in with the doctor trying to make their penis hard? Right. I thought it was going to be a low percentage, like 20%. And I'm like, oh God, it's like almost 100%. Once I awoke to the female side of sexual dysfunction, I was like, let's see how many men have seen who's taking care of the female partner. Zero. And then women who've been shamed, dismissed, talked over, who struggle with obesity and metabolic dysfunction. Women come in, in particular, men too, but feeling like they're broken, feeling ashamed, dismissed.

2:27And so this book I've written is really kind of a user's guide to being a patient in this dizzying landscape where your doctor has 15 minutes and studies show doctors interrupt patients in the first 11 seconds of their visit. It's worse if you're a female with a male doctor too. The amount of data on gender bias, stepping back, did you know about gender bias in medicine in medical school or residency? No, but I felt it as a woman. I felt it as a woman because I was a patient as well at times in my life, right? So I felt it as a woman, but we didn't like learn about it. By the way, we didn't learn about sexual health.

3:05Menopause was not a word that was uttered. We didn't learn about my psychiatry rotation. You know, mental health to me is like foundational. It's part of this ground zero for your whole health in my world with patients and with myself. But, you know, my psychiatry rotation in medical school was in Boston at a psychiatric hospital where people are talking to the wall and wearing straitjackets. Like that was mental health. Whereas in reality, you know, that's, that's an extreme version of someone with severe mental illness, but guess what? We all have mental health, right? Whether you like it or not.

3:36Totally. And our thoughts, our thoughts create our feelings, which create our actions, which is coaching. I was literally texting friends yesterday about this because I'm like, people don't understand the power of their thoughts. And then because they don't, they don't pay any mind to keeping the brain healthy and challenging your thoughts and thinking about your thoughts. And I'm like, they don't teach us any of that in medical school. No, I mean, don't believe everything you think, right? Don't believe everything you think. I had to learn that the hard way in medical school. It's one of the reasons why I became interested in mental health and primary care.

4:09I've practiced primary care for 20 plus years in DC because I realized that I, at 20, wasn't feeling well. I had a ton of physical symptoms and anxiety. And I took myself to doctors and they tested me for giardia and brain tumors. And I had MRIs and scans and everything was normal. And when they told me everything was normal, I felt like a crazy person because I wasn't normal. I didn't feel well. One doctor told me to start running because that helps with my anxiety. And then I lost weight. And then, I mean, it was just this whole cycle. no one ever said to me, how are you doing? Are you okay?

4:44Like what's going on in your life? Ergo, I became the doctor I wish I had had in my 20s. And for people who are human in this era, who are looking for someone to help them connect the dots between their mental health, their physical health, experiences in their past and how they relate to their thoughts and feelings and behaviors now around food, alcohol, other people relating to work, right? There's no lab test for a crumbling marriage. There's no CT scan for despair. That's a conversation. That is a moment in time between two people, patient and doctor, who trust each other to listen and elicit information.

5:29And that is what is lacking in the United States of America, which is why I wrote this book. Let's get into that because a lot of people, doctors say, again, excuse all the stereotypes, that we're going to do today, but in the interest of stereotyping, doctors will say, all your labs are normal. Imaging is normal. Everything's normal. There's nothing wrong with you. What that means is we didn't pick anything up on the tests that we have to discover disease. Doctors say that to be reassuring. It's not a tumor. It's not a tachycardia. But what patients hear is you're making it up. We don't believe you.

6:04It's not real, which is very different than And like, it's a communication problem at the end of the day of what we're saying and how it's being received. It's a communication and everybody's well-meaning. Like the doctors are like super happy it's not a tumor, right? And so what I started telling patients is sometimes doctors are better at saying what it isn't than saying what it is. And to think about the medical system that way of like, we're here to figure out all the big, bad, uglies that it isn't. for you to figure out what it is that can be, once it's not a tumor and tachycardia and blah, blah, more work on your end.

6:38That's right. So I want to stress that I truly believe it's not doctor's fault, right? Like doctors went into the field of medicine. We studied our brains out in our teens, 20s, 30s and beyond to be able to deliver meaningful healthcare to patients. It's just that the system doesn't allow it. Now there are exceptions, of course. There are doctors who deliver exceptional care in the system, it's just hard to. So I think medicine has become very transactional and personal. We treat patients like a set of body parts, a bag of organs, a list of diagnosis codes, CPD code instead of whole people. So there's a difference between saying you're not dying from XYZ, ABC, your labs are normal.

7:23And here's how I want to help you live, right? Health is not just about not dying and not having the brain tumor. It's about living, right? It's about helping people understand what is going on. And sometimes it's not measurable in a blood test. So many problems can be sort of surfaced, addressed, and then problem solved once you have a conversation. That's what's so nuts about our medical system is that conversations between doctor and patient are actually inexpensive. Time's expensive. The conversation takes time. Insurance doesn't cover things that aren't measurable. Well, that's it. So if we could flip the incentives where the commodity was the relationship between patient and doctor to help transfer power from me, knowledge, judgment, access to medical information that I can then transfer to the patient based on what their needs are, what their problems are, what their social emotional circumstances are, the limitations of their lives, their actual lives, that would actually improve outcomes.

8:32We know that to be true, Kelly. We have abundant data to show that when primary care, what I do, is distributed into communities where everyone in that community has access to a medical home where problems are solved in-house and referrals are written only as absolutely necessary. I treat my own patients with their diabetes and their thyroid issues and their heart conditions. And I refer to cardiology for things I can't do. Like I'm not going to cath you. I'm not going to take your appendix out, right? But if you distribute primary care into communities where patients have unfettered access to someone who knows their name, not just their diagnosis codes, patients live longer, they live better and we save money.

9:18So that's to speak to this idea that a conversation, a relationship is paramount. It's just, we don't, we don't do that. The system is broken by design. So you are not broken as a person, but the system sure is. Well, and I think the anger, it comes from many different places, but one of the angers is, are you kidding me? I'm paying$14 ,000 to$30 ,000 a year for health insurance. Right. And you just can tell me it's not a brain tumor, right? Like To me, I'm like, it's so effed up. And in addition, put that forward to Medicare. You mean I've been paying into Medicare my entire working career and it doesn't cover vaginal estrogen because it still thinks it's a carcinogen?

9:55I'm surprised Americans aren't more angry about this because it's insane. I think they are, Kelly. I think they are. I mean, like, if they're not voting for it, they're not, like, nothing's moving. But that's because the drug companies and the insurance companies have a hold on the medical system. Right now, patients and doctors tend to work for insurance companies, even if indirectly, or big hospital systems or private equity. So we have to build a model of primary care because primary care is where basic care that every American deserves access to. We have to build a model that's accessible and affordable for all.

10:34We also need to have graduates of medical schools deciding to pursue primary care fields and not go into, just go into fields that treat two square inches of the body with all due respect for specialists. And we need specialists. Well, when their medical school costs$300 ,000 and they're married to another medical student, we're now at$600 ,000. And that's with no college undergrad. Right? To me, I'm like, oh, people should just do primary care. It's like, not if it's not reimbursed and you're half a million in debt. Right. And if you're getting paid so little, whereas you could get paid a lot to do procedures and, you know, cosmetic derm, that's how it used to be.

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13:53So healthcare and a healthy relationship between patient and doctor requires mutual trust, respect, and time. It also requires understanding you as a patient. It requires some homework. Unfortunately, in the era that we live in where medical care is transactional, it requires a lot more work on the patient side to almost like pre-package yourself to make sure that you're squeezing the juice out of that 10 or 15 minute appointment with your doctor. So this is why I wrote this book, because I'm not gonna reinvent the system overnight, but what I can do is empower people beyond the walls of my own office, one person at a time, by helping them understand, here's how you would map your health onto a two by two grid, four squares.

14:41Because health right now is conceptualized by a lot of people, doctors and patients alike, as a set of lab tests, as a normal mammogram, as the point in time where you see your doctor and then they say, see you next year. When health is actually a process, it's a lifelong process. It's about your whole health ecosystem, not just your labs. It's about your mental health. It's about your nutrition. It's about your body mechanics. And it's also about your insight and self-awareness about your biases, your what I call patient personality, the story you have told yourself about yourself in my job as I see it, and this book helps break it down, is to help people understand the connections between pelvic floor dysfunction that they may not even know they have, their hip pain that they are seeing an orthopedist for who says you've got a hip problem when actually it's a pelvic floor problem, the ibuprofen they're taking for the hip pain that they're calling a hip problem when it's actually a pelvic floor problem, and the ibuprofen causing heartburn and high blood pressure, and the high blood pressure causing them to see the cardiologist and prescribe all these medications, the medications causing them to have, you know, lightheadedness and dizziness.

15:53And then here we go. What you need is someone or this book, if I may, to help you understand the connection between the different parts of your ecosystem. And you can do that on your own. You can do that because guess what? You as a human being, as an individual, have so much data in your body, in your mind, in your story, your biography that needs to be surfaced in a doctor's appointment, but there's no time to. Like the fact that you were raised by an alcoholic mother, the fact that you grew up in poverty, the fact that you had a hip injury in your teenage years, the fact that you have a genetic predisposition to heart disease, all of that matters.

16:34That's all data. So more than just your cholesterol, your blood pressure, your blood counts in that one appointment a year, you need to get a lot of more data, biographic data put in that health to populate that health map. You need to download all the things you put in your body, all the inputs, you know, from kale and quinoa to alcohol, marijuana, whatever supplements and vitamins, peptide stack you take. All that needs to be downloaded in one quadrant, one part of the ecosystem. Let's talk about your body mechanics. Not just do you exercise, but like, let's talk about symmetry of your pelvis.

17:06Let's talk about your posture. Let's talk about mobility and function. And then your mental health. So my point here, Kelly, is that patients have a repository of information that they don't even know is relevant to their health. They don't understand the dots connecting the different parts. So this is what this book is about. Health is not just about having more answers. It's about asking better questions of yourself and then to the people responsible for your care. Yeah, I love it. And I think the other thing is like testing hypotheses. And what I mean by that is try something, see how it feels, see how it works, write it down.

17:43try something else and see. And I see a lot of people being like, I don't know, should I do this? Should I not do this? Should I do this? Should I not do this? Case in point, hormones. Should I do this? Should I not do this? Should I do it? Should I not do it? I'm like, give it a three-month trial. Try it. And when I educate on how to talk to doctors, say, can I have a trial for three months of X, Y, and Z for X, Y, and Z? I'll make a follow-up appointment. We'll adjust as needed. Doctors love follow-up. What you have just done, that's what I'm talking about in this book, is that you're giving people, Kelly, direct instructions on how to kind of prepackage yourself, right?

18:19Instead of going in with a vague question like, should I take a GLP-1? Which implies there's a permission giving, like you're asking your mom for their car keys when you're a teenager or something. Don't say that. I mean, it's okay. No harm, no foul. Just better question is, what are the pros and cons of GLP-1s for me? What are the pros and cons of not being on a GLP-1? and then can I do a trial and can I do a try? What's your goal? What are you trying to do? Are you trying to be your younger sister? Are you trying to run a marathon faster? Are you trying to stop drinking, right? You know what your goal is because if you just say, is GLP-1s right for me, narrow that down.

18:58Well, amen. Step one in any conversation about any prescription the patient's asking for or sort of solution is to like, what is the question in the first place? What are you trying to solve for? So when someone asks me, should I take GLP-1s or should I take HRT? I want to reframe it to risk and benefit, risk and benefits. But yes, measure it against what your goal is. If your goal is to, yeah, be your 20-year-old self just to say you did, okay, be honest about it. If your goal is to improve your diabetic markers and improve your blood pressure, okay, let's talk about it. But it does depend on you and your goals, not my goals, right?

19:37Yep. I mean, if you look into the guidelines, well, again, I'll pick on hormones. Guidelines for hormones say after the age of 60 or after 10 years post-menopause, individual risk-benefit analysis should be undertaken. And what a risk-benefit, that sounds really heady. What a risk-benefit analysis is, what's your goals? What's your underlying health issues? Is this right for you? That's what a risk-benefit analysis is. And we say like, oh, risk-benefit analysis. this. That's what it means. What's your goal? What's your underlying health? Is this going to meet your goals and not be too risky for you?

20:10That's right. So I just wrote a piece for Maria Shriver about a patient asking a doctor, can I take hormone therapy is the wrong question. I'm not trying to shame patients for asking this question. I'm trying to say, let's together understand why the reframe matters. The question isn't, can I? The question is, what are the risks of HRT for me and my situation with my particular goals and what are the benefits? And then on the flip side, what are the risks of HRT for me, not populations of women, and what are the benefits of not taking hormone therapy? Risk of not doing something. Risk of not taking a GLP-1.

20:47That's right. The risk lives on both sides of every decision. I mean, let's go back to COVID, for example. You know, when someone would call me, that kind of drove me crazy at the end of the day because it was COVID and I was, but patients would call me and say, can I go to my granddaughter's bat mitzvah? And I'm like, the question isn't, can you? The question is, what are the risks? What are the benefits? The obvious benefits of seeing your grandchild, you know, in a bar mitzvah or bat mitzvah. What are the risks and benefits of not going? The benefit is you probably wouldn't get COVID if you don't leave your house, but you can mitigate that risk by getting vaccinated and being in an outdoor setting.

21:24So again, every decision has risk on both sides of the decision. You take, people undertake these risks every day, right? When it's raining and it's dark and you can't find your glasses and you really want to go somewhere in your car, you might decide, huh, it's raining. I can't find my glasses. It's too dark. I'm not going to go. But if you're like, you know what? I really want to go to this thing. Maybe you take the back route and you put on your, you find your glasses, but you tolerate the fact that it's dark. And I think people, I think risk is very hard to understand. And I think I understand why it's hard to understand because we are constantly telling patients, you're high risk for this, you're low risk for this.

22:04That's what I always tell patients. I'm like, when somebody says you're high risk, say, what does that mean? What does that mean? Does that mean one in a thousand? Then I need to understand that. And with the amazing tools, open evidence, actual, you can type in stuff. And again, it's not specific to you, but it gets damn close. what's the actual risk of stroke, your risk of stroke at 73, way higher than your risk of stroke at 43, just by living, just by having 73-year-old blood vessels. Just age alone. Age alone, your stroke rate skyrockets in your 70s. Nobody knows that. But that's the thing is like, is it adding a medication with no known stroke risk, transdermal low-dose estradiol, you have a risk of stroke at 73.

22:46You need to know that. I think open evidence is great, but this is where hopefully human physicians will always have a role is to help people weigh risk and benefit in a more nuanced way because there's so many variables that inform risk. You and only you know the person who's sitting in front of you. And also people have different tolerances for risk. Like there are people who don't want to tolerate a one in 1000 risk, like slightly increased risk for breast cancer's association between the synthetic progesterones and breast cancer. when we don't even know if it's causal and we don't even prescribe synthetic progestins anymore.

23:20So, but there's some people who are just like, I would rather, I wouldn't sleep at night thinking that there's any chance. And I'm like, well, you could still get breast cancer even not on synthetic progestin. And risk of hip fracture or any fracture is one in three without hormones, right? So it's like, again, the risk of not doing something versus the risk of doing something. I want to flip the coin because we talk a lot about patients kind of being passive or like whatever the doctor says, the doctor said it was high risk, but then I didn't feel comfortable asking what the actual risk. So we talk about patients being passive, but I see this flip side too, which also can be problematic.

23:57I have, you know, women come and see me. They're incredibly exceptional in what they've been trained in, but they didn't go to med school. And the doctor says, just tell me what you want. And they're like, I'm a realtor. They did not go to medical school, right? And so I also think that is kind of, I don't know if it's a dismissal or a deferral, but like it kind of paralyzes people. Cause I'm like, if somebody was like, hey, Kelly, just design your house. Well, yeah, I mean, we're not like in and out burger, right? Like my personal belief is that we as physicians should not stand on high. We should not preach from a pulpit.

24:31We should not peer down our noses as if we are moral experts. We do, however, have an arsenal of tools, information and experience from which to partner with a patient and dispense advice and the concept of trade-offs. And that is something that is, I think that's a moral obligation to help some, I would feel like a total asshole. Am I allowed to say that on Kelly? I think I am. I think you're at this. I think I'm in the right place. If I was like, whatever you want, here's the menu, choose your own adventure. I mean, that is to me lazy. I don't personally know many doctors who do that. I do think doctors are exhausted and they sometimes can default to being like, fine, whatever you want.

25:15Like I'll prescribe an antibiotic, even though you've had a cold for two days and it's probably viral. Like, I don't believe in that either. I think that we owe patients the intellectual honesty of being critical thinkers, but also centering the patient and not ourselves. Like it's almost centering yourself to say whatever you want. That's not critically thinking. I also think patients come in like more informed than ever. They come armed with information. They come armed with like opinions. And I think that's great in many, many ways. I love an informed consumer. I also think, you know, the internet is the wild west and often...

25:49And it's getting wilder, Wester, because I just did a Substack article on like physicians going into business and physicians consulting for products and doing all this. And I'm like, would you rather have no physician on the board? Would you rather have this just be a tech bro who has an AI YouTube doctor channel, right? Like it's getting wild westy-er. And I think the trust in physicians is high. And then at the same time, just telling physicians to stay in their lane and stay in a box and see patients every 10 minutes and don't start companies and don't try to change the world and don't try to make it better is so narrow-minded.

26:25A hundred percent. I think everybody should do what they feel is right for them. But I think as a consumer of health information, patients who are looking at Instagram, who are looking at ChatGPT, looking, they don't know who to trust. They don't know where to look. And they have so many answers and so many solutions. But what they haven't had necessarily is time to surface the right questions. Again, of themselves to understand their goals, their patient personality, as I call it, the stories they tell themselves that are limiting narratives and their whole health ecosystem. and then time to discuss what their goals are with a physician who actually understands who they are and is motivated to help them understand trade-offs inherent in any decision.

27:08I think most of this truthfully comes down to time of like the doctor-patient relationship cannot exist in 10 minutes once a year. It just can't. And we're all trying to cope with that reality until it changes. And I think the second thing, I'm like, doctor's two biggest fears right now, number one, being sued, number two, losing their job. because the majority of physicians are employed now. And with those two fears at the forefront of your frontal lobe, the patient comes third. This podcast is sponsored by Addy. Let's stop pretending low libido isn't a big deal. If it's bothering you, it's worth paying attention to.

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30:34Like it does not feel good to a human being who's a physician to have 10 minutes with an 80 year old man who's just lost his wife, broke his hip, is on five medicines for his heart and is like, needs advice about grief. Like that's the patient I saw earlier this week, right? So hard. You like, you handle the whole person. There's no AI that could ever integrate his hip problem, his grief, his medications, his particular needs, the limitations where he lives to access medications that mean that I need to give him medicines that are like 90 days supply and like the logistical aspects, right? Like sometimes you don't need...

31:09You know, the bathroom is on a different floor. So you don't want to give them a diuretic at night. Like an AI can't do that. And I also argue an AI can't hold your hand. Well, AI cannot look him in the eye and pause and put your pen down and then look at the person in the eye and have that rapport so that he trusts that I have his best interest in mind. But I've known this guy for 20 years or something. But my point is, there's no doubt that doctors are feeling distressed by the lack of time. And I think a lot of doctors are leaving medicine. I mean, not I think, I know the data are clear that people are leaving medicine.

31:42You see the new paper that women are leaving at age 48? Yeah, I mean, a lot of physicians are leaving and I think a lot of, you know, the harms there are obvious, which is that the population is aging and we need doctors, we need primary care doctors. I think one of the big things, going back to like how to be your best advocate, know what you put in your mouth and swallow. Like the deference that patients give to the electronic medical record, like it's just in my chart. It's like, oh my God, know what you're swallowing. You mean like what? Pharmaceuticals? Yeah. Well, I mean, and also, you know, all the other things, but I don't swallow enough vegetables.

32:18I know that. But, uh, you know, like people are like, you don't put something on a med list and then you tell your doctor it's in the chart. I mean, the charts are the wild West, right? Like, cause you have a digital avatar of you that's, that looks one way in an ER that looks a different way in your gynecologist office. that looks different in your primary care doctor's office. And then you go on vacation and you stub your toe or need a tetanus shot or something in an urgent care. And that never gets put into the record. I got a fax today from the ER, as I do commonly, about a patient of mine who was in the ER.

32:50And, you know, it's like a 20-page document that I'm looking through. And it's like the front and back of her driver's license and like all these questionnaires about like... The nursing notes, Ivy Light. Right, right. When all I need to know is like which ankle broke and did she get a tetanus shot? What I do is manually pull that information from all those records and then put it into the curated chart so I have it. But like, that takes time. So we're back to square one, which is that in this era of modern medicine, you need to be your own best self advocate. You need to like, it's like working out of the gym.

33:25You need to go and spend time and figure out what your goals are. You need to figure out what your pain points are, what your limitations are, and find a partner, someone who will spend time with you enough to make sure that you're asking the right questions. You know, it's crazy. I just, you see problems, you see business opportunities everywhere. It's crazy that there isn't a bigger market for patient advocates. Because, man, that's a, well, that's a wide open market right now to help people navigate the health system. Because we don't always have like sisters who can come listen with us or spouses who can come listen to us.

34:04I think where people go, I think where people go is they go on their like mom's groups. They go on like Facebook groups. They people crowdsource, right? Like how many, how many messages do I get from like neighbors, friends, friends of friends, not my own patients, because I have me, just people in my life who will text me and be like, Hey, my mom was just diagnosed with stage four lung cancer. Like, who do I go to? My daughter, you know, has this weird, mysterious illness or like my daughter's depressed and like we can't get in for six months. Like, what do I do? I mean, people are completely lost, even people with resources, right?

34:37So again, like I'm beating a dead horse here, but like you need to find a partner. You need to find someone who can answer your phone, answer the phone and talk to you in a crisis. And we need more physicians to choose primary care as a field. And you need to empower yourself as a patient to know how to do preventative health. Yeah. And they're so boring. People use it against doctors. Like my doctor told me to exercise more. My doctor told me to sleep more. My doctor told me to blah, blah, blah. It's like, because the basics, my God, the health gains that America could get if you just stopped smoking, vaping, drinking alcohol, stop marijuana.

35:14Like it's not easy, but as far as unhealthy things that you do chronically that add up over time? 100%. That's what drives me crazy about this whole peptide movement, right? Is like, it's bells and whistles, like, you know, GLP-1s are a peptide. So I think the GLP-1 revolution has given other like sort of stepchildren peptides like this moment in the sun where they don't deserve it. But the point I'm trying to make is that the simple stuff is always going to be better. Like if you can get seven or eight hours of restful sleep, eat three meals a day. They don't have to be Pinterest perfect. They just need to be something protein, fiber, healthy fats, limit carbohydrates, but don't ditch them altogether because life isn't worth living without ice cream in the summer and Fourth of July weekend.

35:58like your birthday, whatever, and get exercise and make it fun and not fanatical and trick yourself into exercising by doing it with a friend. As the young kids say, touch grass. Yeah, and then limit your screen time. I need to do that massively and connect with other human beings. If you can get a hug, oh, gold. Prioritize your sexual health. Talk about your problems with your spouse, your partner, your friends. Engage in psychotherapy if you need it. work on your relationship with food, alcohol. It's not just about quantity. It's about how you relate to alcohol. Do you use it because you're bored, excited, lonely, or do you use it just because it's something that pairs with food?

36:40Ask yourself hard questions about what's your relationship with your own body. Do you stress eat? What's going on in your life that's driving habits that are causing you problems that show up in your lab work? And be radically honest about what thoughts and feelings are going on that drive the behaviors that are sticky. I love it. People will use this advice against, to be like, it's your fault because you caused your disease. Nobody's saying that. What we're saying is everything is important. Yeah. Not to get super stressed because then you see the people who are super stressed about everything because you can't possibly do all the things in a 12-hour day.

37:18No, no, no. 80%, have it be good. And then you're doing pretty damn good. Health is a process, right? It's not a game to win, right? How many patients do I see in my office who are like, you know, I just started exercising again two weeks ago before I came in here. And I'm like, you know, you can't win this appointment. There's no judgment for like, if you've gained weight or your sugar levels are higher, this is just a point in time. Health is just an ongoing process. You're never done. I want to bring up something again to pick on gender bias in healthcare because I see this a lot. Women, as a woman in healthcare, you are either too old or too young for something.

37:52So you better make sure you go to the doctor on the exact right day where you're the right age for something. Right. All the time. So I recently saw somebody, not even of retirement age, according to American standards, so is younger than that, was denied a medication that's FDA approved for what her goal was. She was just told she was too old. On the flip side, we've got these peptide stacks that are not FDA approved coming off the dark side of the internet. They're like the Nepo babies of the GLP-1s. It's like, they are. They're riding the coattails, right? Yeah, totally. But I'm like, women are told they're too old or too young for something.

38:29Men are never. I've got 90-year-olds on testosterone and Viagra. But the ageism that comes with being female, men just don't have in healthcare like women do. How would you counsel a woman if she's been told she's too old or too young for something? First thing is get a new doctor, right? I mean, that's just like this whole 10-year window of menopause, I think has thrown people into a tizzy as if there's a stop sign at 10 years where you can't. I'm like, if you're going to use the guidelines against a woman, I actually said this to this woman. I'm like, if you're going to use the guidelines against you and say the guidelines say you're too old, you should actually read the guidelines, which don't say you're too old.

39:06It says risk benefit discussion over age of 60. Right. I think the guidelines are saying basically the benefits tend to outweigh the risks on a population level of HRT. And when you start it within the 10 years of a woman's last menstrual period, but it doesn't mean it's a no afterwards. I have a patient I just saw this morning, actually, who had ovarian cancer. Now, she had ovarian cancer, like, in her 30s. And it was not estrogen sensitive. She had a hysterectomy. All of her parts are taken out. She's 71 now. She wants to have sex. She wants to work on her bone density. She's got osteoporosis.

39:42I mean, I've told her, like, it's not the first-line treatment for osteoporosis. like the ship already sailed. You've been estrogen depleted for so long. But like, is it going to hurt you to be on estrogen? You don't need the progesterone because you don't have a uterus. She's like, I just want it. I just want it. Whatever the risks are. I want it because I know that it's going to help me feel sharper. It's going to help my bones. Like it's, what's the downside? I'm like, I can't really think of any downsides. So why don't we try three months and see yoga? There it is. It came out for three months and it went up a little bit.

40:11Her FSH came down and she's like, I don't know if it's the estrogen or not, but I just feel sharper. I feel a little more alert. I feel, I'm like, I don't either, but here you are. Great. You did your trial. You made, you reassessed, you made your decision. And she doesn't have other, and importantly, she doesn't have, you know, she's got a normal A1C. She has a clean coronary artery calcium score zero. Oh God. I mean, my other comment is, if a woman at age of 83 or pick an age doesn't have body autonomy, when is she going to get it? Yeah, I don't look at my job as a gatekeeper. And I'm also not an In-N-Out burger.

40:43I'm not like, what do you want? I am someone who has studied since I was like a fetus to give you information and guidance on both sides of any decision, right? And to partner and center your goals, not mine. Yeah. A nice place to wrap is I think to give all the love to the doctors, the clinicians, the nurse practitioners, the PAs, the nurses, the mental health therapists, the coaches, everybody who's in this. We went into this because we love people. We wanna help people. We want to make a difference. And please appreciate that. And I think part of this transactionalism that has been created by the insurance system and the big corporations is people treat you like shit now.

41:28And then we're like, there's not enough doctors left. And you're like, yeah, these are the people that gave up their entire 20s to learn and to apply and to help people. If you treat them like shit, they'll leave. I think that's the plea at the end of like, listen, it's hard to be a patient and we're all going to be patients. I am, you are. We're all going to be a patient. It's hard. Have your advocate. Know what medics you take. But please don't treat your healthcare people like shit. We're not widgets and we're not replaceable. I'm like, you want to go replace a urologist? 20 years of training.

41:59Yeah. Patients and doctors are, and providers are all, it's a tough spot to be any of us. And so I think we got to start a revolution, Kelly Casmussen. We've got to reinvent the healthcare system where patients are given time with someone who understands them as a whole person. So how's that going to happen? I don't think it's going to happen in the federal government. I think it's going to happen in the private sector. I think it's retain the human elements, the human elements of care. Then it could actually be, we could build a scalable model of primary care that's distributed nationally. Yeah.

42:31I mean, well, states where it's illegal for physicians to own hospitals and clinics, like you took the people who took the oath out of the business, and now you're wondering why the business is just for profit. But getting doctors back into it to feel like they matter and they can make a difference. Because they're leaving. They're going to go start companies. And they're going to go do things where they can use their brain and help people. If it's not going to be in the clinic, it's going to be somewhere else. And I think physicians need to be empowered with business-savvy skills. If we can take an MCAT and do a residency, you can start your own business and practice.

43:07I mean, patient care practice, you can. And I think more and more doctors are doing that. They're taking matters into their own hands because we don't actually have a healthcare system in this country. We have a health insurance system. So to build a healthcare system, sometimes you just have to do it yourself. That's what I did. I love it. Let's talk about preventative medicine for a second because again, so many, we can go back to the hormone theory of like, hormones are preventative medicine. They don't help treat disease very well, but they can prevent stuff. But we live in a, you're broken, so let's fix it system.

43:36We live in a damage control kind of system, right? I was in the ER with my dad a couple of Christmases ago and I couldn't help but hear the other patients, you know, separated by the little thin curtains in the ER. You can't help but hear them talking to the nurse about why they're there. And so many people in the ER are there for things that could have been prevented with just access to good primary care, right? Like getting a pneumonia shot or managing their diabetes. One patient was there because they ran out of their insulin, right? I mean, that's like the most expensive insulin refill on the planet.

44:08Right, right. Like on the planet. So prevention is key and prevention requires a conversation. Because I can tell people all day long, eat less sugar, exercise more, sleep seven hours, meditate, be social, take your vitamins, consider hormone therapy because it's the standard of care around menopause or perimenopause. It takes a guidance on what to prioritize and then how to action that advice in real life, like IRL, right? It's like you can't tell a person who's depressed, just go exercise and eat better and ditch the alcohol. You can't tell an alcoholic, just ditch alcohol. You actually need psychosocial support.

44:45So, but prevention is everything. It just takes time and effort. It's much harder to do preventative care because you have to partner with the patient. It takes time than it is to just do the end stage damage control. Kudos to my cardiology colleague. I was sitting next to a dinner, my friend, who had just done a cardiac cath. for a patient who had a ST elevation heart attack on a weekend. My friend went in and opened up his artery, the guy's living. But that guy could have been, if he had seen doctors, which he hadn't in his 30s or 20s, had been counseled about metabolic health and cigarette smoking and exercise and given not just the advice, but a roadmap on how to action that advice.

45:31But instead, you're doing damage control. You can't prevent all heart attacks. No, it's interesting because I have a friend who's a CT surgeon. And I'm like, what percentage of your heart surgeries, your bypasses, have seen a primary care doctor within the last three years? A lot of these people have not seen a doctor in 20 years. Well, right. I mean, so much of this is preventable. I do think the GLP-1 revolution is putting a significant dent. And you see how the GLP-1s not only help with weight loss, they help with cardiovascular disease reduction, stroke reduction, you know. Is it breast cancer, breast cancer reduction, not just in recurrence, but primary cancer?

46:09Right, because we already knew that obesity was a risk factor for the development of breast cancer, as is being a woman, as is age. So it's not surprising that GLP-1s have these universal applications because so much of what they're doing is helping undo root cause issues, which is about your eating, it's about your exercising, and it's about access to primary care. So I'm not saying that at GLP-1, it should be distributed to all people. I'm saying that it's sad that we have had to get to the place where so many people need them because we didn't have, well, our food system is terrible and tobacco is wildly addicting and humans are human.

46:45And we do things that sabotage our health all the time. Even if we have the best doctor in the world, I do myself, right? Like I am my own worst enemy sometimes. I should start giving myself gold stars for when I go to bed at the exact same time every night because like the data coming in on regular bedtime, regular wait time, like it's coming in pretty strong at this point. And I'm like, dude, Kasperson, can you try to just hit 10 p.m. seven days in a row? Oh my God, me too. Like we should have a challenge, Kelly, because I get in bed and every night I'm like, don't go on your phone, don't go on your phone.

47:16I'm like, oh, but what about the like fun videos and cats and like random - Literally like a benefit of marriage for me is that the husband makes me go to bed at 10 p.m. Oh my God, my husband does the same thing. And then he's out of town this week and I'm like, shit. Right, that's accountability. I'm watching Saturday Night Live clips from 1974. Exactly. Like it's urgent. Oh my God, Debbie Downer, so funny. Literally watched something on that yesterday. Debbie Downer, when they go to Disney World, one of the best clips in history. Insane, I know, it's so good. But what you're talking about is accountability, right?

47:49So preventative health is not just about a doctor saying do this, do that. that it's about how do I execute on these things? And some of it is accountability. So I have a cross the street neighbor and we are walking every single Monday and it's a pain in the ass to get out of my office at five o 'clock on Monday. It's like the busiest day, but I am not gonna disappoint her. And so I go. Exactly. No, fitness accountability. Apparently I couldn't have been accountable to myself enough, but now I have a fitness Facebook group. Ooh. And you just show up, post your picture. What are you doing today?

48:22We've been doing that since like probably before COVID at this point. And it was like, it was the unlock for consistent weightlifting for me. It's so good because doctors are people too. We can tell people all day long what to do and what not to do. And then we sometimes are our own worst enemy. We default to factory settings. Oh God, like dopamine. It's all ones and zeros up there. Dopamine. Oh, and the denial plan. Like I had the shoulder injury and I'm like, okay, the denial plan is not working. The denial plus fistfuls of Advil pretending that that's going to just make it go away. And so I saw my orthopedic friend.

48:57We did an MRI. I did what everybody does, which is you go on the portal and you look at the report before you've spoken to the doctor and you see like supraspinatus tendinosis, you know, itis, itis, itis, tear, tear, tear. And I'm like, oh, my God, I need surgery. He calls me and he's like, Lucy, you have a 53-year-old shoulder. Get your ass into PT. I'm like, put, put, put, put, put, put, put, put. Throw an estrogen patch on it. I have an estrogen patch. the estrogen is coursing through my veins as we speak, but that doesn't protect you from having a 53-year-old shoulder. So I'm in PT and guess what?

49:26It works. It works. PT works. That's a great wrap up because PT is a miracle. Every time I bring up PT, I get messages from PT being like, thank you for bringing up PT. So I have like a reward system going on with me mentioning PT now. But like the amount of people who are like, what's it going to do? It's not going to help. It's like they got PhDs, you guys, in things that doctors aren't good at. That's it. And people take care of their cars more than they take care of their skeletons, right? So it's a very underutilized resource. People wait till the car is broken down on the side of the road before they go to PT.

50:03Use it as a way to maintain this skeleton, this vehicle you're driving through life. You only have one. You only have one. You can't trade in your skeleton like you can your Honda, your Prius, or your Tesla, whatever, depending on your politics. You've got to maintain it. So go to PT, like default to PT. These PTs are great. They're so good. And the accountability thing going back, I was joking with a friend. I'm like, personal trainers, that's paying for accountability and paying to not be afraid of heavy things anymore. And like so high yield. I highly recommend it. And for people who say it's not my budget, just do it once or twice or three times.

50:40Right. Just try it. You know what's interesting? Kids are so stoked about learning new things. And then at some point, humans are like, nope, it's like, maybe there's things to learn here. Maybe a personal trainer will teach you about something you didn't know about yourself. Right. Sometimes you don't need a hip replacement. You just need pelvic floor PT. God, sometimes you just need, yeah, hamstring strength. Just like sometimes you don't need Prozac, you need work on in the divorce or you need like a marriage counseling, right? It's like, it's the thought mechanics, just like it's the body mechanics, the thought mechanics with the therapist, just like the body mechanics with a physical therapist.

51:17I love it. Well, hopefully people have realized we don't hate patients and we don't hate physicians and we actually don't hate anybody. And I think the other thing about this talk today is like just us acknowledging that like the system's stinky right now. Like it's so bad. And you know, like we grew up in the 90s. We had a balanced budget. Republicans and Democrats were friends. It was super, I mean, you didn't always agree, but you like could talk about it and people weren't like throwing plates at each other. It's really hard, especially for Gen X to be like, dude, we grew up in America, the hero.

51:47Like we solve problems, right? And now we're like, holy shit, this is big. And especially doctors who like, I like solving problems. I'm a surgeon. I like knowing the world's changed because I showed up today. I can't solve this one. Like this isn't like Kelly's going to figure it out. But I think just talking about it and realizing like if it seems hard. And the other part is like, doctors don't understand until you start an Instagram account or a Substack or whatever the hell you're going to start. And the suffering comes to you and you realize we all think we're doing a really good job and we are, but as a population, it's sucking for people.

52:26Oh, I mean, it breaks my heart every single day. That's part of what motivated me to write this book. The messages I get from Substack, I have 40 ,000 people reading my Substack every week and people write me that they never thought about the fact that their childhood trauma could have to do with their relationship with food and their diabetes. Or they don't know who to ask about some basic, the bar is so low out there, Kelly. It's so terrible. Dude, I'm fully convinced God put me on earth just to tell people to use vaginal estrogen. Like my fruit is very low hanging, right? And it's like, I will spend the rest of my career telling people to use vaginal estrogen and still find the people.

53:02I got two messages yesterday from women saying, maybe my mom wouldn't have died of urosepsis had vaginal estrogen ever been brought up. Right. Vaginal estrogen is not just for your comfort. It's for life-saving purposes. It is to prevent urosepsis. I mean, sing it from the hilltops. Absolutely. It's crazy. It's like what we think of as simple stuff. I got a message from somebody. They're like, do you think there's enough doctors on social media already talking about X, Y, and Z? And I'm like, no. No. Double it, triple it, quadruple it. No. No. 80 million women over the age of 40. That's just the women.

53:3980 million over the age of 40. I'm the same way. I'll be like, what should I write about my subsect this week? And I'll be like, maybe I should write about menopause. And I'm like, no, I've written about that so many times. But then I'll write about it. And people are like, oh, I didn't know you could start hormone therapy in your late 50s. Or I didn't know that hormone therapy doesn't cause breast cancer. I'm like, oh my gosh. So you cannot say it too much. The definition of an expert, somebody who can say the same thing on repeat and not get bored. Yeah. Well, we've got our work cut out for us because there's a lot of stuff that is low hanging fruit, low hanging fruit.

54:11Find what you're passionate about and not getting bored by. I'm like, like literally I'm like, use lube. People's like, and what would you, wrapping up this podcast, what would you like to tell people? Use lube. That's my low hanging fruit. All right. For you, beyond the prescription, A Doctor's Guide to Taking Charge of Your Health. Thank you for writing it. Writing books is a beast. It is. I mean, I really enjoyed it, but birthing it into the world is a beast. So thank you for helping me get the word out. Yeah. And then you're like, does anybody like my baby? Does anybody like my baby? When I was naming it, I was like, I'm not going to tell anybody the name until I figured it out, right?

54:43Just like you don't want to tell your parents your baby name ideas until they're externalized. You're like, it's George. And people are like, oh God, my middle child is George. I had a crush on a George in seventh grade. He was the cutest. Well, my little George is the cutest. Yeah, see, I'm totally George. I'm totally George biased. This podcast is sponsored by Joy and Blokes. One thing I've always believed, if I'm helping one person with their sexual health, I always have to think about who's on the other side of that relationship because intimacy doesn't happen in isolation. And I've said this for years.

55:16If I'm prescribing a blue pill for a man, what about his partner? Are they dealing with pain during sex, low libido, hormonal changes? are they both healthy enough to enjoy the relationship they're trying to build together? I see it with women and their health all the time too. She starts optimizing her hormones, more energy, better sleep, the brain fog lifts, libido comes back, and the next thing I hear is, now my husband needs help too. That's one of the reasons I like Joy and Blokes. They care for both women and men, connecting patients with licensed clinicians for personalized hormone optimization when it's clinically appropriate.

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56:30That's J-O-I and B-L-O-K-E-S.com backslash not broken code not broken. So yeah, read the book. Thank you for writing the book. It's not easy. It'll help people. And I hope it'll help people. It's connecting people. It's the unmet need of like, what should I do? How can I get the healthcare I need? How can I look inside, put a mirror up to myself and figure out what I need, what my goals are? Who am I as a person, as a patient? Not as a person. People know who they are as a person, but who are you as a patient? Like you have an identity as a patient. You bring a different version of yourself to the doctor's office and you may be in other parts of your life.

57:07You know what I want to prescribe more of? Self-love. And I don't mean masturbation. Yes. You know, Kristen Neff has done some incredible work on self-compassion. I mean, sometimes you don't need a prescription for a GLP-1, you need self-compassion for the body shaming you experience when you're a kid that caused you to binge eat, that caused you to have obesity. And self-compassion is the missing link so that you can give yourself permission to like feed yourself at lunch. Sometimes you don't need a GLP-1, you need permission to have lunch, right? Which starts with self-compassion. Like these are basic things, but self-compassion is very difficult to access even harder than getting vaginal estrogen sometimes.

57:44A hundred percent. And people will be like, Dr. McBride dismissed me. She just told me I had to love myself more. It's like, there's a kernel of truth. If you can hear that, the kernel of truth in the power of that. I was, you know, I was looking up the other day, the relative risk of dementia based upon like your underlying, like mood, optimism, purpose in life, meaning. It is almost as much as the reduction that exercise gives you. Yeah, absolutely. Can you write a substack on that, please? Yeah, I mean, look at also Vivek Murthy's work. He's the former Surgeon General under Obama and then Biden.

58:19And look at Jennifer Wallace's work on mattering and all that neuroscience is there. They're like dementia prevention. And I'm like, you loving yourself and having a purpose in life is actually huge. Right, absolutely. It all matters. It's the social emotional stuff. And it's like, we have research. It's like, you know, everybody's always like, there's not enough research. I'm like, yeah, but we have research and we have guidelines and nobody's fucking looking at it anyways. So like, why actually do we need more research? We're not utilizing the shit we have. That's right. I'm like, you want more research?

58:48Why? Because we're paying attention to the stuff we have? We have a ton of data already, like on a population-based level and then also on an individual level. People have a lot of data, like in their own bodies and minds and just if you ask them the right questions. So sometimes you don't need to like just, you don't need more tests and you don't need more studies. You just need someone to ask you the questions, right? And you need to have a little bit of permission to understand how the lack of self-compassion, the lack of a sense of purpose and meaning in your life is relevant to the way you feel.

59:19So hopefully that's why you and I will never be replaced by AI because we're like master question generators, right? All I want to do, literally, we were talking about this before the podcast required, all I really want to do is love on people and help them in their own personal growth. The absolute wins I see now, because I don't give an F what the scale says, I care about how much muscle you have. right and like and then the whole conversation changes and all i want to do is love on people and then effing cvs and the estrogen patch shortages and the prior odds for generic fda approved medications are wrecking it for me it is bananas it is bananas kelly gaspersen poor patients i really feel bad for them and poor us why did kelly quit because finally on tuesday she's had enough of cvs and you're atna fucking injured yeah cvs is chafing because of the estrogen in pad shortage.

1:00:07It's really crazy. You know the scene in Pretty Woman where she comes back, she finally goes shopping on Rodeo Drive and then she comes back with the bags and she says, big mistake, huge mistake to the store that had turned her down the day before. Oh, right. Because they were snobby, right? They were snobby. So she went and she spent thousands of dollars somewhere else and then came back and they're like, can we help you now? And she's like, no, fuck off. That's how I feel with CVS and the pad shortages. I'm like, women better not ever buy Kleenex from them. Better never buy a Pepsi again. Don't ever buy your title.

1:00:36Like CVS, big mistake, huge mistake. 80 million women over the age of 40 don't have patch shortages. It's crazy. That's my final rant. Any final words, Dr. Lucy McBride? Thank you for your work. Use loop. Use loop. That's Kelly's. But mine is if you're feeling, if you're feeling dazed and confused by the medical system on one side and then the wellness industry beckoning you trying to make up for the failures of the medical system, but equally prescriptive. It's wide open for a reason. Then there's this gulf in the middle where you live, where I live as a patient as well, and where most humans live, where they want evidence-based advice.

1:01:10They want a physician. They know they can't DIY their health. They also want to be well. Wellness is good. It's just that wellness that's prescriptive and not evidence-based supplements and vitamins and gizmos and gadgets, you run the risk of being over-promised certainty. And then becoming very cynical. If you live in that space, like the real world, where you want a doctor and you don't want to do it on your own, but you want a better way to game the system, you want to utilize to engage with the system that we have, then read my book. I love it. Thank you for coming on the podcast today. Thank you for having me, Kelly.

1:01:49It's always a pleasure. If you found this episode funny, helpful, insightful, please take a moment to follow, rate, and share the You Are Not Broken podcast with someone who might need this conversation too. That support is how this information reaches more people. And thank you. For courses, books, and my monthly membership and the Casperson Clinic information, visit kellycaspersonmd.com. This podcast and all content from Dr. Kelly Kasperson is intended for educational and informational purposes only, and this is not a substitute for individual medical, coaching, or psychological advice, diagnosis, or treatment.

1:02:28Always seek the guidance of your qualified healthcare professional with any questions you may have regarding your health. Never disregard or delay medical advice because of something you've heard on this or other podcasts. Thanks for being here, and remember, you are not broken.