Beyond the Prescription: Recent Episodes

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Dear friends,

The day I’ve been working toward for 3 years is finally here!

It takes an army of supporters to launch a book. The video above is to say HUGE THANKS to everyone who has purchased books and supported this process.

I wrote Beyond the Prescription to help you, your friends, and loved ones become empowered patients, armed with tools and actionable information to get what you need from our medical system.

If you haven’t yet purchased your copy of Beyond the Prescription, today is the day! 🥳 🙏 📣 🎁 🎉 🥰

You can purchase and gift a copy here:

With love and gratitude,

Lucy

P.S. If you purchased the book through my website, it will arrive within a week. And to anyone in DC, come celebrate with me at Politics & Prose (Conn Ave location) tomorrow night 8/12 at 7 pm ET. 🥳 🎉

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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BEYOND THE PRESCRIPTION officially goes on sale next week.

Get your advance copy here:

Last week, I spotted a large box on my front stoop as I pulled in from work. It was either the dog food I‘d ordered from Amazon or fresh-printed copies of my debut book. When the return address read “Simon & Schuster, New York City,” I thought to myself: the dog is going to be hungry and THIS IS IT!

I called out to my husband and asked him to film this moment. He shot it in one take, no prep. As you can hear, I have lots of instructions for him 😆

Let me know what you think! (Besides needing a box-cutter ✂️)

Last, a huge THANK YOU to this readership. Without you, I wouldn’t have gotten the book deal, I wouldn’t be reaching people far and wide, and I wouldn’t have built a community of supportive, curious, thoughtful people who want to be more okay tomorrow than you are today.

See you next week!

🙏 Lucy

BEYOND THE PRESCRIPTION BOOK UPDATE: UPCOMING EVENTS 👉

• August 6 @ 6-7 pm PT | Zibby’s Bookshop | Santa Monica, CA |in conversation with Elise Loehnen | RSVP here!

• August 12 @ 7-8 pm | Politics & Prose | Washington, DC | in conversation with Franklin Foer

• August 15 @ 1-2 pm | Mitchell’s Book Corner | Nantucket, MA | book signing

My book, Beyond the Prescription, comes out on August 11. I wrote it with you in mind. The book is a roadmap for navigating your health in real life without perfectionism, pseudoscience, or shame.

You can order your copy at Amazon, Bookshop.org, or Barnes & Noble.

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

Episode Summary

Dr. Lucy McBride sits down with Dr. Amy Commander, breast oncologist at Mass General Brigham and author of Paving Your Path Through Breast Cancer and Beyond, to cut through the fear and misinformation around breast cancer. They cover who is actually at risk, what the screening guidelines mean in practice, what lifestyle factors move the needle, and how to make sense of the HRT and breast cancer conversation — including what the evidence actually says about hormone therapy for survivors.

Risk: Genetics, Bad Luck, and Everything In Between

• Only 5–10% of breast cancers in the U.S. are due to identifiable inherited gene mutations — BRCA1 and BRCA2 account for roughly half of those

• Another 10–15% involve familial patterns without a single identifiable gene; the remaining majority are sporadic, meaning they occur without an inherited cause we can currently explain

• Having breast cancer in your family doesn’t mean you have a genetic mutation — given that one in eight women will develop breast cancer in her lifetime, sometimes it just means you have women in your family

• A strong pattern — grandmother, mother, and sister all with breast cancer — is a signal worth discussing with a doctor; a single relative is not necessarily a reason for genetic testing

Screening: Mammograms, Dense Breasts, and MRI

• Mammograms do not cause breast cancer — annual screening starting at 40 is recommended for average-risk women, with the end point determined by a shared conversation with a doctor

• Dense breast tissue makes mammograms harder to read — finding a tumor in extremely dense tissue is like finding a snowman in a snowstorm; about 10% of women have extremely dense tissue and most should add an annual breast MRI staggered six months from their mammogram

• Heterogeneously dense tissue is common — up to 40% of women under 50 — but not everyone with it needs an MRI; the decision depends on other risk factors and should incorporate a validated risk model like the Tyrer-Cuzick calculator

• Breast MRI catches more, but also generates more false positives, particularly on the first scan; the downstream anxiety and biopsies are real costs that belong in the conversation

Lifestyle and Prevention

• Alcohol is the most consistent and modifiable lifestyle risk factor for breast cancer — even one drink per day carries a small but real increased risk, and the relationship is dose-dependent

• Maintaining a healthy weight and engaging in regular physical activity reduce risk — partly by reducing circulating estrogen in post-menopausal women and by improving metabolic health overall

• Soy is not a risk factor for breast cancer — this is a persistent myth; soy foods are a good source of plant-based protein and the evidence is clear that they are safe

• Risk factors divide into fixed (age, sex, genetics) and modifiable (alcohol, weight, exercise, metabolic health); the goal is to lean into what can be changed without catastrophizing what cannot

HRT and Breast Cancer: Separating Fear from Evidence

• The fear around HRT and breast cancer stems largely from the 2002 Women’s Health Initiative study, which used synthetic progestins — not the bioidentical hormones most commonly prescribed today

• In the WHI, women who took estrogen alone — those who had undergone hysterectomy — actually had a reduced risk of breast cancer, a finding that was not widely reported

• The overall increased risk from combined hormone therapy is small, and causation has not been established; a family history of breast cancer is not an automatic disqualification from HRT

• HRT is a tool in the toolkit, not a solution for everyone — the right answer depends on individual risk factors, symptom burden, and what a woman is willing to weigh

Vaginal Estrogen and Breast Cancer Survivors

• Vaginal estrogen is considered safe for virtually all women, including most breast cancer survivors, because systemic absorption is minimal

• It is distinct from systemic HRT and should not be lumped in with it — women who have had breast cancer and are suffering from genitourinary symptoms should know this option exists

• For women on systemic HRT who also use vaginal estrogen, the two can be used together; the patch is not a substitute for vaginal estrogen because the tissue itself needs local treatment

• Oncologists are increasingly getting educated on menopause management — the divide between oncology and women’s health is closing, and patients benefit when their cancer doctor and primary care doctor are working from the same playbook

Survivorship: Thriving Beyond a Diagnosis

• Too many women feel defined by their diagnosis, or guilty that they somehow caused it — neither is warranted, and neither serves the goal of getting better

• Breast cancer is not one disease; genomic tools like the Oncotype DX and ProSigna help determine whether chemotherapy is even necessary, sparing many women from treatment that won’t help them

• The pillars of thriving after breast cancer mirror the pillars of health generally — sleep, movement, stress management, social connection, and a sense of purpose

• Patients have more agency than they often believe: where genetics and diagnosis are fixed, how a woman shows up for her body, her relationships, and her care is not

Upshot

Breast cancer is common, but fear and misinformation make it harder to navigate than it needs to be. Most cases have nothing to do with inherited genes. Screening saves lives. HRT is not the villain it was made out to be. And a diagnosis, however frightening, is not the whole story — patients have more agency than they think, and thriving after breast cancer is a real and achievable goal.

And, if you liked this episode, check out my conversations on Hormone Therapy, Hot Flashes and Sexual with Dr. Laura Streicher and Menopause and More with Dr. Sharon Malone!

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Dr. Lucy McBride sits down again with Dr. Greg Katz, cardiologist at NYU, to tackle the questions patients ask most about blood pressure: what the numbers actually mean, why a single reading in the doctor’s office can mislead, what drives hypertension in the first place, and how to think about treatment.

Tune in for practical, plainspoken advice, grounded in the reality of everyday patient care.

What Blood Pressure Actually Measures

• Blood pressure is the force your blood vessels experience as the heart contracts and relaxes

• Optimal depends on who you are — but is roughly 115 over 75

• Blood pressure is supposed to fluctuate — for example it goes up with exercise, stress, and other drivers of adrenaline; it goes down with deep breathing and rest

White Coat Hypertension and the Case for Home Monitoring

• Elevated readings in the doctor’s office don’t always reflect a diagnosis of hypertension

• Getting more data points by assessing home blood pressure readings is almost always the right call before making a treatment decision

• White coat hypertension is real, but so is the converse: people whose numbers are genuinely high regardless of setting, and who benefit from earlier intervention

What Drives High Blood Pressure

• High blood pressure is due to a combination of genetics, age, lifestyle, and underlying conditions

• Controllable contributors include weight, alcohol, sleep apnea, sodium intake, and chronic stress; uncontrollable ones include family history, age, and sex

• The blood pressure “serenity prayer” is a useful frame: accept what can’t be changed, lean hard into what can, and if blood pressure stays high after all of that, medication is not a defeat

The Consequences of Untreated Hypertension

• Stroke, heart attack, kidney failure, heart failure, and dementia are the major downstream consequences of untreated hypertension

• Dr. Katz calls it the “boring killer” — doctors see it so constantly it stops feeling urgent, but the cumulative damage of even mildly elevated pressure over years is not trivial

• The good news: blood pressure medications are cheap, well-tolerated, and effective; the hard part is implementing the right solution for each individual patient

How Blood Pressure Is Treated Pharmacologically

• ARBs like telmisartan or candesartan are often first-line, especially for patients with diabetes.

• Calcium channel blockers like amlodipine are a strong alternative and require no lab monitoring

• Beta blockers, once standard first-line treatment, have largely fallen out of favor for uncomplicated hypertension

• Importantly, medication is never a life sentence; it can be adjusted as circumstances change

Blood Pressure, Cholesterol, Blood Sugar aka the Cardiovascular Trifecta

• Blood pressure, cholesterol, and blood sugar are independent risk factors for vascular disease

• Metabolic syndrome (elevated blood pressure, large waist circumference, high triglycerides, low HDL) is a single condition that dysregulates all three simultaneously

• Getting all three under control is the most reliable way to reduce cardiovascular risk for the vast majority of patients

Upshot

High blood pressure doesn’t make headlines, but it drives some of the most serious and preventable health outcomes there are. The science and the tools to treat it exist. What requires more attention is the human context — who this patient is, what their life looks like, and which solution will actually work for them.

📣 Don’t miss out! You’ve got a few more days to join me this summer for the official Beyond the Prescription Book Club! It’s open exclusively to Substack readers and gives you early access to the book, pre-publication. 👀 We’ll get into the nitty gritty of health and wellness and what it all means for YOU.

Just a few days left! Sign-ups are open in May only.

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Dr. Lucy McBride sits down with Benoit Denizet-Lewis, longtime writer for the New York Times Magazine and bestselling author of You’ve Changed: The Promise and Price of Self-Transformation, for a wide-ranging conversation about how people actually transform.

What Transformation Actually Means—and How It Happens

• The self-help industry focuses on habit change and optimization; Denizet-Lewis was interested in something deeper: shifts in identity, perspective, and personality that make people feel genuinely different

• Change happens in multiple ways: sometimes it’s intentional and goal-directed, sometimes it arrives uninvited through illness, aging, or a moment of unexpected awe

• People are deeply conflicted about change: they want it for themselves and are simultaneously threatened by it in the people they love

• The narrative of transformation is almost always tidier in retrospect than it was in the living of it

Identifying What is Fixed vs. What Is Dynamic

• Core personality traits can be tweaked with real effort, but wholesale personality transformation is rare

• Genetics and childhood shape us in ways that are largely fixed, but how we relate to those things is not

• Trauma can be repaired; relationships fractured by the past can, with sustained work, become the closest ones we have

• The serenity prayer captures something clinically true: distinguishing between what is fixed and what is dynamic is the definition of wisdom

Self-Compassion as the Engine of Change

• The transformation Denizet-Lewis describes most personally wasn’t a dramatic identity shift: it was learning gentleness toward himself

• Ram Dass’s approach to jealousy—welcoming it in, naming it, refusing to let it run the show—illustrates what it looks like to observe a feeling without being consumed by it

• Honest self-observation is essential to change, but it has to be paired with compassion; without it, the mirror is too painful to look into

• An apology that ends with a period is one of the clearest expressions of self-awareness and change

Shame vs. Guilt—and Why the Difference Matters

• Guilt says “I did something bad”; shame says “I am bad”—and the distinction has real consequences for whether change is possible

• Research on young people who committed crimes found that guilt was a positive predictor of rehabilitation; shame, counterintuitively, increased the likelihood of reoffending

• The shame of failing to change—of breaking a resolution, relapsing, or falling short of a goal—is under-appreciated and causes many people to stop trying altogether

• Shining a light on shame, naming it, and normalizing it is often the first step toward dismantling it; living in it while organizing behaviors around it is one of the most reliable ways to stay stuck

Change as a Social Act

• We like to think of transformation as private and interior, but it happens in community—getting buy-in from others, having change witnessed and reflected back, is part of how it becomes real

• Social media has complicated this: performing transformation publicly creates skepticism, making it harder for genuine change to be legible to others

• Asking people close to you whether they’ve noticed a change—awkward as it is—can be one of the most grounding forms of accountability

Technology, Distractions, and Reclaiming Space

• The phone has become the first place most people go when anxiety surfaces — which means it’s both a cause of anxiety and the default coping mechanism for it

• Denizet-Lewis and McBride argue that the best thinking—in writing, in medicine, in life—tends to happen in stillness

Upshot

Transformation is messier, slower, and more social than many before-and-after stories suggest. The question isn’t whether change is possible—it is—but whether we’re willing to do the unglamorous work of honest self-observation, shame reduction, and showing up differently over time.

📣 HELLO READERS! Please join me this summer for the official Beyond the Prescription Book Club! It’s open exclusively to Substack readers and gives you early access to the book, pre-publication. 👀 We’ll get into the nitty gritty of health and wellness and what it all means for YOU.

Sign-ups are open in May only.

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Dr. Lucy McBride sits down with award-winning journalist Jennifer Wallace, author of the New York Times bestseller Mattering: The Secret to a Life of Deep Connection and Purpose, to explore why feeling valued—and adding value—may be one of the most powerful and overlooked determinants of health. They discuss the physiology of mattering and what you can do today to feel more grounded in their own worth.

What Mattering Actually Means

• Mattering is defined as feeling valued by family, friends, community, and society—and having the opportunity to add meaningful value back

• After food and shelter, it is the motivation to matter that most drives human behavior

• When people feel they matter, they contribute, engage, and show up pro-socially; when they don’t, they suffer and can act out in ways that harm themselves and their communities

• Mattering isn’t simply a feel-good concept; it’s physiologically measurable and directly linked to behaviors, blood pressure, and chronic stress

The Body Keeps Score on Mattering

• Feeling worthless or useless registers in the body as chronic stress, i.e., cortisol stays elevated and the nervous system does not feel safe

• In a study of suicidal men, the two words most commonly used to describe their suffering were “useless” and “worthless”

• The social proof that we matter—once delivered through neighbors, religious communities, and stable workplaces—has been quietly outsourced to the market, leaving a gap that Uber Eats and Amazon cannot fill

How Modern Life Is Eroding Our Sense of Mattering

• Signals of mattering used to be embedded in daily life—neighbors relied on each other, communities were interdependent; that infrastructure is dissolving

• The Dutch theologian Henri Nouwen’s three great lies—“I am what I have,” “I am what I do,” “I am what others think of me”—condition people to believe their worth is entirely conditional on external forces

• Workplaces have broken the loyalty contract; social media algorithms reward outrage over connection; AI threatens to make human contribution feel obsolete

• We’ve become less interdependent, and in losing that interdependence, we’ve lost one of the most reliable sources of feeling needed and valued

Mattering to Yourself First

• One of the hardest lessons: you cannot sustainably matter to others if you don’t matter to yourself

• A simple daily practice: while brushing your teeth each morning, ask what one small need you can meet for yourself

• The cultural message—especially for women and caregivers—that prioritizing your own needs is selfish is precisely backwards; burnout serves no one

• Sturdy adults need sturdy adults: surrounding yourself with even one or two people who remind you of your importance is a legitimate health intervention

Making Mattering Actionable

• Researchers identify four core ingredients of mattering, organized by Jennifer as SAID: Significant, Appreciated, Invested in, Depended on

• Feeling significant doesn’t come from life’s big moments; it comes from being remembered in the details, like a colleague checking in after a hard week

• Appreciating the doer behind the deed—not just thanking someone for what they did, but naming who they are—feeds mattering more deeply than gratitude alone

• A nightly practice: ask what one small need you filled today, one small way you added value, and one small way you felt valued—this works against the brain’s negativity bias and reinforces a sense of mattering over time

Upshot

The question isn't whether mattering affects your health — the research is unambiguous that it does. The question is whether you're tending to it with the same seriousness you bring to your labs.

📣 I’m starting an official Beyond the Prescription Book Club. We’ll get into the nitty gritty of health and wellness and what it all means for YOU. It’s open exclusively to Substack readers and gives you early access to the book. Sign-ups are open in May only.

Learn how to join here!

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Episode Summary

Dr. Lucy McBride sits down with Dr. Vivek Murthy, the 19ths and 21st U.S. Surgeon General and the founder of the Together Project, to talk about why the “achieve, acquire, optimize” model of success leaves so many people empty, and what actually fills the gap. They explore the science of social connection, the hidden costs of optimization culture, social media’s complex role in our lives, and why relationships matter for human health.

The Limits of “Achieve, Acquire, Optimize”

• When Dr. Murthy asked young people across the country how they defined success, the answer was remarkably consistent: money, power, and fame. Yet many who had all three were deeply unhappy.

• The real triad of fulfillment isn’t money, power, and fame; it’s relationships, purpose, and service

• Over-optimization culture sells false certainty; the three-, five-, and seven-step programs over-promise and often obscure the fact that what we actually need is community, not a protocol.

• We weren’t built to navigate life’s challenges alone. The myth of rugged individualism as a proxy for strength is a harmful story modern culture tells.

The Four Dimensions of Health

• Physical health is only one piece; mental, social, and spiritual health are equally important dimensions that medicine has been slow to embrace. (Read Dr. McBride’s two-part series, Mental Health is Health, here and here.)

• Someone can have perfect vital signs and a clean lipid panel and still be profoundly unhealthy if they’re isolated, purposeless, or disconnected from meaning.

• Dr. McBride wrote a prescription for human connection for an isolated patient during the pandemic—not a medication, but an instruction to reconnect with old friends.

• Expanding the lens through which we look at health isn’t soft or quaint; it’s what the evidence demands.

The Data on Social Connection

• The WHO Commission on Social Connection, co-chaired by Dr. Murthy, synthesized decades of research in a June 2025 report showing that social disconnection nearly doubles the risk of depression.

• Physical health consequences are equally striking: a roughly 30% increased risk of heart disease and stroke, and a 50% increased risk of dementia among older adults.

• The overall mortality impact of social disconnection is on par with obesity and smoking, yet we treat it as a lifestyle preference, not a public health priority.

• People often need explicit permission to prioritize relationships; both doctors here agree that medicine needs to “prescribe” it.

Social Media and the Erosion of Real Connection

• Social media was designed to maximize time on platform. Addictive features are not accidental but intentional.

• Movements like Logoff are helping peers take deliberate breaks and reclaim their attention.

• Practical starting points include tech-free dinner tables, devices charged in the kitchen overnight, and designated offline windows—none of which require waiting for a legislative fix or accountability from tech companies.

The Together Project and What to Do Today

• The Together Project focuses on three things: telling the story of connection and its science, supporting community builders who are often isolated in their own work, and expanding the research base.

• Dr. Murthy’s framework for a good day asks not how many to-do items were completed, but whether he loved, served, and grew.

• His single practical prescription: spend five minutes every day reaching out to someone you care about, just to check in.

Upshot

Human connection is as essential to health as any biomarker. The question isn’t whether relationships matters, it’s what we do every day to center them in our lives.

My book, Beyond the Prescription, comes out on August 11! I wrote it with you in mind.

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Episode Summary

Dr. Lucy McBride sits down with Dr. Greg Katz, cardiologist and educator at NYU, to make sense of the new 2026 cholesterol guidelines — and what they actually mean for real patients. Together, they cut through the noise on coronary artery calcium scores, Lp(a), statins, GLP-1s, and the lifestyle factors that matter most for heart health. The upshot: we treat people, not numbers.

The New Cholesterol Guidelines — Goals and Limits

• The 2026 guidelines were released in March, endorsed by eleven groups of medical experts, and they reflect a synthesis of existing cardiovascular evidence, not new data.

• The goal of updated guidelines isn’t for doctors (or patients) to treat them as the Bible, but rather to help assess cardiovascular risk, estimate the benefit of various interventions, and help patients understand how medical evidence applies to them.

• Guidelines are built on large populations; they can’t account for the individual patient sitting in front of you. For example, two people with identical LDL levels can have entirely different risk profiles, family histories, reasons their cholesterol is elevated, and therefore completely different treatment pathways.

• Read more on what the new guidelines don’t tell you here.

Coronary Artery Calcium Scores — What They Can and Can’t Tell You

• A calcium score looks for calcified, hardened plaque in the coronary arteries — it tells you about the “plumbing,” not the whole story of a patient’s heart health.

• A score of zero doesn’t mean you have no plaque; soft plaque is invisible on this test and can still cause blockages.

• A non-zero score doesn’t mean a heart attack is imminent — age, sex, and the rest of your risk profile matter enormously.

• When doctors overreact to elevated scores, it can set off a cascade of unnecessary tests and procedures and lead to patient anxiety. As always, context and appropriate communication matter when transmitting information to patients.

Blood Pressure: The Underappreciated Risk Factor

• Blood pressure is probably the most underappreciated driver of cardiovascular risk — contributing to heart disease, heart failure, kidney failure, and dementia.

• If someone has an elevated calcium score and imperfect blood pressure, controlling the blood pressure often matters more than starting a statin.

• Most heart disease prevention comes down to three things: blood pressure, cholesterol, and metabolic health (Read more on what your blood pressure is telling you here).

Statins — Who Needs Them, and What the Side Effects Actually Mean

• Statins reduce cardiovascular risk by about 20-25% on average — but if your baseline risk is very low, 20% of near-zero is still near-zero!

• Side effects are real but manageable: about 8-10% of people get muscle aches that are predictable and reversible when the medication is stopped.

• Claims that statins cause diabetes are overblown — the blood sugar rise is not inevitable and often is small and predictable.

• Non-statin options give patients who can’t tolerate statins real alternatives.

Lp(a) — What It Is and What to Do With It

• Lipoprotein(a) is a genetically driven particle that accelerates plaque formation, promotes inflammation, and makes blood more likely to clot.

• It is not modifiable by lifestyle, and statins actually raise it slightly — the LDL remains the primary therapeutic target.

• A very high Lp(a) combined with a strong family history of early heart disease is a red flag that should sharpen clinical decision-making across the board.

• Drugs to directly lower Lp(a) are in late-stage trials and look promising, but aren’t yet on the market.

Exercise, Diet, and the Case Against Prescriptive Protocols

• The best exercise is the one you’ll actually do — movement matters more than which movement.

• Strength training is especially important in midlife to preserve muscle mass, but the barriers are real; YouTube body weight workouts are a legitimate starting point.

• Most people know what junk food is; the best dietary strategy is the one that fits your actual life — and only a real conversation reveals which approach will stick.

Upshot

The new cholesterol guidelines are a useful framework — not a personal prescription. Whether the question is statins, calcium scores, or Lp(a), the answer almost always depends on who you are, what your family history looks like, and what you’re willing to do. Numbers need context, and good medicine means treating the human behind the chart.

Drop your comments here!

Pre-order Beyond the Prescription — out August 11!

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Dr. Lucy McBride sits down with Dr. Zeke Emanuel — physician, bioethicist, and key architect of the Affordable Care Act — to discuss his new New York Times bestseller Eat Your Ice Cream: Six Simple Rules for a Long and Healthy Life. They explore the challenges of navigating our fragile medical system alongside a bustling wellness industry, what the data show about longevity, and why a living meaningful life is the best health strategy of all.

The “Wellness Industrial Complex”

• The wellness industry is flourishing in part because people lack access to primary care and they want to be well, but they don’t know who to trust with their health — their doctor? ChatGPT? the online guru?

• Biohacking, optimizing, and obsessive self-tracking are marketing terms — whereas biology is built for moderation, not extremes

• Both doctors cautioned against wellness influencers who may have conflicts of interest or whose advice is aspirational, extrapolated from animal studies, and not evidence-based

Zeke Emanuel’s Six Rules to Live a Long & Healthy Life

• Don’t be a schmuck, socialize, eat well, sleep, exercise, and stay cognitively engaged — all well-supported by evidence, none requiring expensive protocols

• The goal isn’t perfection; it’s a sustainable routine you enjoy, because you’ll need to maintain it for decades

• Missing a workout or a healthy meal once isn’t the problem — what matters is the overall pattern

Social Connection Is Not Optional

• Social isolation is one of the most dangerous and least-discussed health risks — chronic loneliness carries risks comparable to smoking 15 cigarettes a day

• Among 50-year-olds followed over eight years, those without close friendships had a 25% higher mortality rate

• Nearly 20% of Americans now have zero or one friend, up from about 5-6% in prior decades — and more than half of meals in the U.S. are eaten alone

Meaning and Purpose as Medicine

• Getting outside yourself — directing attention outward toward others — is both the antidote to modern narcissism and the foundation of genuine fulfillment

• Meaning doesn’t have to be grand; a school bus driver who made it his purpose to help each child start the day well illustrates how ordinary roles can be deeply sustaining

• People who have a sense of meaning tend to live longer — and unlike supplements or cold plunges, cultivating curiosity about others costs nothing and is accessible to everyone

The Primary Care Crisis

• The U.S. spends nearly 18% of GDP on healthcare, yet 95% goes to hospitalizations and procedures — only 5% to primary care

• Research shows that adding primary care doctors to a community lowers mortality; adding specialists, counterintuitively, raises it

• To fix the system, patient panels need to shrink, administrative burden needs to drop, and primary care physicians need to be paid comparably to specialists

AI, Aging, and the Quality-of-Life Question

• Dr. Emanuel has reviewed the full published literature on AI in medicine since January 2024 and is more bullish than many expect

• AI holds particular promise for expanding access in rural and underserved areas where providers and facilities are scarce

• His pre-pandemic essay arguing against aggressive medical intervention past 75 wasn’t policy — it was a provocation designed to get people thinking seriously about the life, and death, they actually want

Upshot

A long and healthy life doesn’t require biohacking or obsessive self-monitoring — it requires a sustainable routine built around things that actually work. The hard part isn’t the science. It’s building a culture that makes those things accessible to everyone.

Pre-order Beyond the Prescription — out August 11!

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Episode Summary

Dr. Lucy McBride sits down with Dr. Lauren Streicher, Northwestern University professor and sexual medicine expert, to untangle two decades of fear-based messaging about hormone therapy in the wake of the Women’s Health Initiative. They revisit what the WHI actually showed (and didn’t show) and make the case for individualized, evidence-based menopause care across hot flashes, sleep, bone health, genitourinary symptoms, and sexual health.

The WHI: A High-Quality Study That Was Badly Misread

• The WHI was the first randomized controlled trial on menopausal women and hormone therapy — well-designed, but its early termination generated fear-based messaging clinicians are still undoing

• The women who took estrogen only showed a reduced risk of breast cancer; the combined arm showed an increase of one case per thousand women, with breast cancer mortality still reduced

Hot Flashes Are Not Harmless

• The average duration of hot flashes is seven years — 10 years in Black women, lifelong for 10%

• Each hot flash triggers a spike in heart rate, blood pressure, cortisol, and inflammation that accumulates real cardiovascular damage over time

• Chronic sleep disruption from menopause compounds that cardiovascular risk significantly

Local Vaginal Estrogen: Safe and Woefully Underused

• Genitourinary syndrome of menopause — urgency, recurrent UTIs, pain with intercourse, pelvic floor dysfunction — is treatable at any age, including in women on aromatase inhibitors

• The FDA recently removed the black box warning from vaginal estrogen; it was never warranted and existed only due to blanket class labeling tied to oral estrogens (listen to more discussion about the removal of the FDA black box warning here)

The 10-Year Window Is Not a Stop Sign

• Women who start hormone therapy within 10 years of their last period tend to do better at a population level — it does not mean therapy must stop after 10 years

• A woman still symptomatic at 62 is a very different conversation than a symptom-free woman who feels she missed the boat (read about options you may have after the 10 year window here)

Hormone Therapy and Breast Cancer: What the Science Actually Shows

• For women with BRCA mutations, multiple studies — including a large 2025 prospective analysis — show no increased breast cancer risk on hormone therapy after oophorectomy. Breast cancer incidence was actually significantly lower in HRT users, with the protective effect concentrated in estrogen-only formulations.

• For women with a prior breast cancer diagnosis, the evidence on HRT risk is limited and formulation-specific: older trials showed increased recurrence risk with combined estrogen-progestin (particularly in ER+ disease), but modern formulations are understudied, vaginal estrogen appears safe, and a 2025 expert consensus endorsed shared decision-making for women with severe symptoms. Existing data are too outdated and heterogeneous to apply universally.

Perimenopause Requires a Different Playbook

• During perimenopause, estrogen levels surge and crash erratically — standard menopause-dose hormone therapy often does nothing; a low-dose birth control pill is frequently the better tool

• The decision to start, continue, or stop hormone therapy should be driven by symptoms and medical history — not arbitrary rules or influencers

Upshot

The fear that followed the WHI left generations of women under-treated and misinformed, and many are still paying the price. Hormone therapy is not right for everyone, but the decision should be driven by symptoms, history, and honest risk-benefit conversation, not by outdated warnings, arbitrary timelines, or wellness culture overcorrections. Women deserve accurate information about their own bodies, and that starts with clinicians who know the evidence and are willing to have a nuanced conversation.

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Episode Summary Dr. Lucy McBride uses a patient's obsession with getting a facelift to explore what aging well actually requires — and why the $60 billion anti-aging industry is designed to ensure you never feel like you're winning. She breaks down the four areas where aging actually shows up in your health and offers a more honest framework for deciding where to focus your time, energy, and money.

• The anti-aging industry profits from a moving goalpost — you get older every day, and the message that aging is a failure of discipline ensures you never feel like enough

• A patient's fixation on her neck and jowls turned out to be a proxy for loneliness, grief, and fear about her memory — concrete, "fixable" feelings standing in for things that felt unfixable

• Aging well isn't about your telomeres or your biological age score — it's about identifying which parts of your health ecosystem are actually under strain

• The four areas where aging shows up: your medical data, what you're putting in your body, your physical infrastructure (muscle, balance, strength), and your inner landscape (grief, loneliness, fear)

• Muscle loss accelerates in midlife — especially in women not on hormone therapy — and affects metabolism, confidence, and literally how you carry yourself through a room

• The questions worth asking before booking a consultation: What are you actually trying to fix? Is it your face, or your sense of agency? Is it fatigue, or loneliness?

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Dr. Lucy McBride sits down with Dr. Bob Wachter, chair of the Department of Medicine at UCSF and bestselling author of A Giant Leap to discuss artificial intelligence in healthcare. They explore the current frustrations with electronic health records that don't communicate with each other, the unprecedented rapid adoption of AI scribes and tools among clinicians, and how AI can free doctors from documentation burden to focus on patient relationships. The conversation addresses the promise of democratizing healthcare access through AI, but also the critical need for oversight of tech companies whose profit motives may not align with patient welfare.

The Electronic Health Record Problem

Both patients and doctors are frustrated with fragmented EHRs—multiple patient portals that don’t communicate with each other create disparate care and wasted time

Doctors spend huge amounts of time documenting in EHRs but get very little useful intelligence out of them

AI as Documentation Solution, Not Relationship Replacement

The act of caring for another human being is relationship-based, rooted in trust, rapport, and understanding the whole person

AI can make the paperwork and documentation side more efficient, giving doctors more time to care for the person, not just their lab data

The Rapid Adoption of AI Tools in Medicine

The uptake curve of AI scribes and knowledge tools among clinicians has been astounding

This rapid adoption reflects the superpowers of the tools and the desperation clinicians feel to better manage administrative burdens of care

Patient Access to Information vs. Understanding

Federal statute now requires patients to see doctors’ notes, lab results, and x-ray results through patient portals

Patients see abnormal results but the portal gives them absolutely no assistance understanding what it means

Portal access has created an average of three hours of after-hours work for physicians

The Promise of Scalable Healthcare Access

AI offers potential for patients to get fast, fact-based information

The scalability and access to information that AI provides could democratize healthcare beyond just those who can afford to pay for a doctor

This accessibility represents a significant opportunity to expand quality medical guidance to more people

The Perils of Profit-Driven AI in Healthcare

AI companies building healthcare tools didn’t take the Hippocratic Oath and will be trying to maximize revenue

AI without physician oversight, training, and guidance is unlikely to prioritize patient welfare over economic advantage

If stewarded by physicians who understand the human elements of care, AI holds promise to help elevate, not eliminate, the patient-doctor relationship (read Dr. McBride’s article about why AI won’t be able to replace doctors here)

Upshot

The question isn't whether to adopt AI tools (doctors already do), but how to shape them so they serve patients and preserve the human elements of care. Doctors and patients alike must be part of the solution—ensuring AI becomes a tool for democratizing quality healthcare rather than creating new barriers driven by profit motives disconnected from the Hippocratic duty to put patients first.

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Episode Summary

Dr. Lucy McBride sits down with registered dietitian Ashley Koff, best-selling author of "Your Best Shot," to discuss metabolic health, GLP-1 medications, and why the medical profession needs to shift from weight loss to weight health. They explore why BMI is just one data point, debunk the myth of the non-compliant patient, and examine how GLP-1s teach us about hunger and fullness. The conversation addresses why personalized healthcare that addresses trauma, family dynamics, and individual biology matters more than any single medication or diet approach when tackling America's metabolic health crisis.

Shifting From Weight Loss to Weight Health

Weight is a symptom, not a diagnosis, and the goal should be weight health—making the hormones and biological systems that regulate weight—rather than pursuing weight loss through willpower.

The Myth of the Non-Compliant Patient

Patients who struggle with weight aren't lazy or noncompliant—they've been dismissed and shamed by a medical system that lacks time to address the complex factors driving metabolic health.

Understanding Metabolic Health Beyond BMI

BMI is just one metric and doesn't indicate metabolic health—body composition, genetics, hormones, and social determinants all matter more than a number on the scale.

GLP-1 Medications as Teachers About Health

GLP-1s teach people to recognize actual hunger versus emotional eating, helping them establish sustainable eating patterns they can maintain even after tapering off the medication.

The Non-Linear Journey of Metabolic Health

Taking GLP-1s often means unpacking childhood trauma, navigating family disapproval, and gaining agency over your body—it's not just about losing weight.

Ending Judgment Around Bodies and Medication Choices

Society readily judges others' bodies and medication choices, but acceptance of what you can't control frees up mental energy for genuine empowerment.

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EPISODE SUMMARY: In this week's episode, Dr. Lucy McBride reads from her newsletter addressing how witnessing collective trauma affects our physical and mental health. Through patient stories, she introduces her "3 A's" framework (Awareness, Acceptance, Agency) for navigating anxiety during turbulent times and offers practical guidance for knowing when distress signals a need for help.

KEY CONCEPTS:

1. EVERYONE HAS MENTAL HEALTH—NOT JUST "THE MENTALLY ILL"

Mental health is not a diagnosis for a small percentage of people; it's a universal aspect of being human.

Mental health has been treated as the "stepchild of physical health"—when in reality, it's ground zero of health.

Physical symptoms (racing heart, jaw tension, abnormal bloodwork) often reflect underlying mental health struggles.

Your genetic predispositions, personal history, and past traumas shape how you respond to crisis.

2. THE 3 A'S: A FRAMEWORK FOR MENTAL HEALTH

Mental health is a lifelong process built on three steps: Awareness → Acceptance → Agency.

Awareness: Understanding the facts of your story and recognizing your mental health patterns.

Acceptance: Making peace with what you cannot control—genetic vulnerabilities, past trauma, current crises.

Agency: Taking action over the thoughts, feelings, habits, and relationships you can change.

3. KNOW YOUR PATTERN: CATASTROPHIZING, INTELLECTUALIZING, OR NUMBING

Catastrophizers imagine worst-case scenarios; they need reality checks.

Intellectualizers can explain every policy failure but can't sleep; they need to feel their feelings.

Numbifiers stop watching entirely because it's overwhelming; they need to stay connected.

Self-awareness about your pattern is more important than having the most resources.

4. WHY WELLNESS AND TRADITIONAL MEDICINE BOTH FALL SHORT

The wellness industry offers oversimplified solutions: meditation apps, "limit news consumption," "practice self-care."

Traditional medicine screens for anxiety disorders and offers prescriptions without addressing complexity.

Both approaches miss what's actually happening and are disempowering to patients.

Medication can quiet anxious thoughts, but there's no pill for insight; therapy builds awareness but can't alone reverse anxiety spirals.

5. PRACTICAL STEPS FOR PROTECTING YOUR MENTAL HEALTH NOW

Get honest about your baseline: Are you eating, sleeping, taking medications? Disruption signals something important.

Notice your pattern: Identify whether you catastrophize, intellectualize, or go numb—then compensate accordingly.

Set boundaries: Check news twice daily, call friends instead of doom-scrolling, turn off phones at 9pm, allow yourself to cry.

Awareness of your limits is not weakness—it's wisdom.

6. WHEN TO ASK FOR HELP

The signal: difficulty functioning—not sleeping, not eating, not taking medications, not showing up for work or family.

This isn't about being "mentally ill"; it's recognizing when your mental health needs support right now.

The real questions: How aware are you of your patterns? Where do you live on the continuum of anxiety and resilience?

Call your doctor not because something is "wrong with you," but because mental health sometimes needs professional support.

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Episode Summary

Dr. Lucy McBride sits down with behavioral economist Emily Oster, PhD, to discuss the newly released USDA dietary guidelines. They explore what the guidelines actually say, debunk common misconceptions, and examine the problematic framing that suggests individual dietary choices alone can solve America’s health crisis. The conversation addresses the USDA’s appropriate emphasis on whole foods, but why access to quality healthcare and nutritional guidance matters more than specific recommendations when tackling America’s chronic disease epidemic.

The Guidelines Are Mostly Unchanged

• The new USDA guidelines are largely similar to previous versions, contrary to fears or hopes that they would radically shift dietary recommendations

• Key advice remains consistent: prioritize protein, fiber, and healthy fats while limiting sugars, alcohol, and processed foods

• One notable improvement is that the guidelines are shorter, tighter, and more digestible than previous iterations

• The guidelines reflect evidence-based advice that most primary care doctors already give their patients daily

The Real Problem: Most Americans Don’t Eat This Way

• The biggest issue isn’t whether the guidelines emphasize protein enough or get saturated fat recommendations perfect—it’s that most American diets look nothing like what’s recommended

• The average American diet contains a tremendous amount of ultra-processed, high-salt, high-sugar foods that aren’t satiating

• Habit change around food is incredibly difficult, making implementation far more important than guideline details

• Even previous sensible guidelines didn’t translate into widespread dietary improvements

• The gap between recommendations and reality highlights why access to personalized nutrition guidance matters

The Problematic Framing of Individual Responsibility

• While the content of the guidelines is generally sound, the framing places disproportionate emphasis on personal dietary choices as the solution to health problems

• The framing ignores systemic barriers including food deserts, economic constraints, lack of healthcare access, and limited time for meal preparation that are often the biggest barriers to healthy eating

• The presentation creates a “blame the victim” mentality that suggests America’s chronic disease epidemic is primarily due to poor food choices when, in reality, obesity and metabolic diseases stem from a combination of genetic, environmental, biological, social-emotional, and behavioral factors

• Effective nutrition change requires relationships with healthcare providers, not just information on a poster

The Beef Tallow Controversy

• The inclusion of beef tallow in the guidelines raised eyebrows and generated confusion among the public

• Beef tallow is not a common cooking fat for most Americans and is less accessible and practical than butter, olive oil, or avocado oil

• The emphasis on beef tallow appeared to reflect someone’s personal agenda rather than evidence-based nutritional guidance

• For most people, traditional cooking fats like olive oil and avocado oil remain better, more practical choices

• The controversy highlighted how specific recommendations can sometimes reflect ideological positions rather than public health priorities

The Healthcare System Failures Behind Dietary Struggles

• Nutrition is a foundational pillar of health, but meaningful dietary change requires supportive relationships with healthcare providers, not just guidelines

• The current healthcare system often limits doctors to five-minute visits, making it impossible to address complex nutritional needs (Read my article on our broken primary care system here.)

• Health is about relationships, not transactions—yet many Americans lack access to doctors who can spend adequate time with them

• People’s relationships with food are deeply ingrained and often begin in childhood, making simple advice to “eat better” ineffective without strategic planning and support

• Doctors frequently lecture patients about diet and exercise without addressing barriers like body shame, food access, financial constraints, or fear of change

• Until every American has access to quality primary care that addresses nutrition, behavioral health, and whole-person wellness, dietary guidelines will have limited impact

Upshot

The new USDA dietary guidelines offer sensible, evidence-based nutritional advice that aligns with what most doctors already recommend. However, the real challenge isn’t refining what goes on the food pyramid—it’s ensuring Americans have access to the healthcare relationships and systemic support necessary to make meaningful dietary changes. Without addressing food access, economic barriers, and the broken healthcare system that limits meaningful doctor-patient interactions, even the most well-designed guidelines will remain just a poster on a wall.

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Episode Summary

Dr. Lucy McBride discusses hormone replacement therapy (HRT) and menopause, breaking through the noise of conflicting medical information. She explains the science behind menopause, addresses common misconceptions about HRT risks, and examines the recent FDA announcement about removing black box warnings on estrogen products. Throughout the episode, she advocates for evidence-based, individualized decision-making that considers a woman’s complete health profile rather than fear-based restrictions.

Key Concepts

Understanding Menopause and Perimenopause

• Menopause occurs when the ovaries stop producing consistent, robust amounts of estrogen and progesterone

• Perimenopause is the 7-10 year lead-up to menopause, characterized by irregular periods, hot flashes, night sweats, mood instability, sleep interruption, and vaginal dryness

• The average age of menopause in the United States is 51, but symptoms and experiences vary dramatically among women

• Testosterone decline in women is age-related rather than menopause-related, beginning in a woman’s 20s and 30s (Listen to Dr. McBride’s conversation on testosterone for women with New York Times journalist Susan Dominus here.)

• Every woman who lives long enough will experience menopause, affecting 50% of the population

The WHI Study and Its Lasting Impact

• The Women’s Health Initiative (WHI) study was the largest-ever randomized controlled trial studying menopause and hormone therapy. It was halted abruptly in 2002 and created widespread fear about HRT by linking it to increased breast cancer and cardiovascular disease risks

• The study had significant design flaws: participants were older (average age 63), used synthetic hormones (Premarin and Provera), and the timing hypothesis wasn’t considered

• McBride argues the study measured “harm of late initiation” rather than harm of HRT itself

• The study led to black box warnings on estrogen products that persisted for over two decades

• These warnings resulted in generations of women being denied information and treatment options for menopausal symptoms

Health Implications of Estrogen Deficiency

• Estrogen deficiency increases cardiovascular disease risk, with women losing their protective advantage over men after menopause

• Bone density loss accelerates during perimenopause and menopause, increasing osteoporosis and fracture risk

• Genitourinary syndrome of menopause causes vaginal dryness, painful intercourse, and increased urinary tract infection risk (Listen to Dr. McBride’s conversation on sexual health with Dr. Rachel Rubin here.)

• Cognitive changes and dementia risk may be associated with long-term estrogen deficiency

• Quality of life impacts include disrupted sleep, mood changes, and diminished sexual function that shouldn’t be dismissed as “just part of aging”

The Science of HRT Benefits

• Transdermal estrogen (patches, creams, gels) carries lower risks than oral estrogen by avoiding first-pass liver metabolism

• Micronized progesterone is preferred over synthetic progestins for women with a uterus to protect the uterine lining

• Early initiation of HRT (within 10 years of menopause onset) shows cardiovascular benefits rather than risks

• HRT can reduce fracture risk, improve genitourinary health, and potentially offer cognitive protection

• Local vaginal estrogen is topical (i.e, not the same as systemic hormone therapy) and is highly effective for genitourinary symptoms with minimal absorption into the bloodstream

Breast Cancer Risk in Perspective

• One in eight women will develop breast cancer over the course of their life; most breast cancers are sporadic (i.e., not hereditary or due to an inherited genetic mutation)

• The absolute risk increase of breast cancer from HRT is approximately 1 additional case per 1,000 women per year; data from the WHI showed that women who took estrogen-only HRT had a reduced risk for breast cancer

• Alcohol consumption (one drink per day) carries comparable or higher breast cancer risk than HRT

• Obesity presents a significantly higher breast cancer risk than HRT

• Having a family history of breast cancer doesn’t preclude HRT use

• Dr. McBride emphasizes viewing women’s health holistically rather than solely through the lens of breast cancer risk

Reframing Medical Decision-Making

• The question to ask your doctors isn’t “Can I take HRT?”; it’s “What are the potential risks and benefits of taking hormone therapy given my unique health profile?”

• Doctors should provide evidence-based information and guidance that honors patients’ unique health issues, tolerance for risk, and ability to understand tradeoffs inherent in any medical decision

• Risk exists on a continuum; it’s not monolithic. Risk cannot be reduced to zero—it’s about weighing competing risks and benefits which will very person to person

• Fear is real and valid, but shouldn’t be the sole driver of medical decisions

• Women deserve comprehensive information about their bodies and treatment options, regardless of age or time since menopause onset

• Read more of Dr. McBride’s article on vaginal hormone therapy and importance of empowering women to make informed decisions about their own health here.

Upshot

The conversation challenges decades of gatekeeping around hormone replacement therapy by emphasizing evidence-based, individualized care. Dr. McBride advocates for removing the stigma and fear surrounding HRT, encouraging women to ask better questions and doctors to provide evidence-based guidance that considers the whole person. Her central message: HRT isn’t right for every woman, but every woman deserves comprehensive information about her body and the right to make informed decisions.

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In this conversation, Dr. Lucy McBride sits down with New York Times journalist Susan Dominus to discuss her recent article “‘I’m on Fire’: Testosterone Is Giving Women Back Their Sex Drive—and Then Some” on testosterone supplementation in women. With testosterone use surging among midlife women, they explore the gap between recommendations from the medical establishment and the wellness industry, examining why women are turning to testosterone for sexual health, energy, and vitality—and what the limited evidence really tells us about risks and benefits.

Key Concepts

Women Actually Make Testosterone (And More Than Estrogen)

• The common misconception is that testosterone is purely a male hormone

• Most women don’t realize they naturally produce testosterone—and in higher quantities than estrogen

• Women’s bodies produce testosterone from three sources: 25% from ovaries, 25% from adrenal glands, and 50% from peripheral tissues

• Testosterone plays a role in libido, energy, metabolic health, and muscle tone throughout women’s lives, however the role of supplemental testosterone for issues other than low sexual desire remains unclear

The Decline in Testosterone Levels Starts Earlier Than You Think

• Testosterone levels in women begin declining around age 30, dropping to approximately 50% by age 60

• This is a gradual, age-related process, not a sudden menopausal crash

• Menopause doesn’t cause testosterone to plummet; it coincides with the end of a depletion that’s been happening all along

• Women in their mid-40s can feel the effects of low testosterone long before they’re perimenopausal

• Understanding this timeline challenges the narrative that testosterone issues are specifically about menopause

The Testosterone Surge: From UK Trend to US Phenomenon

• Just a few years ago, testosterone therapy for women was primarily a UK conversation; the US medical establishment was dismissive

• In the past six to eight months, testosterone use has exploded across the US

• Women are discussing it on streaming feeds, social networks, and with their friends, indicating a cultural moment

• The treatment has moved from relative obscurity to mainstream conversation at remarkable speed, and the wellness industry is seizing the moment

The Evidence Gap: What We Know and What We Don’t

• The medical establishment has been cautious about testosterone in women due to limited research and because supplemental testosterone is not currently approved by the FDA

• Existing studies support the use of supplemental testosterone in women only for libido and sexual function (i.e., hypoactive sexual desire disorder)

• Anecdotal evidence suggest that testosterone can help women with energy, muscle mass, metabolic health, cognitive “clarity,” and overall wellbeing; however more research is needed to understand where these are true effects versus placebo

• The potential downsides are real (especially if given at high doses): voice changes, irritability, hair loss, hyper-arousal

• Long-term effects remain unknown, particularly regarding cardiovascular health, metabolic changes, and other systemic impacts

• Doctors face the challenge of counseling patients when definitive evidence is lacking, creating tension between patient demand and evidence-based medicine

• This uncertainty leaves both physicians and patients navigating uncharted territory

Navigating the Gray Zone Between Medicine and Wellness

• Women find themselves caught between traditional medical systems that historically have not made space to discuss sexual health and wellness practitioners who proselytize products without adequate evidence

• This dynamic mirrors other areas of women’s health where quality-of-life concerns have been historically undervalued compared to longevity metrics

• The conversation reflects a broader cultural shift toward prioritizing women’s subjective experiences as legitimate healthcare goals

• There’s a growing concern about polypharmacy: using multiple pharmaceutical interventions to address interconnected symptoms, then needing additional treatments for side effects

• The question remains whether people are reaching for pharmaceutical solutions too quickly instead of evidence-based lifestyle interventions like exercise, sleep, and stress management

• Both Dr. McBride and Ms. Dominus stress the importance of seeking care from practitioners who are well versed in medical evidence—for example those who are certified by the Menopause Society—and addressing testosterone levels in context, ruling out other causes for issues like fatigue and brain fog before jumping to testosterone as a quick fix, while acknowledging the lack of access to evidence-based care to address the nuances of patients’ health

Upshot

The conversation about supplemental testosterone represents a pivotal moment in women’s health—where patient demand for quality-of-life improvements collides with limited evidence. This moment underscores the need for nuanced, individualized discussions between patients and providers that honor women’s subjective experiences while acknowledging medical uncertainties, a challenge that extends far beyond testosterone to many aspects of midlife women’s healthcare.

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Episode Summary

In this conversation, Dr. Lucy McBride sits down with psychiatrist Dr. Jessi Gold to discuss how to manage emotional wellbeing during times of political upheaval. With the country feeling unsettled by ongoing violence and crisis, they explore practical strategies for emotional regulation, the importance of naming feelings without judgment, and why small daily acts of self-care aren't indulgent—they're essential for functioning in a chaotic world.

Key Concepts

The Importance of Naming What's Really Happening

• Pretending the external world doesn't affect you is both unrealistic and counterproductive

• Avoiding the "grief Olympics"—comparing your struggles to others' and dismissing your own feelings

• Everyone exists in the same messy world, and acknowledging its impact creates space for authentic connection

• Naming feelings reduces the underlying current of stress that affects work performance and relationships

• You don't have to fix the world's problems to acknowledge they're affecting you

Feelings as Information, Not Pathology

• Social media makes it easy to conflate normal human emotions with clinical diagnoses

• All emotions serve a purpose and provide valuable information about your needs and circumstances

• The continuum approach: you don't need to meet clinical criteria to deserve self-compassion and support

• Feelings are temporary and meant to be experienced, not immediately eliminated or "fixed"

Acceptance vs. Resignation: Reallocating Your Resources

• True acceptance means redirecting energy from things you can't control to areas where you have agency

• The serenity prayer framework: identifying what you can and cannot change provides clarity and reduces helplessness

• Acceptance isn't giving up—it's strategic resource allocation of time, energy, and mental bandwidth

• Small acts of self-efficacy can counter overwhelming feelings of powerlessness

• Control-seeking behaviors often increase anxiety rather than providing the relief we're seeking

Dialectical Thinking: Holding Two Truths Simultaneously

• Both difficult realities and moments of joy can coexist without negating each other

• Social media algorithms push people toward emotional extremes

• You can care deeply about global suffering while still finding meaning in daily life

• Examples like Viktor Frankl demonstrate that hope can survive even in the most dire circumstances

• Dialectical thinking protects against all-or-nothing emotional spirals

Practical Micro-Strategies for Daily Emotional Regulation

• Small, discrete coping tools work better than major lifestyle overhauls for most people

• Fidget tools, breathing exercises, and physical grounding techniques provide in-the-moment relief

• Gratitude practices counter the brain's evolutionary bias toward remembering negative experiences

• Body awareness (like noticing jaw clenching while scrolling) provides early warning signals for stress

Digital Boundaries and Media Consumption

• "Mindless scrolling" is actually highly stimulating and often traumatic content consumption

• Watching repeated footage of traumatic events creates secondary trauma, especially for vulnerable populations

• Moving phones out of bedrooms and avoiding immediate morning phone checking reduces anxiety activation

• Setting specific times and limits for news consumption prevents information overwhelm

• Parallel activities with friends (working quietly together) can provide connection without amplifying distress

Upshot

Dr. McBride and Dr. Gold emphasize that managing anxiety during chaotic times requires both self-compassion and practical action. Their message: you don't need to be clinically depressed or anxious to deserve support, and tiny daily interventions can make a significant difference in emotional resilience.

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Episode Summary

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

Key Concepts

The Regulatory Meltdown

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

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

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

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

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

The Backstory Nobody's Talking About

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

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

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

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

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

Making Sense of Who Should Get Vaccinated

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

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

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

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

What Vaccines Actually Do (And Don't Do)

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

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

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

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

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

Beyond Vaccines: Testing and Treatment

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

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

• Home rapid tests can help gauge contagiousness as you recover

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

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

Trust, Messaging, and Moving Forward

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

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

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

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

Upshot

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

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Episode Summary

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

Key Concepts

The Systemic Breakdown of Primary Care

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

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

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

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

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

Medical Care vs. Healthcare: Understanding the Critical Distinction

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

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

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

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

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

Primary Care Options in the Current System

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

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

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

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

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

How to Evaluate & Select a Primary Care Provider

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

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

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

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

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

Self-Advocacy Strategies & Appointment Preparation

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

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

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

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

The Future of Healthcare Technology and Innovation

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

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

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

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

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

The Upshot

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

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

Key Concepts

Active vs. Passive Engagement with Information & Technology

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

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

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

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

Emotion Regulation & Stress Recovery

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

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

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

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

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

Focus & Attention Training in a Distracted World

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

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

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

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

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

“Hormesis” & Finding the Right Level of Challenge

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

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

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

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

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

Flexible Thinking & Perspective-Taking

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

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

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

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

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

Purpose and Meaning as Cognitive Protection

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

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

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

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

The Upshot

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

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

Key Concepts

Redefining "Good Death" Beyond Idealized Visions

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

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

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

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

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

The Crisis of Medicalized Dying in Modern Healthcare

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

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

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

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

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

Transforming Medical Communication Through Radical Honesty

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

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

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

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

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

Practical Framework for Advance Care Planning

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

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

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

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

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

Embracing Uncertainty and Impermanence as Spiritual Practice

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

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

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

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

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

Mercy and Dignity as Core Medical Values

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

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

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

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

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

About Dr. Sunita Puri

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

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Episode Summary

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

Key Concepts

The Surprising Gift of Self-Discovery in Aging

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

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

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

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

Freedom from Others' Opinions and Social Expectations

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

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

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

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

The Power of Vulnerability in Building Community

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

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

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

Healthcare System Failures and the Crisis of Trust

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

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

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

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

GLP-1 Medications: Sophisticated Weight Management Tools

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

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

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

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

Creating Authentic Communities Through Shared Stories

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

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

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

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

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

Key Concepts

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

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

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

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

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

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

Blowback: The Primary Barrier to Women's Authentic Expression

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

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

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

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

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

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

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

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

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

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

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

Community and Female Friendship as Essential Infrastructure

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

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

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

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

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

Avoiding "False Fires": Redefining Success and Fulfillment

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

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

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

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

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

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

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

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

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

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

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

The Upshot

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

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

Key Concepts

The Current "Menopause Moment"

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

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

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

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

The Women's Health Initiative Legacy and Medical Education Gaps

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

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

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

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

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

Hormone Replacement Therapy: Estrogen Formulations and Prescribing

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

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

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

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

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

Progesterone: Beyond Endometrial Protection

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

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

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

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

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

Testosterone: The Overlooked Hormone

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

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

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

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

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

The Zone of Chaos: Understanding Perimenopause

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

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

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

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

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

The Upshot

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

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

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

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

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Episode Summary

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

Key Topics Discussed

The Importance of Comprehensive Sexual Health Care

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

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

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

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

The Bio-psycho-social Approach to Low Libido

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

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

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

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

Testosterone: The Forgotten Hormone for Women

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

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

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

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

Hormone Replacement Therapy: Safety and Efficacy

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

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

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

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

Vaginal Estrogen: A Life-Saving Treatment

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

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

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

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

Building a Healthcare "Pit Crew" for Sexual Health

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

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

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

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

Key Takeaways

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

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

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

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Episode Summary

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

Key Concepts

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

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

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

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

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

GERD: WAY MORE THAN JUST HEARTBURN

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

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

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

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

Bloating and Gas: The Usual Suspects

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

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

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

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

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

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

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

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

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

COLON CANCER SCREENING: THE GOALPOST HAS MOVED

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

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

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

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

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

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

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

Upshot

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

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Episode Summary

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

Key Concepts

The New COVID Vaccine Landscape

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

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

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

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

Risk Assessment and Trade-offs in Medicine

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

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

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

The Limits of Scientific Certainty

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

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

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

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

Long COVID: Perspective and Reality

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

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

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

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

Medical Misinformation and Trust

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

• Algorithms reward confident messengers over those who acknowledge uncertainty

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

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

The Irreplaceable Value of Primary Care

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

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

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

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

Key Takeaway

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

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Episode Summary

Dr. Lucy McBride speaks with physician and bestselling author Dr. Aditi Nerurkar about managing stress and vulnerability in times of uncertainty. Dr. Nerurkar shares her personal journey with stress-related health issues and discusses practical strategies from her book "The Five Resets" to help people rewire their brains for resilience. Both physicians emphasize that mental health is universal, not optional, and offer actionable advice for managing stress amidst life's challenges.

Understanding Mental Health as Universal

• Dr. Nerurkar emphasizes that mental health is a universal phenomenon that everyone has, just like cardiovascular health

• Many physical symptoms (migraines, jaw tension, back pain, stomach issues) can be manifestations of stress

• 60-80% of all primary care visits have a stress-related component, yet only 3% of doctors counsel for stress

• Both doctors share personal experiences of physical symptoms caused by stress during their medical training

• Mental and physical health are inseparable; there's no partition between the brain and the rest of the body

The Five Resets Framework

• Reset 1: Get clear on what matters most using the MOST goal-setting framework (Motivating, Objective, Small enough to virtually guarantee success, Timely)

• Reset 2: Get quiet and find calm in a noisy world

• Reset 3: Sync your brain to your body

• Reset 4: Bring your best self forward

• Reset 5: Come up for air

• Creating a "backwards plan" to visualize steps from current state to desired goal

• Each reset includes 3-4 science-backed strategies for implementation

Practical Stress Management Techniques

• "Stop, Breathe, Be" - a 3-second brain reset to get out of "what if" thinking and back to the present moment

• 4-7-8 breathing technique (inhale for 4, hold for 7, exhale for 8) to activate the parasympathetic nervous system

• Digital boundaries: keeping phones off nightstands, switching to grayscale mode, using alarm clocks instead of phones

• Combating "revenge bedtime procrastination" - the tendency to delay sleep despite knowing better

• Using accountability partners for both digital boundaries and exercise commitments

The Science of Stress

• Understanding amygdala activation (fight-or-flight) versus prefrontal cortex functioning (planning, organization)

• The delayed stress response: keeping it together until you feel psychologically safe, then experiencing symptoms

• How scrolling impacts brain chemistry and primes the brain for stress

• The relationship between anxiety and insomnia creates a self-reinforcing cycle

• Stress from the pandemic and current events creates a collective delayed stress response

The Importance of Social Connection

• Research shows both deep relationships and casual interactions ("weak ties") benefit mental health

• Weak ties (brief interactions with strangers or acquaintances) build community without requiring emotional depth

• Finding community through shared activities like exercise classes

• Digital life has made isolation easier and social connection more challenging

• An accountability partner can help bridge the gap between intention and execution

The Gap Between Knowledge and Action

• Most people know what they should do for better mental health, but struggle with implementation

• Self-compassion is essential during the process of forming new habits

• It's normal to fall off track and get back up during habit formation

• Asking for help is a strength, not a weakness

• Recognizing we're living through a "perfect storm" of stressors that the human brain wasn't designed to handle

Upshot

Both Dr. McBride and Dr. Nerurkar underscore that improving mental health isn't about a knowledge deficit but about closing the gap between intention and action. Through practical strategies like the MOST framework, breathing techniques, and intentional social connections, everyone can build resilience even amid ongoing challenges. As Dr. Nerurkar quotes Pema Chödrön: "You are the sky, everything else is just the weather" – a powerful reminder that while we can't control external circumstances, we can develop tools to navigate them more effectively.

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Episode Summary

In this episode, Dr. McBride explores the critical topic of brain health and cognitive function, addressing common concerns about dementia while providing evidence-based strategies for protecting brain health. She discusses the different types of dementia, explains the diagnostic process, and outlines six essential pillars for maintaining cognitive health. With a focus on empowering listeners with actionable information, Dr. McBride emphasizes that individuals have more control over their cognitive destiny than previously believed and offers practical advice for incorporating brain-healthy habits into daily life.

Key Concepts

THE TWO TYPES OF DEMENTIA YOU SHOULD KNOW ABOUT

• There are two main "buckets" of dementia: vascular dementia (when your brain isn't getting enough blood flow) and neurodegenerative dementia (like Alzheimer's, where there's an intrinsic brain problem)

• Those everyday moments like forgetting where you parked aren't usually dementia - they happen because you weren't paying attention when you parked or because you're stressed and overwhelmed

• Having dementia in your family doesn't mean you'll automatically get it - genetics may set the stage but lifestyle factors play a huge role in determining cognitive health

WHAT REALLY HAPPENS DURING A DEMENTIA EVALUATION

• A proper workup includes brain imaging (focusing on memory centers called hippocampi), vascular health checks (blood pressure, cholesterol, diabetes screening), and testing how blood flows to your brain

• Neuropsychiatric testing works like a "stress test" for your brain - it's like taking your brain to the gym to see how well it's functioning

• There's no simple "dementia test" - diagnosis requires putting together many pieces of the puzzle, and genetic tests like APOE4 aren't usually helpful without specific treatments available

MOVEMENT: YOUR BRAIN'S BEST FRIEND

• Exercise literally waters your brain garden by improving blood flow, reducing inflammation, and helping control blood pressure and blood sugar

• The best exercise is simply the one you'll actually do consistently - walking, dancing, swimming, or cycling with a friend makes it more likely you'll stick with it

• Start small with realistic goals (like 20 minutes twice weekly) rather than aiming for perfection - a little movement is significantly better than none

KEEP YOUR BRAIN CHALLENGED AND GROWING

• Our brains remain adaptable well into middle and older age - forming new connections when challenged with novel activities

• Learning something new (like a language, instrument, or game) creates cognitive reserve - Dr. McBride's dad uses Duolingo for French and it's keeping his mind sharp

• Mental stimulation means engaging your brain differently than scrolling or passive TV watching - try puzzles, crosswords, Wordle, or learning to cook new recipes

SLEEP AND STRESS: THE HIDDEN BRAIN DRAINS

• Sleep isn't a luxury - it's when your brain cleans up metabolic waste, preparing you for the next day

• Chronic stress and worry can actually mimic dementia symptoms - when we're anxious or overwhelmed, our attention and memory naturally suffer

• Social connection acts as both stress relief and brain stimulation - isolation during the pandemic showed how quickly cognitive health can decline without regular human interaction

FEEDING YOUR BRAIN: WHAT REALLY MATTERS

• Focus on antioxidant and anti-inflammatory foods like blueberries, nuts (especially walnuts), avocados, and salmon rich in omega-3s

• Alcohol isn't doing your brain any favors - Dr. McBride notes that while she occasionally enjoys a glass of wine herself, there are now excellent non-alcoholic options like specialty beers and kombucha for those looking to cut back

• It's not just what you eat but when - your brain goes "hungry" if you only have coffee for breakfast and eat most calories at night, so maintain regular eating patterns throughout the day

Upshot

Dr. McBride's message is clear: you have significant power to protect your brain health. By implementing the six pillars—physical movement, mental challenges, quality sleep, stress management, social connection, and brain-friendly nutrition—you can take meaningful steps toward cognitive protection. The key is making sustainable changes rather than pursuing perfection. As Dr. McBride reminds listeners, "You have more agency over your health than you might think."

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EPISODE SUMMARY

In this week’s episode, Dr. McBride dives deep into one of the most underappreciated yet essential pillars of health: sleep. Drawing from scientific evidence and her experience caring for patients medical practice, she explores why sleep isn’t a luxury but a biological necessity. She breaks down what’s really going on in the brain while we sleep, why so many people are struggling with sleep in modern life, and what we can do—without shame or gimmicks—to reclaim restful, restorative sleep. Whether you struggle to fall asleep, wake up in the middle of the night, or just want to improve the quality of your rest, this episode offers practical, evidence-based insights to help you tune in to your body’s natural rhythms and get the sleep you need.

KEY CONCEPTS

WHY SLEEP IS A BIOLOGICAL NEED, NOT A LUXURY

• Sleep is foundational for mental, physical, and cognitive health—impacting everything from immune function to emotional regulation.

• It’s not downtime or “me time”—it’s when your brain clears metabolic waste, consolidates memory, and resets for the next day.

• Lack of sleep is linked to mood disorders, metabolic dysfunction, immune suppression, and even increased risk of dementia.

THE “NOISY BRAIN” AND MODERN LIFE

• Many patients suffer from insomnia because their minds are overloaded with darting thoughts, worries, and to-do lists.

• The analogy of surface waves (busy thoughts) vs. the calm ocean beneath (deep stillness) helps explain how meditation or mindfulness practices like Transcendental Meditation (TM) can be helpful.

• Quieting the noisy brain requires intentional stillness throughout the day—not just at bedtime.

SLEEP APNEA AND PHYSICAL DISRUPTORS

• Sleep apnea is common and underdiagnosed; it’s more than snoring—it’s interrupted breathing that can affect cognition, blood pressure, and mood.

• Common culprits include alcohol, sedatives, back-sleeping, and anatomical features like a small oropharynx.

• A proper diagnosis and treatment (like CPAP) can dramatically improve quality of life—even reversing symptoms misattributed to dementia or depression.

STIMULANTS, SCREENS, AND SLEEP DISRUPTION

• Caffeine can linger in your system for 12 hours or more, quietly sabotaging your sleep even if consumed in the morning.

• Alcohol reduces REM sleep and fragments sleep architecture—creating a deceptive sense of relaxation.

• Screens stimulate both visually (via light exposure) and cognitively (via content), making it harder to access natural sleepiness.

BEHAVIORAL STRATEGIES FOR BETTER SLEEP

• Sleep hygiene matters: cool room (65–68°F), dark environment, white noise, and screen-free wind-down time are all simple but effective.

• Build a bedtime ritual—stretching, bathing, journaling, gratitude practice, or breathing exercises like 4-7-8 can cue your body and mind for rest.

• Regular sleep-wake timing helps anchor your circadian rhythm—even on weekends (though I admit I don’t always follow that one!).

WHEN TO CONSIDER SLEEP AIDS (AND WHICH ONES)

• Over-the-counter options like magnesium glycinate, CBD, and melatonin can be helpful—but shouldn’t mask underlying issues like anxiety or apnea.

• Prescription medications like Trazodone may be appropriate in some cases, especially when insomnia is part of a larger anxiety or mood picture.

• Medications like Ambien or Benadryl may work short-term but carry cognitive risks if used nightly or long-term.

UPSHOT

Sleep is not a bonus or an indulgence—it’s a requirement for your health, resilience, and emotional well-being. By recognizing what’s standing in the way—whether it’s anxiety, lifestyle habits, medical conditions, or external disruptions—you can begin to approach sleep with the respect it deserves. And the good news? Most sleep problems are figure-outable. Small shifts in awareness and daily routines can unlock deeper rest, greater clarity, and a more grounded version of you.

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EPISODE SUMMARY

This week’s conversation is all about your heart—how cardiovascular disease develops, how to think differently about cholesterol and blood pressure, and what you can actually do to prevent problems before they start. Heart disease is still the leading cause of death worldwide, but the good news? You have far more agency over your heart health than you might realize. In this episode, we break it down in plain English: the numbers that matter, the tests that are worth it, and the simple steps that make a big difference.

KEY CONCEPTS DISCUSSED

What Cardiovascular Disease Actually Means

• Cardiovascular disease includes conditions of both the heart (cardio) and blood vessels (vascular).

• It’s not just heart attacks—it can also mean strokes, valve disease, arrhythmias, and more.

• Women are especially vulnerable, and heart disease kills more women annually than all cancers combined.

Cholesterol 101: What Matters and Why

• LDL ("bad" cholesterol) is the main target when we talk about lowering risk.

• Genetics, age, hormonal changes (like menopause), diet, and lifestyle all influence cholesterol levels.

• Your LDL goal depends on who you are—not everyone needs super low cholesterol.

• Lifestyle changes come first, but when needed, cholesterol medications (statins) are safe, effective, and sometimes lifesaving.

The Role of Coronary Artery Calcium (CAC) Scans

• CAC scans help determine if cholesterol is visibly sticking to the arteries—a crucial decision-making tool, especially for people at intermediate risk.

• A score of 0 is very reassuring; a higher score suggests the need for more aggressive treatment.

• The test carries a small amount of radiation risk, so decisions about ordering it should be personalized based on your risk factors.

Blood Pressure: Why It’s So Important

• High blood pressure can silently damage the heart, leading to heart attacks, strokes, arrhythmias, and heart failure.

• Risk factors include genetics, aging, diet, alcohol use, sleep apnea, stress, and certain medications.

• Lifestyle changes can have a huge impact, but medications are crucial when blood pressure stays high despite your best efforts.

Newer Blood Tests You Might Hear About: Lp(a) and ApoB

• Lipoprotein(a) and apolipoprotein B are newer markers that can add additional information about heart disease risk.

• Lp(a) is mostly genetic and usually only needs to be checked once.

• ApoB is dynamic and can be monitored along with regular cholesterol panels.

• Research is ongoing into treatments targeting these markers specifically.

How to Prevent Heart Disease

• You have more control than you think—but it's not about chasing perfect numbers.

• Keys to prevention:

• Daily movement and strength training

• A high-fiber, heart-healthy diet (think: plants, healthy fats, fewer processed foods)

• Limiting alcohol and eliminating smoking

• Prioritizing sleep and managing stress

• Regular, personalized checkups—including discussions about your cholesterol goals and whether a CAC scan makes sense for you

UPSHOT

You don’t need perfect cholesterol numbers, a flawless diet, or a gold-star exercise routine to protect your heart. You need good information, clear goals tailored to you, and sustainable habits that respect your real life. Cardiovascular disease may be the leading cause of death — but with the right tools and mindset, you can be firmly in the driver’s seat of your own health.

SEEKING YOUR FEEDBACK, PLEASE 🙏

I’d love to hear from you!

• Do you like 3 pm ET for the time of this weekly show? Or would 8 pm on a Tuesday or Wednesday work better for you?

• Do you prefer an hour, or is 30 minutes better?

• Do you prefer I do a deep dive into one organ system each week, or a hodgepodge of topics each week?

• What other topics do you want to hear about most?

I’m all ears! Drop me a comment!

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Episode Summary

In this week’s episode of Are You Okay?, Dr. Lucy McBride tackles a subject that touches every one of us: anxiety. In the midst of political upheaval, global conflict, climate change, and personal unpredictability, it's no wonder many of us are feeling unmoored. Dr. McBride offers a framework for understanding and managing anxiety—not as a pathology, but as a normal human response to an abnormal world.

Drawing from clinical experience and personal insights, she explores how anxiety shows up in the body and mind, how to listen to its messages, and how to build a coping toolkit that supports long-term health. She reminds us that the goal is not to eliminate anxiety but to calibrate it to reality—and to reclaim our agency in the process.

Key Concepts Discussed

Anxiety Is Not a Flaw—It’s a Feature

• Anxiety is a normal, adaptive human response to stress and uncertainty.

• It becomes a problem only when it interferes with physical health, relationships, or quality of life.

• Our brains haven’t evolved to distinguish between real-time threats and headline-driven stressors, so the same fight-or-flight response gets activated either way.

The Physical, Emotional, and Behavioral Manifestations of Anxiety

• Physical: Elevated blood pressure, jaw tension, back pain, digestive issues, disrupted sleep.

• Emotional/Cognitive: Rumination, catastrophizing, inability to concentrate, persistent worry.

• Behavioral: Avoidance, procrastination, substance use, overworking, binge behaviors.

The Five-Step Framework for Managing Anxiety

• Name it: Identifying anxiety helps restore the rational brain and reduces its power.

• Normalize it: Feeling anxious doesn't mean you're broken—it means you're human.

• Listen to it: Anxiety often signals unmet needs—like sleep, nutrition, or connection.

• Take action: Small steps like deep breathing, sleep, nature walks, and journaling can re-regulate the nervous system.

• Seek support: Therapy, social connection, and medical guidance can be critical, even before anxiety becomes debilitating.

Knowing Your Anxiety Baseline and Triggers

• Each person lives at a different point on the anxiety continuum (0–10); knowing your “set point” helps you track and manage your symptoms.

• Identifying what spikes your anxiety (e.g., health concerns, news cycles, loneliness) enables targeted coping strategies.

• Avoiding self-shame for feeling anxious is crucial—your suffering doesn’t have to be the worst to be valid.

Coping Tools That Actually Work

• 4-7-8 Breathing: A simple breathing technique to engage the parasympathetic nervous system.

• Grounding in Nature: Walking barefoot outside, connecting to the earth, and observing the present moment.

• Writing: Journaling allows for cognitive defusion—separating thoughts from identity.

• Food and hydration: Recognizing hunger and avoiding overuse of caffeine or alcohol as they amplify anxiety.

When to Ask for Help

• Anxiety is universal, but when it interferes with functioning, it’s time to seek professional support.

• Anxiety disorders are among the most common medical conditions, though often invisible and under-treated.

• Calibrating anxiety—not eradicating it—is the goal of treatment and emotional growth.

The Upshot

Anxiety is a normal response to an abnormal world. It’s not a personal failing—it’s your body’s built-in alarm system trying to keep you safe. By learning to name it, normalize it, listen to it, and take small, deliberate steps to manage it, you can begin to feel more in control—even when everything around you feels uncertain. The goal isn’t to eliminate anxiety, but to calibrate it. That’s how we reclaim agency in chaotic times.

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For too long, women have been left to navigate menopause in the dark—without facts, without context, and without a roadmap.

In this episode, Dr. McBride is joined by Dr. Sharon Malone—OBGYN, menopause expert, and best-selling author of Grown Woman Talk—to bust myths about hormone therapy, unpack the history of medical misinformation, and talk plainly about what women deserve to know about their bodies.

We cover:

• What really happened with the 2002 Women’s Health Initiative study

• The truth about hormone therapy and breast cancer risk

• Why quality of life is health

• How to advocate for yourself in the doctor’s office

• And why context, nuance, and individualized care matter more than ever

Key Concepts Discussed

The Cultural Silence Around Menopause is Breaking

• A generational shift—Gen X and Millennial women are demanding better information and care.

• The internet and social media (Instagram, Substack) have democratized access to menopause conversations.

• Women are no longer willing to settle for a diminished quality of life or misinformation about their health.

• What was once confined to private doctor’s offices is now in the public discourse.

The 2002 Women's Health Initiative (WHI) Study—What Really Happened

• The WHI was designed to explore if HRT reduced cardiovascular disease—not to assess menopause symptoms.

• The media misrepresented the study's results, causing widespread fear of HRT, especially linking it to breast cancer.

• Crucial context was lost:

• The increase in breast cancer risk was less than 1 in 1,000 women per year.

• No increase in breast cancer deaths was found.

• The WHI included women ages 50-79—skewing results because older women were more vulnerable to risks that don’t apply to younger menopausal women.

Rethinking Hormone Therapy: Benefits, Risks & The Power of Context

• Estrogen remains the most effective treatment for menopausal symptoms like hot flashes, night sweats, sleep disruption, and vaginal dryness.

• Newer studies show that estrogen-only therapy (in women without a uterus) may decrease breast cancer risk.

• The timing of HRT initiation matters:

• Starting HRT within 10 years of menopause offers the most benefit and least risk.

• Risks of not taking HRT—including osteoporosis, cardiovascular disease, and cognitive decline—are often under-discussed.

• Breast cancer risk, while real, must be understood in context alongside these other risks.

Estrogen and Brain Health—What We Know & What We Don't

• Estrogen plays a profound role in brain function, mood regulation, memory, and cognition.

• Early menopause (before 45) increases dementia risk—HRT is standard care to mitigate that risk.

• There’s strong observational evidence (but no definitive RCT) suggesting HRT may help prevent vascular dementia.

• Science is evolving—but waiting for absolute certainty means women may unnecessarily suffer.

Quality of Life is Health

• Health should not be defined solely as the absence of disease.

• Improving sleep, reducing brain fog, alleviating painful sex, and managing mood swings are essential components of wellbeing.

• The medical system often centers longevity without addressing how people feel.

• There are risks in taking HRT—but there are also significant risks in not taking it, especially for some women.

How to Advocate for Yourself in the Doctor’s Office

• Many doctors are still practicing based on outdated information from 2002.

• Women need to come prepared to advocate for themselves:

• Ask direct questions about HRT.

• Know that family history of breast cancer is not an automatic contraindication.

• Understand that cardiovascular disease is a far greater threat to women’s health than breast cancer.

• Vaginal estrogen is safe and effective for almost every woman at any age—especially for urinary symptoms and vaginal dryness.

• Consider virtual care platforms like Alloy Health for evidence-based menopause treatment if access to informed physicians is limited.

Final Takeaway

This conversation is about reframing the narrative around menopause and women’s health. HRT is not for everyone—but informed choice, context, and patient agency should be the standard. Women deserve nuanced, science-backed care that addresses their full humanity—mind, body, and spirit.

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In this week’s episode of the Q&A live from the office, Dr. Lucy McBride takes a deep dive into metabolic health. She unpacks the often-misunderstood concept of “prediabetes,” explains how blood sugar regulation works, and offers practical tools for improving insulin sensitivity and overall health—without obsessing over the scale. The conversation also includes a nuanced look at medications like Metformin and GLP-1 agonists (e.g. Ozempic), continuous glucose monitors, and the mental health aspects of our relationship with food.

KEY CONCEPTS:

1. RETHINKING “PREDIABETES”

• The term "prediabetes" often implies inevitability, which Dr. McBride challenges.

• Hemoglobin A1C levels between 5.7% and 6.4% signal elevated blood sugar but not guaranteed diabetes.

• This gray zone presents an opportunity for intervention and agency, not fear.

• Metabolic health should be viewed as a continuum—not a binary state.

2. UNDERSTANDING INSULIN AND BLOOD SUGAR REGULATION

• Type 1 diabetes = not enough insulin production.

• Type 2 diabetes = insulin resistance (insulin is produced but doesn’t work efficiently).

• Insulin helps move sugar from the bloodstream into tissues for fuel.

• Prolonged high blood sugar can damage organs and lead to serious health issues.

3. LIFESTYLE AS MEDICINE: EXERCISE AND DIET

• Cardio and strength training both improve insulin sensitivity.

• More muscle mass = more efficient carbohydrate processing.

• Diet tips:

• Reduce simple sugars and alcohol.

• Opt for high-fiber, protein-rich foods.

• Don’t skip meals—especially lunch.

• Trade-offs matter more than perfection.

4. WHY BMI IS NOT THE WHOLE STORY

• Weight and BMI are just one part of a person’s health picture.

• Some people with higher BMIs are metabolically healthy; others with “normal” BMI are not.

• The goal is not thinness—it’s functional metabolic health and agency.

• Personalized care trumps cookie-cutter weight goals.

5. TOOLS IN THE TOOLKIT: METFORMIN, GLP-1s, AND CGMs

• Metformin helps insulin work better but isn’t a weight loss drug.

• GLP-1 medications like Ozempic improve insulin sensitivity, reduce appetite, and can reset relationships with food.

• Continuous Glucose Monitors (CGMs) help clarify real-time blood sugar trends, revealing hidden issues or test inaccuracies.

• These tools must be used judiciously and with clear goals.

6. MENTAL HEALTH, STRESS, AND THE METABOLIC CONNECTION

• Chronic stress releases cortisol, which raises blood sugar.

• Emotional eating is common; food often functions as reward or comfort.

• Managing stress, improving sleep, and fostering satiety are essential components of metabolic health.

• Agency—not perfection—is the ultimate goal.

NEXT WEEK’S EPISODE PREVIEW:

Dr. McBride will be joined by OBGYN and women’s health advocate Dr. Sharon Malone to discuss menopause, hormone therapy, and how to get what they need out of our medical system.

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EPISODE SUMMARY

In this week’s live Q&A, Dr. Lucy McBride dives deep into the complex and often misunderstood topics of weight loss, anxiety, and how to navigate medical advice in a noisy health landscape. With her signature warmth and clarity, she explores what it means to approach health from a place of awareness, acceptance, and agency—not shame or quick fixes. This episode is a must-listen for anyone feeling overwhelmed by wellness culture or confused about how to pursue sustainable well-being in real life.

KEY CONCEPTS DISCUSSED

1. THE TRUTH ABOUT WEIGHT LOSS

• Weight loss is not a moral issue—it’s a medical one when appropriate.

• The first question to ask isn’t how, but why you want to lose weight.

• The number on the scale is only one small piece of the puzzle; context matters.

• Effective weight loss centers on sustainable behaviors, not restriction or shame.

• She challenges diet culture’s toxic messaging and emphasizes a whole-person, bio-psycho-social approach.

2. WHAT ACTUALLY WORKS FOR SUSTAINABLE HEALTH

• Exercise is critical for mental, metabolic, and cardiovascular health, but it’s not the magic bullet for weight loss.

• Eating enough—especially during the day—is often more helpful than eating less.

• Small, sustainable habits trump crash diets or extreme regimens.

• Accountability (walking buddies, scheduled classes, support systems) can help make habits stick.

3. HOW ANXIETY SHOWS UP IN OUR BODIES AND LIVES

• Anxiety is normal and adaptive—but becomes problematic when it overtakes emotional, cognitive, or physical functioning.

• She defines “healthy anxiety” versus harmful anxiety, using personal and clinical examples.

• Chronic stress and vigilance can wreak havoc on metabolism, sleep, and well-being.

• Dr. McBride encourages listeners to identify their personal “coping kit”—strategies that have worked in the past—and build from there.

4. WHEN TO GET A SECOND OPINION

• If you don’t feel heard, that’s reason enough to seek another perspective.

• A doctor may have the credentials—but if they aren’t treating you, the person, they’re missing the mark.

• Trust and communication are essential to good medical care.

5. SLEEP AS A HEALTH STRATEGY

• Screens, stimulants, alcohol, and chronic stress interfere with restorative sleep.

• She shares practical, real-life tips: nighttime stretching, magnesium, guided meditation, and creating a calm bedtime routine.

• Exercise during the day (even a walk!) supports better sleep quality.

6. WHO TO TRUST IN MEDICINE AND WELLNESS

• Dr. McBride urges skepticism of anyone selling simple solutions to complex problems.

• Health is not an outcome—it’s a process.

• Your best tool is not a supplement or gadget, but your own awareness, questions, and support system.

UPSHOT

This week, Dr. McBride unpacks the messy truths about weight loss, anxiety, and health advice overload. She reframes wellness as a practice rooted in awareness—not shame—offering real-life strategies for sustainable health, better sleep, and knowing when to seek a second opinion.

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EPISODE SUMMARY

In this episode of our weekly live Q&A, I answer your pressing health questions, covering a range of topics from measles outbreaks to arthritis treatments. We discuss how to navigate common health conditions, identify where you have agency over your well-being, and make informed choices about your care.

KEY CONCEPTS DISCUSSED

MEASLES: UNDERSTANDING IMMUNITY AND PROTECTION

• Measles is a highly contagious respiratory virus causing fever, cough, congestion, and a characteristic rash.

• Outbreaks are occurring in various parts of the U.S., including the Southwest and the DMV (DC, Maryland, Virginia).

• The MMR (measles, mumps, rubella) vaccine is highly effective, offering 97% protection with two doses.

• If unsure about immunity, options include a blood test for measles antibodies or getting a booster dose, particularly before travel to outbreak areas.

• People born between 1957 and 1989 may need to check their immunity since vaccine efficacy was lower during that time.

PREDIABETES: WHAT IT MEANS AND HOW TO TAKE CONTROL

• Prediabetes is defined by an elevated hemoglobin A1C (5.7-6.4), indicating higher-than-ideal average blood sugar.

• Unlike diabetes (A1C of 6.5+), prediabetes doesn’t always progress to diabetes and can often be reversed.

• Key risk factors include genetics, age, metabolic inefficiency, diet, and physical activity levels.

• Stress and poor sleep can elevate blood sugar by increasing cortisol levels.

• Strategies for lowering A1C: reducing processed carbohydrates, increasing fiber, building muscle mass, and improving cardiovascular fitness.

CONTINUOUS GLUCOSE MONITORS: WHO SHOULD USE THEM?

• CGMs provide real-time blood sugar data, which is invaluable for people with diabetes.

• Non-diabetics sometimes use CGMs for insight into how food, stress, and lifestyle affect their blood sugar.

• While CGMs can be empowering, they should be used with a clear purpose—self-awareness, not unnecessary optimization.

• Many learn that stress, sleep deprivation, and alcohol significantly impact glucose levels.

• The rise of health tracking tech reflects people’s desire for control over their health but should be balanced with medical guidance.

ARTHRITIS: MANAGING JOINT PAIN AND INFLAMMATION

• Osteoarthritis (wear-and-tear arthritis) is common, especially in weight-bearing joints like hips and knees.

• First-line treatments include anti-inflammatory medications (NSAIDs like ibuprofen), ice, and physical therapy.

• Strengthening surrounding muscles (quads for knees, glutes for hips) can reduce joint strain.

• Cortisone injections may be needed for severe cases, but frequent use suggests the need for a joint replacement.

• When pain and disability become significant, a knee or hip replacement can dramatically improve quality of life.

THYROID HEALTH: UNDERSTANDING HYPOTHYROIDISM AND HYPERTHYROIDISM

• The thyroid is a butterfly-shaped gland in the neck that regulates metabolism, energy, digestion, and more.

• Hypothyroidism (underactive thyroid) symptoms include fatigue, weight gain, constipation, swelling, and slow metabolism.

• Hyperthyroidism (overactive thyroid) can cause jitteriness, weight loss, and heart palpitations.

• The TSH and free T4 blood tests determine thyroid function.

• Many symptoms of thyroid dysfunction overlap with other conditions, so proper testing is crucial before assuming a thyroid problem.

GASTROESOPHAGEAL REFLUX DISEASE AND BARRETT’S ESOPHAGUS

• GERD occurs when stomach acid refluxes into the esophagus, causing heartburn and chest discomfort.

• Triggers include stress, certain foods (acidic, spicy, alcohol), eating too fast, and medications like NSAIDs.

• Lifestyle adjustments such as elevating the head of the bed, reducing acidic foods, and using acid-blocking medications (e.g., pantoprazole) can help.

• Chronic reflux can lead to Barrett’s esophagus, a precancerous condition where the esophageal lining changes due to prolonged acid exposure.

• Not everyone with GERD develops Barrett’s, but it’s important to monitor symptoms and consult a doctor if needed.

Final Thoughts

This episode covers a broad spectrum of health concerns, emphasizing the importance of understanding your body, knowing where you have control, and making informed decisions about prevention and treatment. If you have questions for next week’s Q&A, send them in!

Thanks for tuning in, and see you next time!!

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Join Dr. McBride every Friday at 3 pm ET for her live Q&As in the app!

EPISODE SUMMARY

In this episode, Dr. Lucy McBride is joined by Professor Emily Oster to discuss the overwhelming flood of medical information, how to interpret health news, and how to determine whom to trust. They explore how context, communication, and risk assessment play critical roles in understanding health-related topics. From pandemic-era confusion to hormone therapy debates, this conversation is packed with insights to help listeners become more discerning consumers of health information.

KEY CONCEPTS DISCUSSED

THE IMPORTANCE OF CONTEXT IN INTERPRETING MEDICAL NEWS

• Headlines often lack necessary context, making it easy to misinterpret the significance of new studies.

• A single study rarely overturns decades of existing research; step back and assess how it fits into the larger body of evidence.

• Understanding the background of a medical claim can help avoid unnecessary fear or overreaction.

• Science communication should explain not just the facts but also the limitations of what is known.

HOW TO DETERMINE TRUSTWORTHY SOURCES OF HEALTH INFORMATION

• Seek experts with relevant credentials who acknowledge both the knowns and unknowns.

• Be wary of sources that claim absolute certainty, especially when discussing complex or evolving medical topics.

• Avoid health advice from influencers or practitioners outside their area of expertise (e.g., chiropractors advising on cancer risk).

• Trust is built on humility, transparency, and an ability to communicate uncertainty effectively.

THE FAILURE OF SCIENCE COMMUNICATION DURING THE PANDEMIC AND BEYOND

• Overconfident messaging and abrupt reversals in public health recommendations eroded trust in institutions.

• Many doctors and scientists communicated with authority but failed to provide accessible explanations of why recommendations changed.

• Social media and news outlets amplified polarization, leading to a black-and-white understanding of complex issues.

• The best communicators are those who explain the reasoning behind medical recommendations, not just the recommendations themselves.

THE WELLNESS INDUSTRY AND THE DANGERS OF OVERSIMPLIFIED HEALTH ADVICE

• The wellness industry often capitalizes on fear and uncertainty, promoting solutions without sufficient scientific backing.

• While lifestyle factors (exercise, nutrition, mindfulness) matter, they are sometimes framed as cure-alls.

• Overselling optimization strategies can create a false sense of control and blame individuals when health issues arise.

• True health empowerment comes from balancing personal agency with an understanding of biological, environmental, and systemic factors.

UNDERSTANDING RISK: THE CONCEPT OR HARM REDUCTION MATTERS

• There is no such thing as zero risk; every decision involves trade-offs.

• Whether considering vaccines, hormone replacement therapy, or COVID precautions, individuals must weigh risks and benefits.

• Public health messaging often fails when it does not acknowledge the risks of both action and inaction.

• Patients should be encouraged to ask better questions, frame their concerns clearly, and seek expert guidance rather than falling into all-or-nothing thinking.

HOW TO CURATE A HEALTHY “INFORMATION DIET”

• Avoid doom-scrolling and consuming health news in an emotional state.

• Choose a few reputable sources and resist the temptation to react to every alarming headline.

• Use strategies like “future-dating” articles to revisit later in a more rational frame of mind.

• Recognize that just because a piece of information is true does not mean it is relevant to your individual health situation.

THE UPSHOT

Dr. McBride and Emily Oster emphasize the need for nuanced, context-driven health communication. The path to better understanding medical news involves critical thinking, seeking trusted sources, and managing anxiety in response to health risks. In a world full of conflicting advice, the key is to embrace uncertainty while making informed decisions based on the best available evidence.

QUOTES FROM THE EPISODE

• “Certainty is at a premium in an era of information overload—but certainty is rarely possible in medicine.” – Dr. Lucy McBride

• “All options have risks. The idea that there is a perfectly safe choice is an illusion.” – Emily Oster

• “Wellness culture sometimes gives the illusion of control, but true health is about balance and trade-offs.” – Dr. Lucy McBride

• “Good science communication isn’t about telling people what to do—it’s about giving them the tools to make informed decisions.” – Emily Oster

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ICYMI 👉

• Need Better Sleep? Start here.

• Make Kindness Great Again

• How Much Alcohol is Okay?

Hundreds of you tuned into my live conversation with Shannon Watts on Saturday. While neither of us claims to have all the answers, we discuss some coping strategies to manage distress. You can watch the full conversation above.

👉 Let me know in the comments what you found most helpful from the conversation and how you’ve been coping in the week following the election.

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Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.

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Life transitions are sprinkled with possibility. They invite adventure and hope. They can also force us to look inward, to reevaluate our life choices. They can beget sadness and regret, a mourning over the passage of time.

There’s nothing like kids getting older to remind us how it goes so fast.

Mary Louise Kelly writes out these very issues in her memoir It. Goes. So. Fast. It is a heartfelt chronicle of her eldest child’s final year at home, the death of her father, and other curve-balls in her life that forced her to reckon with her evolving roles as a parent, mother, daughter and wife. On this very special episode of Beyond the Prescription, Mary Louise describes the emotional and physical manifestations of grief, the bittersweet moment of sending a child to college, and the heartbreak of losing a parent and ending a marriage.

It turns out that even a woman who “has it all” isn’t immune to feelings of regret and sadness over the passage of time. Mary Louise’s authentic voice provides reassurance and hope that we are all caregivers at heart, doing the best we can with the time we are given.

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ICYMI 👉

• 4 Steps Toward Reclaiming Your Health

• It’s Okay to Not Be Okay

• How to Care For Your Body with Kindness & Respect

A note to paid subscribers: Join me for our next Zoom hangout on Tuesday, Feb 6 at 8:30 pm ET. The topic: Reclaiming Your Health in 2024. Bring your questions! Click here to register. 🎉

In a special video episode of today’s newsletter, my friend Shira Doron, MD, and I discuss the state of COVID—new variants, testing, treatment, boosters, and long COVID.

Shira is the Hospital Epidemiologist at Tufts Medical Center, an infectious diseases doctor, and Professor of Medicine at Tufts School of Medicine. She is a nationally recognized expert in antimicrobial stewardship and infection control. During the COVID-19 pandemic, she played a key role in helping the general public separate fact from fiction.

I hope you take a listen above!

In addition, here is Dr. Doron’s take on the current state of COVID & respiratory viruses in the U.S.:

Respiratory viral season is upon us. It’s likely that you know several people who are sick right now. These days, it can be hard to figure out how worried to be. Is this a “normal” flu season? Is COVID-19 “surging”? The media is paying more attention to respiratory infections than they did before the pandemic, and the headlines are often designed to garner clicks, which is to say they are sensationalist. Let’s cut through the hype.

Here are a few things to know:

Current state

There are many respiratory viruses circulating right now, most of which are always more prevalent in the winter. You cannot tell the difference between them without a test. Health authorities track a metric called “ILI” which stands for “influenza-like illness.” This metric encompasses all of the respiratory viruses including but not limited to COVID-19, influenza (“flu”) and COVID-19. Right now, where you live determines how much ILI you are seeing.

source: CDC.gov

Trends show that ILI peaked in the last week of 2023 and is coming down. The peak this season was lower than the year before, and comparable to the year before the pandemic, despite the fact that we have a new virus in the mix. In other words, this is a “normal” respiratory virus season in terms of severity.

This is an ad-free, reader-supported newsletter. Consider supporting this work with a paid subscription!

Testing and treatment

Health authorities still recommend that everyone test themselves for COVID-19 even if they have mild symptoms. That’s because everyone is still advised to stay home for 5 days if they have COVID-19 infection (plus another 5 days of mask wearing). Testing is especially important for people with risk factors for progression to severe disease (such as those over 65 years of age, who have multiple medical problems, are immunosuppressed, or are pregnant), because there are highly effective antivirals like Paxlovid for those who qualify. You should be aware that, while the accuracy of home tests hasn’t changed, widespread population immunity means that the levels of virus in your nose might not reach the detectable threshold until later in your illness, as late as day 4, so keep testing.

If you haven’t gotten the latest round of free tests from the government (announced November 20, 2023), they can be obtained at https://special.usps.com/testkits.

Testing for influenza is indicated if you are within 48 hours of symptom onset and have risk factors for severe disease. Antivirals for influenza can shorten the duration of symptoms. Talk to your doctor if you think you have the flu, which is characterized by sudden onset fever, body aches, fatigue and cough.

It is rarely necessary to test for other respiratory viruses, including RSV, because there are no available treatments for them.

Prevention

Updated annual vaccines are available for COVID-19 and influenza. For the first time, we now have immunizations for RSV too.

COVID-19 vaccines

No longer to be referred to as a “booster,” the 2023-2024 annual vaccine was reformulated to target more recently circulating strains of the virus. Everyone age 5 and older who is not moderately to severely immunocompromised is recommended to receive one annual dose. While vaccination is recommended for all individuals over the age of 6 months, those at highest risk stand to benefit the most. There are three options: the Pfizer vaccine, the Moderna vaccine, and the Novavax vaccine which is a good option for people who need or want an alternative to the mRNA vaccines.

RSV immunizations

Almost overnight, an entire arsenal of preventative strategies have been approved for RSV. They are:

• The Pfizer and GSK vaccines for adults over age 60—public health authorities recommend that people in this category discuss with their doctor whether the RSV vaccine is right for them.

• The Pfizer vaccine for pregnant women—all women should receive this vaccine if they are between weeks 32 and 36 before the end of January. This will protect their newborn baby from RSV infection. Fortunately, the RSV season is almost over for the year.

• The monoclonal antibody, Nirsevimab, for newborns—this preventative treatment has been in very short supply. Talk to your pediatrician if your baby’s mother did not receive the RSV vaccine during pregnancy.

Influenza

Annual flu vaccination is recommended for everyone over the age of 6 months. Patients age 65 and older should receive a high-dose, recombinant or adjuvanted vaccine for greater potency. People with egg allergy may now receive any vaccine (egg-based or non-egg-based) that is otherwise appropriate for their age and health status without the need to be vaccinated in a medical setting.

Other preventative measures

If you are high-risk or risk-averse, you may want to avoid crowded indoor spaces where the risk of respiratory virus transmission is higher. You can protect yourself with a well-fitting high-quality mask.

Maintaining your general health will go a long way to helping you successfully weather a respiratory infection, as it is inevitable that everyone will catch one at some point. Remember to eat well, get plenty of sleep, exercise, manage your stress, and optimize your underlying medical conditions like diabetes and high blood pressure.

-Shira Doron, MD

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You can also listen to this episode on Spotify!

The new weight loss drugs such as Ozempic are stunningly effective at helping patients lose weight and improve their metabolic health. Their existence also seems to have intensified polarizing rhetoric around weight, health and BMI.

On one end of the ideological spectrum, there is the “Healthy at Every Size” (HAES) movement that aims to decouple weight from worthiness—and argues that doctors who recommend weight loss to their patients with obesity do more harm by enabling body shaming without evidence to support the benefits of weight loss on health. On the other end of the spectrum is the camp that believes obesity is a result of poor health and life choices—and that patients with obesity should simply eat better and exercise more rather than succumb to the pharmaceutical industry’s latest fad.

is a Professor at Brown University, a best-selling author, and a leading voice in health economics. In her wildly popular newsletter, , she tackles pressing health issues of the day, helping people frame risk in order to make everyday decisions. Dr. Oster joins Dr. McBride on this week’s episode of Beyond the Prescription to discuss the data on BMI and health, and how to empower readers and listeners with nuanced information to be healthy, inside and out.

They review the data on the health benefits of exercise, independent of weight loss; the arbitrariness of BMI cut-offs; and the importance of focusing on health habits over a specific target weight. They agree that doctors do harm when they narrowly define health as a number on a scale—and the metabolic health involves addressing the medical, nutritional, behavioral or social-emotional elements of people’s health. As Dr. McBride says, “Sometimes that includes weight loss medication. Sometimes it’s a prescription to stop dieting and start eating lunch.”

The transcript of our conversation is here!

[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.

[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.

[00:00:57] So let's get into it and go Beyond the Prescription. Today we have an amazing guest joining us, my friend Dr. Emily Oster. Emily is a renowned economist, a bestselling author, and a professor at Brown University. Emily is one of the leading voices in health economics. Her superpower is applying data to some of society's thorniest health questions, including why people don't always make rational health decisions.

[00:01:30] In her wildly popular newsletter called Parent Data, Emily tackles pressing issues about pregnancy and parenting, helping decisions. I grabbed Emily today because I wanted to talk with her about her recent piece on body weight and health: What is the relationship between BMI and health? She pulled together a lot of data, and because weight is something I talk about with my patients every day, I thought I'd grab her for a chat. Emily, thank you so much for joining me today.

[00:02:03] Emily Oster: Thank you so much for having me. It is a delight as always to see you. It's such a treat.

[00:02:09] LM: Emily, you are no stranger to controversy. In fact, I was with you in the proverbial bunker during COVID, hiding from the haters who didn't like that you and I were trying to help message about risk. We were trying to help people better calibrate their degree of anxiety around COVID to their level of actual risk.

[00:02:31] By the way, I stand by everything I said and wrote. I hope you do too. And it was so fun to work with you then as it is now. So when I think about sensitive subjects, I think also about weight. And so, why did you want to write about weight? Is it just that you like putting your finger in the electrical socket? Or, did you have something to say?

[00:02:49] EO: So I've actually written about weight a bunch of times. So it is a topic that I work on in my academic work. So as a professor in economics, the work that I do is about health economics and statistical methods. And I actually work a lot on diet and dietary choices and why people make the dietary choices they do.

[00:03:07] And so it's not specifically about weight, but it really is about food. And so this is a kind of source of data that I think about a lot. And as a result, I've written about a lot in many different ways. And every time I come at this and I've come at it from all of the angles. So I wrote a piece once called what's the best diet?

[00:03:31] And it was just like the diet that you can stick to which is a sort of standard finding. But the frame was, you know, a lot of people are interested in diet. And when I write that, many people are very angry. They're sort of like, no diet works, we should never talk about dieting, is kind of what comes back.

[00:03:48] I did an interview with Virginia Sol Smith, who I really like, and we don't always agree but is just one of my favorite people to talk to. She always makes me think about her book Fat Talk, which is very much in the other direction, sort of very much in the space of, we should definitely not be talking about BMI, we should throw away our scales, all foods are neutral.

[00:04:10] And when I published that interview, I got it from the other side. I got the, you know, how could you possibly say this, cake and apple are not the same, like this is, this is insane. And I've written about Ozempic, so just anything, I mean, you know this—anytime you write about it in this space, there's really, really strong feelings from both sides.

[00:04:26] So this piece was trying, as I always do, more or less, sometimes more successfully than others, is to try to thread the needle and say, look, let’s look at the data and see between the view of BMI is completely meaningless and correlated with nothing, and the view that your BMI is completely deterministic of your health and that is the only information we should use.

[00:04:49] Where is the truth? And how can we use the data to get to that?

[00:04:52] LM: It is such a crucial question because everybody who's paying attention reads the headlines and understands from their doctor even that weight and weight management is good for your health. We have diet culture seeping into our pores. I mean, it's sort of in the air we breathe, everything you look at on the covers of magazines, on Instagram, and in doctor's offices is about weight, or it feels like it's about weight.

[00:05:20] I see people all the time who have avoided coming to see me, even if I've known them for decades, because they thought they would feel better about themselves, and I would feel more proud of them if they had just lost weight before they came in. And as I say to patients all the time, weight is one piece of a larger puzzle.

[00:05:36] It is not a reflection of your value, your worth. And it certainly doesn't tell us everything about your health. So I'd love to hear about your findings about the relationship between BMI and actual health.

[00:05:50] EO: In my mind, the most, the sort of most important thing to note here is that something can be correlated and can have some explanatory power and not be all of the explanatory power. So one version of this question is to say, on average, if your weight is higher, are you more likely to have other health conditions?

[00:06:13] And I should say, that's actually different from the question of whether weight causes other health conditions. But purely taking this from like a correlational standpoint, if you saw one piece of data about someone, you saw their BMI, would you learn anything about their health? And the answer is, yes. On average, there is a relationship, particularly at the upper end of BMI, between increasing BMI and worse health.

[00:06:41] And in particular, worse metabolic health. So things like, there's a strong correlation between high weight and diabetes. That's just true in the data. Now, those relationships... are there, but they're actually not as big, I think, as many people think. And that's sort of the other thing that comes out of this.

[00:06:58] And that, that has two parts. So one is actually, even to the extent that there's a positive relationship there, it doesn't show up until you start getting to sort of higher levels of BMI. So sometimes we talk, we talk about overweight being 25 BMI versus 24. Actually, the health differences between people with a BMI in the 25 to 30 versus 20 to 25, if anything, probably favor the 25 to 30, but you're certainly not seeing much in that range.

[00:07:30] As you get into a BMI of 35-40 you do see some of those, some of those correlations. But it's also true that in almost any health outcome you look at there is variation within a group and that's the thing I was sort of trying to illustrate in the piece is you look at something like diabetes or the distribution of blood pressure, like the distribution of blood pressure, it's shifted up for people who are higher BMI, but there's a lot of overlaps.

[00:07:56] Plenty of people with high blood pressure whose BMI is 19 and plenty of people with low blood pressure whose BMI is 38. And so that's the sense in which like this number Tells you maybe a little bit, but really not that much.

[00:08:12] LM: let's talk about what BMI is. BMI, I mean, you define it for us here, Emily.

[00:08:17] EO: BMI is a weight in kilograms divided by your height in meters squared. It's just a number.

[00:08:22] LM: So what you pointed out so beautifully in your piece is that medicine does this weird thing where we say that a normal BMI, body mass index, is between 20 and 24.9, and overweight is 25-29. 9

[00:08:37] EO: You guys love a sharp cutoff. It's your, it's your favorite. You love it.

[00:08:42] LM: I don't, but fine. The medical establishment loves these arbitrary cutoffs. There's nothing magical or particularly different between somebody who has a BMI of 24.9 and 25 and moreover, there are so many different elements that go into this whole person's health. That to call it a diagnosis point X and not a diagnosis at X minus .1 is ridiculous. So, you know, herein lies why we're here to talk about pulling back the curtain on what this actually means.

[00:09:18] EO: Right. And, and so I should say, like, you might wonder why have any cutoffs in this at all? I think the answer to that is that when people are describing, not even doctors, when population health scientists are describing characteristics of populations, it can sometimes be useful to define categories.

[00:09:40] So, you see this in weight, you also see it in something like low birth weight is another good example which has some cut-offs, right? So when we talk about baby weight, there's a number, 2,500 grams. And if a baby is below 2,500 grams, they're classified as low birth weight, and if they're above 2,500 grams, they're not.

[00:09:56] There's nothing special about 2,500 grams, obviously, but it’s helpful when we sort of describe a population. You want to say, does this, you know, is the low birth weight share in this population bigger than this population? We want to have a common language. And so saying, like, that's the cutoff we're going to use, so we have some number to compare, is helpful, it can be helpful. The same thing happens here. You want to describe characteristics of a population. I think the problem, and it actually shows up in the birth weight also, but the problem comes when we start, we take that, which is just away to use a number to make some descriptive statements about some population.

[00:10:35] When we take that number and we decide it's meaningful. It's like a somehow a meaningful number that we would, that would tell us something if you were on either side of it. Of course it's not. And when you're using it for populations, for individuals and populations on which it was not based, I mean, this is a much deeper issue, but when we talk about BMI in particular, this is something, these are sort of cutoffs that were developed with reference to like a white European population, they may have very different meanings and relationships with health for different populations off of which they are not based. So there's a sort of whole other can of worms there.

[00:11:14] LM: Totally. It's, I mean, to make an analogy briefly that you and I are familiar with is, you know, COVID risk, right? It's not that a 65-year-old, every 65 year old is at so much higher risk for outcomes. Then every 64-year-old, but there is truth to the fact that older people tend to get sicker on a population level when I'm talking to a patient who has just turned 65 and who is generally very healthy and active. I'm not going to counsel them in the same way. I'm going to talk to a 64 year old who's technically not at higher risk, who has myriad health problems. So population level data is one thing and then individual risk calibration and counseling.

[00:11:58] EO: Yeah, and I think the piece of this that my senses provoke so much anxiety and discomfort in people is that it is true that, and I don't think you do this, but it is, I think, an experience people either have or fear having in their doctors. They'll be weighed, their BMI will be calculated, and then they'll be told, you know, well, you just, you edged up above, you know, 20, now you're 25.1, and like this is how we're going to define you, and that becomes such an important, like, number in the conversation, and so salient, and the words, I mean, the words we use, overweight versus normal weight, obese, those take on an attention and a meaning, and they didn't just label them BMI category one, BMI category two, which, Maybe would have been more helpful.

[00:12:46] You're really using words that suggest that there's a way to be, which is normal, and then other ways to be. And that, that's, it's just not helpful. It's not, I don't think it's a helpful part of counseling. It starts people off on, on a bad, on a bad foot.

[00:13:00] LM: Yeah, I mean, I think people, for better or worse, look at doctors as authority figures and people who, whose judgment matters. And if you have a doctor who is doing a little tsk, tsk, tsk, ooh, you're getting up there, that has real power in many ways. And so I think that has real power and can do real harm.

[00:13:20] Which is not to say that doctors shouldn't be honest about the data in that patient's situation and what they could do and help to arm them with tools and information to be healthier. It's to say that shame is not appropriate or meaningful in any space, not to mention

[00:13:37] EO: Yeah, and I think the other, the other piece that I sort of spent some time on in, in this, and is actually quite closely related to stuff I work on, is that it's actually, It's very hard for most people to lose weight. Like, we know, I mean, we can sort of put Ozempic, Wegovy aside, but for people just changing diet, changing habits, consistent long term weight loss happens for a very small share of the population.

[00:14:04] And so, when we sort of start with the advice, you should lose weight, which people get, you know, in these situations, often that's just not possible. So it's like giving people a set of advice that they just... They're just going to fail on and then giving it as if, well, if only you could have this kind of willpower, if only you could achieve this, like that would be so important.

[00:14:24] I think the whole dynamic ends up in a place where you're giving people advice they can't follow based on a number that may or may not be that meaningful and isn't very nuanced, and you can easily see why that generates frustration, sadness, discomfort, lack of productive conversation with your doctor.

[00:14:43] And then by the way, turns off your ability to have a productive conversation because now we're like in defensive. Now you're like, well, you know, screw you, don't tell me what to do. What do you know?

[00:14:54] LM: Right? If we learned nothing else during the pandemic, that trust is precious. And when you don't have trust between the doctor or patient, and there's a moralization of human behavior, we're just at a standstill. And so how do you see the data that you've pulled together in this piece and before this piece helping people, individuals who are reading your stuff and then going to the doctor's office, understand better what their weight.

[00:15:21] EO: The piece I pulled out at the end that I thought was really meaningful was, in this piece I'm actually pulling data from the NHANES, the National Health and Nutrition Examination Survey, which is a very big survey of, of people, it weighs them, it measures them, collects a lot of biomarkers, which is why we can say all this stuff about, about health.

[00:15:39] They also collect information about their exercise. And so if you look at people, if you sort of take a, a second, uh, almost a second metric of health and you ask like, okay, does this person do like some, some moderate amount of exercise a week and it's like some cutoff and you look at that relationship.

[00:15:57] One of the things I show in the piece is that doing more exercise is correlated with better metabolic outcomes, better kind of health outcomes in various ways. And it's quit informative on top of BMI, and so people who are doing sort of exercise who have a BMI of like 40 actually have sort of similar metabolic health to people who like aren't doing any exercise and have a BMI that we would consider, you know, normal or, or thin.

[00:16:26] And so I think for me that has sort of two pieces of it. One is that it just again emphasizes like this is one other thing you could like if you said like you can only learn two things about people It's like well, how much more could I add with a second thing? Well, actually like quite a lot the characteristic knowing somebody's BMI and whether they have exercised rigorously or moderately in the last week that tells you a lot more about their health than knowing their BMI alone You could add on top of that smoking… it's just one simple illustration of like how much more you could learn if you ask some more questions The other thing, and here I'm going to reveal what my husband is always saying, it's just like, just because you like to exercise, fine.

[00:17:08] But like, actually, I think we should tell people to exercise. I think that we spend too much time telling people to lose weight with their diet, which is something we know is really difficult, and I think we should spend more time telling people, like, you should go take a walk after, like, try to walk for ten minutes every day.

[00:17:27] You know, actually, it's not saying, like, you need to go run a marathon. But just some aerobic exercise. I think we have a lot of evidence from a lot of different places that that's associated with better health. And I think if we started telling people that and talking about that, we would then get to the questions like, well, how can we make it possible for everyone to do that?

[00:17:45] How can we make there be safe places for people to do that? How can we increase access to sports? How can we be in a position where everybody is welcome to... to go running no matter what, you know, their race or body size or anything? And I think that's, you know, for me, that's something that's pretty, that's pretty important. And I think we're kind of missing with this focus on food.

[00:18:08] LM: I totally agree. And what I love about the NHANES data is what you earlier said, which is that there's an incredibly tight correlation between the amount of exercise and health outcomes, even more than BMI and health outcomes. So when I'm talking to a patient who wants to lose weight or, you know, Needs to lose weight, perhaps I often tell them, let's not think about the number.

[00:18:35] In fact, I commonly say, let's not think about the number. That's not our end point. And, and I'm not saying that to be politically correct, to pussyfoot around hard conversations is because the number on the scale is immaterial. When we were talking about this whole person, we are the complex sum of these integrated parts.

[00:18:57] And you can, as you said have a BMI of 40, which is technically obese. But if you are exercising on a regular basis, first of all, your mood is better, your sleep is going to be more efficient, your blood sugar control is going to be better, your blood pressure is going to be better, most likely. And so, I focus, with my patients, less on the number and more on the behaviors.

[00:19:21] The relationship with food, not just what you're eating. The cadence of how you're eating. Sometimes you don't need a fancy diet, you just need to have lunch. I just wrote a piece about that. Lunch is an underrated food group, like eat lunch. Honestly, that is huge. Sometimes we don't need to, you know, go to the doctor and be told that our weight is technically higher than it should be.

[00:19:43] We need to be given materials and information on the benefits of exercise. Not just on our weight, but on our mental health, our metabolic health, our cognition, and not just... Are you told to exercise, but to help people figure out where to put it and how to incorporate it in their everyday life. Because as you know, telling someone to exercise is one thing, helping them figure out what to do is another.

[00:20:10] So I think you're absolutely right, Emily. We need to treat people, not just as a set of metrics and data, but as people. And as you know, from your research, human behavior is complicated. We do things that don't serve us all day long. Even doctors do, which is again, ridiculous, why I would shame anybody for a behavior that's part of the human nature.

[00:20:30] So to do a lot of shooting with patients or to say you should do this is less productive than to say like, how do you think you could incorporate a little more movement because of the data on the benefits of regular movement into your whole health?

[00:20:44] EO: I actually think, you know, when we do this kind of counseling and when people hear this counseling and they hear, they sort of hear the phrase diet and exercise, like you should improve your diet and exercise. They think of that as improve your diet and exercise so you'll weigh less. And that's the link we should sever.

[00:20:59] It would be, I think there's a place to say, improve your, let's think about are there changes you could make to your diet that would make you feel better? Are there ways for you that you could incorporate exercise, which by the way, like 10 minutes of walking slightly faster than you would otherwise, that's exercise.

[00:21:16] That's an exercise activity, so just like making it clear that these things are possible. But also without saying, and if you did that then the number will look better on the, no, if you did that maybe some of these elements of health, metabolic health, maybe some of this would improve, your sleep might improve, your mood might improve, that's what we're aiming for. We're not aiming for some number.

[00:21:37] LM: That's right. And by the way, when you're sleeping better and your mood is better and your dopamine hormone axis is being triggered by the lights of being outside and feeling more fit and getting the endorphins going that is good for our metabolic, metabolic health too. But I also want to be clear that I don't shy away from talking about a number when it is relevant.

[00:22:00] So if somebody has bilateral knee osteoarthritis, bone on bone, and their BMI is 40, and they're resistant to, you know, getting a knee replacement, we have to talk about weight. So it would be irresponsible for me to say, oh, weight loss isn't going to matter to this gravity-dependent set of joints. And so that is where it gets really hard, but it is where I actually like for me it's my like superpower is never to have judgment about it because by the way when you have bone-on-bone arthritis in your knees As a result of age and genetics and weight all together you can’t exercise and You gain weight more easily.

[00:22:43] And so this is what happens. So there's no shame about it. It's just, let's figure out what to do. But we have to talk about the number, not just the number, but we have to talk about what weight might make sense to that offset pressure on the knee.

[00:22:56] EO: Yeah, I mean, that's such an interesting, like, it's, this conversation is so hard because it takes, like, it's so hard to have that conversation. And I bet you are really good at this, but I think for me, it's very hard to have that conversation without it feeling like shame because of the, as opposed to just saying, look, there are a bunch of things, like, there is a physical reason why this, this number matters, not because this number has to do with whether you're a good person or not a good person or have willpower or whatever, it's just like, this is putting pressure on your knees.

[00:23:23] LM: Well, and that's why I'd really like to reinvent the healthcare system to have doctors incentivized to have more time with their patients to understand their story and to build trust and rapport and for patients to feel comfortable and then to train doctors on sensitivity on these subjects. Which, by the way, doctors went into medicine, the field of medicine to do that, but it's just people don't have time and then people don't trust and then there's diet culture and then it's just lose weight, exercise more, see you next year.

[00:23:50] EO: This is totally off topic. I mean, it's a little bit off topic, but, but one of the things that's been pretty effective in, you know, obstetrics is these group prenatal care. People have exactly this sort of same complaint about, like, there isn't enough time to talk about all the issues that have come up, da, da, da.

[00:24:05] And so they do these things where it's like six people, but you get two hours, you know, and we do, like, there's this sort of examination component that happens, like, that's short for each person, but then we all, they, people all talk together, and it turns out to actually be, some good evidence on the relationship between that and preterm birth, particularly for black women.

[00:24:20] So I wonder if there's like, I almost think there's like a parallel care model, where it's like, we have a group of people here for counseling about, you know, whatever it is, improving their heart disease metrics or something.

[00:24:33] LM: Yeah, stay tuned for some courses I'm going to be offering in 2024. One of my little kind of mantras is that health is about more than BMI. It is about having awareness of our health ecosystem, which includes ur story, it includes our data, it includes understanding our genetics, and then sort of a laddering up to acceptance of the things we can't control.

[00:25:01] Maybe we are predestined to have a higher-than-ideal body mass index because of our genetics. And we have to accept that. We have to accept that we are predisposed to diabetes. And then agency over the things we can control. So, arming yourself with tools and information to carve out space in your life to work on the things you have control over, which are a lot.

[00:25:26] But if you're stuck in the acceptance bucket where you're not accepting hard parts of your genetics or your story that you can't control and you're then listening to a lot of kind of wellness gurus who are telling you that, you know, thin is better or whatever, even just all this messaging. And then you're spending a lot of brain space trying to accept things you really need, or trying to control things you can't control, that's where people run into trouble, and that's where shame is born, and that's where people, frankly, binge on things like food and alcohol, and that's where we land in trouble. And so if we could just help people understand they're not alone, they're human, and that we all have our challenges. One of them, for a lot of Americans, is weight.

[00:26:12] And that they're not alone, and that there are things they can do to be a lot better off. So... What was the takeaway from this piece you wrote? Like, what was the reaction? Because, as you said, like, there's sort of two camps. It's like health at every size, there's a movement, which I agree with in many ways, except that there are certain medical realities we have to acknowledge.

[00:26:32] And then there's the sort of, weight is genetic, and there's nothing you can do about it. And, I mean, there's just, there's just these false dichotomies.

[00:26:39] EO: So I think like with most things, most people are in the center. And so this kind of like, I think that many people found this interesting. You know, I'm not sure everybody thinks about this data quite the same way, and sort of seeing some graphs about it, it made some people think. A bunch of the comments were like, yes, like I started exercising, and I felt like this is very validating, because like, that, you know, that totally changed, but then my weight didn't change, but still I feel better, and I was trying to understand that.

[00:27:08] So there was like some good stuff there. And then I did get, certainly, some people who said, you know, talking about BMI at all is very fatphobic and I am, like, I will say, like, I'm a relatively thin person and so I think, you know, I don't know, I guess that's part of, part of it. And then certainly there were people on the other side who said, you know, this whole thing is like, you know, anybody who's overweight is just, you know, is just lazy and I don't agree with that at all. But some of those people fought with each other and, you know, that's what comments are for.

[00:27:39] LM: That's what's comments are for. And that is why Emily Oster is here. Emily is here to help us get to these story issues, and ask the questions that... People are wrestling with every day, like, can you have a glass of wine when you're pregnant? Can you have bluebean cheese when you're pregnant? Can you jettison some of the shame about parenting and the parenting industrial complex?

[00:28:01] And thank God for you because I think you're doing so much good, Emily, and you're reassuring people based on evidence. You're not reassuring people for the sake of reassuring them for you to look good. You're reassuring them because you have the data to show. How to calibrate risk to, or sort of how to calibrate anxiety to the actual

[00:28:21] EO: Yeah, I mean, I see a lot of what I try to do is sort of help people see what those risks are and make the choices that work for them, which [are] going to reflect our own risk tolerances and preferences and, and what's important to us.

[00:28:33] LM: Yeah. I mean, at the end of the day, as we talked about during COVID quite a lot, it's about framing risk. It's not about telling people how to feel or telling people how to choose. It's about framing risk. And then it's like, you do you, and that's fine. And if you do something that's not healthy for you, that is fine too. As long as you're armed with the data, then that, that, that is, that is great. Emily, thanks for joining me. And by the way, how can people sign up for parent data?

[00:28:56] EO: So, parentdata.org, you can find me there, we have a newsletter that goes out, we have an enormous volume of writing for pregnant people and parents and, and some things for people who are not parents, and we have like a little search AI, so parentdata.org is the best place, or you can find me on Instagram at profemilyaster.

[00:29:20] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.

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is a pediatrician and public health leader who has lived with bipolar disorder for the last 13 years. She has served on Stanford’s faculty and trained at Harvard Medical School and Johns Hopkins. She's a firm believer that life’s trials and tribulations not only improve our self-awareness, they help us flourish.

While serving as California’s Acting Surgeon General last year, Dr. Bhushan publicly revealed her diagnosis in an effort to reduce stigma and spread hope for people suffering with mental illness:

I believe that our struggles can be the source of our superpowers. They can show us our capacity for vulnerability and strength, and that we can endure and overcome hard things.

Through her popular newsletter, Ask Dr Devika B, she is growing a community to help break down the stigma associated with mental illness. As she says, "Stigma festers in the dark and scatters in the light.”

On this episode of Beyond the Prescription, Dr. Bhushan shares her advice for mental wellbeing. The two doctors also discuss the complex roots of emotional distress; the shame around mental health diagnoses; and the possibility of post-traumatic growth.

Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

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The transcript of the show is here!

[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight. We are the integrated sum of complex parts. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.

[00:01:02] Today I'm joined by the amazing Dr. Devika Bhushan. Devika is a pediatrician and public health leader who has lived with bipolar disorder for the last 13 years. Devika served as California's acting Surgeon General in 2022, where she focused on initiatives around equity, resilience, and innovation. She's a firm believer that our trials and tribulations can help us flourish, and she's learned this through her own experience living with mental illness. Today we will talk about what it's like to face a mental health diagnosis and the individually oriented lessons she's learned along the way. Devika, thank you so much for joining me today.

[00:01:42] Dr. Devika Bhushan: It's so great to be here with you, Lucy. Thanks for having me.

[00:01:46] LM: So in your op ed for the LA Times last year, you wrote some pretty powerful words. You said, I believe that our struggles can be the source of our superpowers. They can show us our capacity for vulnerability and strength, and that we can endure and overcome hard things. Can you expand on that a little bit? What do you mean by our struggles being our superpowers?

[00:02:11] DB: So my toddler, his name is Rumi. And so it's very apt. I'm going to borrow a quote from Rumi. The wound is the place where the light enters us, and this also hearkens on this Japanese tradition whereby when a ceramic bowl breaks rather than throwing it away, they will actually patch it back together with gold.

[00:02:37] And so at the end of that break, what you're left with is a stronger bowl, a more unique bowl, and a more beautiful bowl. And I firmly believe that when you have a chance to walk through a really difficult time in your life, whether that's because of mental illness, whether it's physical health, whether it is an early experience of adversity, whatever it might be, I firmly believe that once you have emerged through that, and walked through it and come out the other side, you become much more self aware, number one. You know exactly where you're able to stretch and flex and accommodate and where you're going to break. Right. And so that knowledge when you acquire it is something that will never leave you and will always make you a better whatever you decide to do after that.

[00:03:29] So, for instance, like for me, I know that. I can endure a lot. But one thing that my brain, and anybody with bipolar disorder's brain, might not be able to tolerate is actually a lot of circadian rhythm shifts. So, for instance, when I was in residency training, I didn't really internalize this. The fact that I should, from the get go, be really careful about day night switches, about 28 hour calls.

[00:03:53] And I learned the hard way that those experiences led me to have mood episodes that required me to be out for three months, two months and really struggle to find an equilibrium again. And so that's number one, right? Like you learn exactly what you're capable of and what you cannot do, where your boundaries need to be as a person.

[00:04:13] Number two, I think you learn that there are superpowers that come from enduring really difficult things. So for me, one of those is that I'm a really deep empath and I really understand other people's struggles and vulnerabilities in a way that I don't think I would have if I hadn't had such deep and dark experiences of my own.

[00:04:36] And so when, you know, when I was a practicing pediatrician sitting with patients, sitting with families, walking through very challenging things, I could connect with how they were feeling and sometimes give them lessons from my own experiences when those were relevant in a way that really helped me be a better pediatrician. And I similarly found that when team members of mine, when I was the leader of a team, when folks would go through stuff in their own personal lives that was difficult, and impacted their work because we're all human beings first, and whatever's happening for us at home or outside of the work context does show up for us at work, I was able to connect again with what they were going through and help them make the space for whatever that was in a way that maybe a leader who hadn't had their own struggles wouldn't have been able to do. So I think on both of those levels, people don't always, acknowledge or talk about the ways in which struggles lead to superpowers.

[00:05:39] But that's a firm sort of belief of mine. And when I'm, for instance, interviewing podcast guests of my own on my podcast called spread the light with Dr. David Gabby, also published in my substack. One of the questions I always ask people is, “So how do you feel like this experience led to your unique strengths or superpowers?”

[00:06:00] And people always love reframing their experiences and distilling those strengths down for people. And I'll tell you, when I published my LA Times op ed, which you quoted from, that was the line that people most resonated with. And that was a line where people specifically said to me sometimes, “You know what? I never thought about my chronic PTSD or my... OCD or my borderline personality disorder as giving rise to these superpowers that I have. But you are so right. That's exactly how I experienced this. So I think it's a very empowering frame and it's an important one,

[00:06:35] LM: I think you're right. And I think mental health is having this moment, rightly so in the popular vocabulary, right? We've been talking about the mental health toll of the pandemic. We've been talking about the, the grief, the loss, the trauma people have experienced. And I think it's fantastic that we're finally identifying mental health as part of whole health.

[00:06:59] I think sometimes though people are confused about what mental health means or what it is. And I think sometimes we think that mental health means that you're happy or mental health means that you're content, mental health means you're not anxious And so I'm very clear with my patients and with my own kids and hopefully with myself as well, that mental health is really about that laddering up from self awareness that you described to acceptance of the things We can't control like we cannot control, for example, genetic predisposition towards bipolar disorder or breast cancer or what have you, and then leaning into the agency that we have and so mental health to me is really about self awareness.

[00:07:45] It's about sort of an understanding of where we can flex, where we have that extra Reserve and then where we need to hold a boundary. And so I think it's important to recognize what health, what mental health is. It's about having the resilience, the self awareness to weather the storms that inevitably come our way.

[00:08:06] It's not about being happy all the time. Happiness is great. We're not against happiness. We're all for happiness. I'm believer in contentedness, but I think it's those tools and that we have to get sometimes the hard way that are the most kind of beautiful and that the things we don't often count in our kind of resume of life skills.

[00:08:25] And I also want to say that Rumi is an old soul. Clearly he understands that even at two years old, when we break is when we repair as well… can shed some wisdom on our resilience. So let's talk about kids for a minute. So in your role as the acting Surgeon General in California, you did quite a lot of work on adverse childhood experiences or ACEs.

[00:08:49] And many people who are listening understand that there's an abundant amount of literature about the effect of adverse childhood experiences or ACEs on social, emotional, mental, and physical health issues later in life. So some of those are my patients, people who have had some sort of childhood experience of neglect, abuse, trauma, that shows up in their bodies in the form of hypertension, an anxiety disorder, binge eating. Our stories live in our bodies. And I commonly try to help patients with various physical problems by looking back at what happened, what's behind the curtain that we can then kind of connect to their current physical state. And it's often the case that a patient who's struggling with binge eating disorder and diabetes gets better when we put them on metformin and we get them in trauma therapy to work on kind of pulling the curtain back on what happened.

[00:09:48] And helping them understand that hypervigilance that was organized around a traumatic childhood experience shows up later in life. And that's, I mean, that's the most kind of fun part of my job, if you will. So adverse childhood experiences show up as social, emotional, mental, and physical health problems in patients later in life. And so I'd love to hear about your work on adverse childhood experiences and do you agree with me that they show up in our bodies, that our stories live in our bodies?

[00:10:18] DB: That is such a beautiful way to put that. And I could not agree more. Our experiences, whether positive or negative, end up living in our bodies, and they end up living in our bodies at a cellular level, at a organismal or organ level, um, systems level, and even for all, for the whole body, right, the whole system.

[00:10:39] And what we recognized around ACEs, so all of the folks listening, are probably well acquainted with this term, but these are essentially 10 experiences that are really difficult before you turn 18 years. So child abuse, neglect, growing up in a household where maybe somebody had an untreated mental illness, intimate partner violence between adults in the home, things of this nature.

[00:11:02] And basically what happens is that you're exposed over and over again to a threat and a stressor that is extreme. And so your threat response system and your stress response systems end up being activated and have trouble getting regulated and have trouble turning back off. And what happens is that can change the way that your brain develops, your hormonal cascades, your immune system, even your genes and the parts of your genes that regulate cellular aging.

[00:11:34] So those are called telomeres for those who are aware of this term and familiar with it. And so, you know, when you look at a population level, there is this dose response relationship between the number of ACEs you've had and all sorts of health outcomes, anything from cancer to heart disease to, of course, mental and behavioral health disorders.

[00:11:53] There's about 60 or more health conditions that you're at risk for. But equally, we know that being really intentional about turning off the stress response and using that, just as you mentioned, as part of the treatment plan for a patient who's coming in with a history of trauma and let's say diabetes or heart disease. If you are not intentionally looking at that toxic stress response that's in the background that has been with them potentially for years since their childhood and you're not specifically intervening on that toxic stress response, then you're leaving part of the physiology on the table.

[00:12:32] So the ACEs Aware initiative, which we launched at the end of 2019, just before some of the biggest traumatic events of our lives were to unfold during the pandemic, the plan there was to really help health care workers of all kinds understand toxic stress physiology. And so, you know, there's a lot of talk about ACE screening, whether, you know, universal ACE screening is worth it on an individual level.

[00:12:59] We know all of this stuff is true at the population level, that ACEs will put you at risk for these health conditions, that sometimes the link gets lost. So the point of ACEs Aware Initiativeis not, in fact, to say, do you have ACEs or do you not have ACEs? It is actually to say, hey, are you coming in with health conditions and symptoms today that are rooted in a toxic stress response? And if so, if you're at risk for a toxic stress response, how can we specifically cater your healthcare to be more individualized, and to not only give you the metformin for your diabetes, but also to help you understand that trauma therapy, as you mentioned, or anti inflammatory nutrition, or certain exercise habits, sleep habits, connection, etc., that there are these other evidence based behavioral strategies that we have in our toolkits as healthcare providers, as individuals that we can start to use to specifically turn off the toxic stress response as a way of treating somebody.

[00:14:02] And so that, that message of hope is, I think, really important because we often talk about ACEs as posing risk for health, but we don't spend equal time sometimes talking about the fact that we do have these evidence based tools for enacting resilience if you do have toxic stress. In other words, toxic stress is preventable. And once it's in place, it's very treatable. And so that was the overall mission that we were working on at the ACEs Aware Initiative.

[00:14:31] LM: I love it. And then on top of it, there is the opportunity to make meaning and to find out where you can flex and where you need boundaries based on the self awareness from the work you might need to do on your toxic stress. So, let's talk about your childhood. Do you look back, Devika, on your childhood and see threads of your bipolar illness that predated the actual diagnosis? And, you know, to the extent you want to share that, I mean, how do you make sense of things that may have happened to you, good and bad, and the evolution of your mental health story?

[00:15:10] DB: It's a really important question. As we know, most people who have mental health symptoms, it's most common to start to have the first symptoms when you are in your teenage years or in your early 20s. And for me, my very first symptoms happened when I was in medical school. I didn't have any kind of sign of mental health instability or any kind of mental health symptom when I was growing up. I did have a very unusual childhood in some ways. So I spent… my first 21 years about a third in three different countries. So the first one was India, which is where my family is from originally and where my majority of my family actually still lives.

[00:15:52] So we started there. I was seven when I left India, and then we came to the US for a few years where my parents were grad students here. Very stressful set of circumstances financially and otherwise. And then we went to the Philippines for my parents’ jobs, which were in health and development. And we didn't know anyone in the Philippines when we first arrived, and we were supposed to have spent three years just trying it on for size.

[00:16:18] And my parents ended up spending over 20 years there. So it was a big part of our lives and big part of their careers. And so, within each one of those countries, even there was a lot of moves. So by the time I was in fifth grade, I was 11, but I had been to seven schools in three countries. So there was a lot of changes and a lot of transitions and a lot of figuring out who I was culturally, you know, where I belonged.

[00:16:45] There were these kind of deep existential questions taking place, although I will say my four person family, so it's my sister and I and two parents are a very close knit unit, and so that unit kept us grounded and it made us feel like we were in home, wherever we were and you know, that, that made all the difference because I think I felt very grounded growing up despite the fact that things were changing on us so often.

[00:17:14] And I felt like a lot of folks who have multiple cultural influences, multiple languages. I grew up speaking Hindi, then had to learn English and. You know, uh, the whole, uh, getting made fun of for my accent in the U S and trying to get rid of that accent overnight, you know, all of those different pieces of like, am I Indian? Am I American? Do I have influences from the Philippines, but I'm not quite Filipino, even though I've spent so many years here, there's all of that stuff growing up, but I will say kind of back to your question, nothing that really would qualify as a mental health symptom, just sort of common experiences around moves and cultural identity that I think anyone would have with a similar set of circumstances.

[00:17:59] And it wasn't until I hit medical school, as I was saying, I was 23 and my first symptoms were of the depressive variety. And I didn't have a family history of bipolar disorder. I didn't have a personal history of either hypomania or mania. And so it looked for all the world, like garden variety, unipolar depression, right?

[00:18:19] And I was treated with antidepressants, which ended up over the course of three years, not working and making my brain worse, which is typical when a brain is on the bipolar spectrum. So often what'll happen is you'll induce sort of the little bit of activation that's not recognized. It's actually hypomania in retrospect, but might just look like anxiety on top of the depression, right?

[00:18:42] And that's essentially what happened to me. I had about three years where I was on the wrong meds. And I tried 20 different meds, you know, in that span of time. And luckily, you know, three years in, I was on three different activating meds and had a frank manic episode. And that really saved my life because it allowed people to understand that I was somebody who had a bipolar spectrum disorder rather than a unipolar depression with anxiety on top of it, which was the working hypothesis.

[00:19:12] And that led me to have the right condition diagnosed and also the right treatments then in place, which, which really, really truly saved my life.

[00:19:21] LM: I want to interrupt you to say, well, I don't want to interrupt you, but I would, I want to say thank you for sharing that because I think there are a lot of people, I don't know the number. I don't think we know the number of people who are suffering with bipolar disorder, who are called. Depression and anxiety, right?

[00:19:39] I mean, depression and anxiety are extremely common conditions. You know, certainly if people have enough depression, they can be anxious about it. If people have enough anxiety, they can get depressed. But I do think there is a subset of people who are inappropriately treated who actually are on that spectrum and they didn't have that manic moment or the doctor to understand that's what that was.

[00:20:02] And then they get further medicated and then sort of down a pathway that isn't appropriate for their diagnosis. So, I mean, did you have trouble recognizing sort of activation, the activation driven by the antidepressant that was then maybe the beginnings of your, of mania? Or did your doctor, like, did it go for a long time without being recognized? Or how did you make sense of those initial failures of the antidepressants?

[00:20:30] DB: It was much more clear in retrospect, you know, we had these three years where I did not feel like myself and I wasn't, you know, depressed for all of that time. At some points I was, you know, hypomanic where I might have been euphoric, right? And just tripping too quickly in terms of the energy and the thought processes.

[00:20:49] Or I had periods where I was hypomanic, but in a sort of dysthymic state of mind, meaning I was just activated and energetic, but I was irritable and angry and anxious. And it wasn't really recognized. Now in retrospect, it's very clear that, okay, all of that was hypomania. But at the time, when you're dealing with, you know, a 23 or 24 or 25 year old, because I crossed all of those numbers as we were seeking treatment, it just felt like, okay, this person is not responding to treatment.

[00:21:24] And as a patient, you feel very vilified because thestatistics will tell us that most people with bipolar 2 disorder end up having symptoms that are mistreated for an average 11 years from the first time they're symptomatic to the time that they get the right treatment in place. And I was lucky that mine was only three years, but I will tell you, they were the hardest three years of my life, like, I was considering dropping out of med school, I didn't think I could hack it, I thought it was something about medicine, potentially, that was kind of triggering these symptoms that I'd never faced before, I was also pretty convinced that, like, the person that I thought I was pre symptoms, was completely gone,inaccessible, lost.

[00:22:11] Like, I would never find that person again. That I was just somehow stuck in this place of unwellness. And I think that's something that most people who have ever had any mental health symptoms can really relate to. Like, in the midst of it, you feel like you are never gonna be well again. And whoever you once were is no longer a person that you can access. I think that is the hardest part when I look back at that period of my life of true terror that I was never going to be myself again.

[00:22:39] LM: There's so many things I want to react to that with. First and foremost is deep gratitude for saying that because I think as I talk to patients with mental health issues, as I talk to family members with mental health issues, as I've talked to my myself when I've been struggling with mental health myself, there is this hijacking of our own brains that happens where you [become convinced that you're never going to feel good again.

[00:23:03] You're never going to feel okay. You're never going to be that person that you thought you were. And it's terrifying. And I think to see someone like you, Devika, who is, I mean, beautiful, healthy, accomplished mother and physician, it just gives people hope that this is not a death sentence. That it truly is a hijacking of your brain that is not a permanent condition and that you can get better.

[00:23:32] I think it's important for people to realize that if they are getting treated for depression or anxiety and they're not getting better, not getting better. You need to ask the question, is there something else going on? I mean, 11 years is too long for people to get a diagnosis. Bipolar 2 is not a zebra.

[00:23:47] I don't know the stats on the commonality of it. I don't know because I don't think we probably have accurate statistics at all. I mean, because it takes 11 years to get the diagnosis, but I know from my own experience seeing patients, I will commonly make a referral to a psychiatrist when I, for example, have tried my patient on Lexapro for what seems like unipolar depression and they're not better, or they have a little bit of an uptick in their energy, irritability, and then we ask the question.

[00:24:12] Because for people who are listening, a diagnosis of bipolar one or two, which are a bit different, we can talk about that, opens the door to another set of medications for treatment. This is one of the things I worry about with online, kind of drive through kind of mental health startups. I mean, I think it's great that people are getting better access, but I worry that we are bucketing people into depression, anxiety, depression, anxiety, when sure there's a lot of depression. There's a lot of anxiety, but first of all, do we need to medicalize all of it? I'm not sure. And secondly, are we making the right diagnosis in the first place?

[00:24:46] Such important points. You know, I think just stepping back, like, from the data, you're absolutely right. There's a whole variety of studies that have been done with differing prevalence rates of bipolar 1 and bipolar 2, depending on sort of what is counted. And it's very common within the bipolar spectrum for you to receive let's say one kind of diagnosis. I was initially diagnosed as bipolar not otherwise specified, which is sort of a soft call it's like somewhere in the on the spectrum. We don't exactly know where and then as people's lives go on you end up realizing like okay You've now had a manic episode off of antidepressants let's say, and now you qualify for bipolar one rather than bipolar two, so there's a lot of shifting along the spectrum and that makes it hard to assess and get true prevalence rates. there's a meta analysis that came out now about 10 years ago, and they said that 2.

[00:25:32] There's a meta analysis that came out now about 10 years ago, and they said that 2.6 percent of the population will meet criteria for bipolar one or two at any given time. But that's not counting the other parts of the spectrum, which we now know is also a sizable portion. But, you know, with depression, when people come in for a first time depressive episode, one in three of them. will end up being on the bipolar spectrum.

[00:25:59] And so if primary care doctors know this, if, you know, other kinds of healthcare providers know this, then we can start to turn the tide on that statistic of 11 years for bipolar 2, and it's shorter for bipolar 1 because it's much more obvious when someone has a manic episode, whereas hypomania can be a little bit more, it can cloak itself as anxiety as you said, and other symptoms that are harder to diagnose.

[00:26:23] LM: So what prompted you to be public about this? I mean, it's a pretty big move. I mean, there's a lot of stigma around mental illness, even though it is having a moment. There's a lot of misunderstanding about what bipolar is. I mean, I think people throw that word around a lot. Like, Oh, she's so moody and crazy.

[00:26:40] She's so bipolar as a derogatory term. You know, we used to call it manic depression. I think patients associate bipolar disorder with someone who's driving a stolen Ferrari a hundred miles an hour down the highway. And then someone who's standing on a ledge about to jump. And there's so much more nuance there.

[00:26:58] There's people in our lives. These are people who are functioning, who are parents, community members, people we know. I think it's, it's very brave of you to come forward as you and I were talking about before we started recording, particularly in a public role, like you had as the acting surgeon general in California, I mean, you're out there. So I'm just going to ask you, what is it that prompted you to go public? And what has that been like?

[00:27:25] DB: I was serving in the role of acting surgeon general in a moment in time when everybody was struggling with something, right? We had been in the pandemic for two years plus at that point. And we all, at that moment, knew somebody who was truly struggling, or we were that person ourselves. And so I felt like it was a really important moment to publicly own my story on a couple of different levels.

[00:27:53] One, to help everyone realize, like, you can walk through a really difficult period of your life and think that you can never bounce back from that, but actually walk through it and then, on the other end, be able to fulfill your own dreams, right, personally, professionally. At a point in my life, I thought I'm never going to have a career.

[00:28:16] I'm never going to be a parent. I'm never going to be a stable partner. But to recognize that even a really stigmatized mental health diagnosis like bipolar disorder, and it does carry a very loaded set of stereotypes with it, that even that, you know, you can look back at your hardest moments and say, those were in my past.

[00:28:36] And... The last 10 years or more, I've been well for the majority of them and now, you know, having figured out what it is that keeps me well, both behaviorally and medication wise, I can hope to be well for the rest of my life and I think that it's an important message because unfortunately, for instance, all of the people I know who are living well with bipolar disorder, there's a very small fraction of them who feel comfortable sharing that truth with their coworkers, with their with the people in their lives beyond just a few.

[00:29:11] And so, if we all live in secret, once we've figured out how to live well with this disorder, then we have a very skewed sample of who it is that has bipolar disorder and what that can look like. So number one, I wanted people to know that when you've got the right treatments and the other systems in place to stay well, you can do the things that you want to do in your life.

[00:29:28] And then number two, I wanted to reach those people who were truly still in their hardest phases who are struggling to know that there is hope for a better tomorrow. That with the right treatments once more things can turn around very dramatically. And to have hope that can happen. And the way that it all came about, and I'll just say one quick other thing, which was NAMI California was having their annual conference and they invited me to keynote it and it felt like that would be the most authentic moment in which to share this journey. And I… same day also shared it in the LA times and online on social media. And I'm really glad that I did because in the wake of that, hundreds of people reached out to me with their stories of, I have been struggling and this meant so much to me where my son is in the hospital and I have hope now that he might be coming out and he'll be back to himself.

[00:30:29] You know, it just, it really opened. the door to understanding that we all have this commonality. We all have known struggle or known someone who has struggled very intimately. And then also it helped me understand that I had a way of connecting to this community and join in on a few different advocacy projects, which have been really meaningful.

[00:30:53] LM: I think that's incredible, and I think you're living proof that there is a better tomorrow, and that with treatment, that’s not just medicine, it's behavioral, it's environmental, you can have hope.

[00:31:06] DB: Yes.

[00:31:07] LM:What do you think, Devika, is the most important element of your wellness? It sounds like you take medication, it sounds like you prioritize sleep, it sounds like you try to eat healthy and have boundaries. I mean, if you had like a pie chart for you, and this is going to be different for different people, but what occupies the biggest slice of pie? Is it the medicine? Is it the sleep? Is it self awareness? I mean, could you break it down a little bit?

[00:31:35] DB: Yeah. There's a lot of elements of that pie. I think a big chunk of it, more than 25 percent is going to be connection and community, right? So the people that I rely on a daily basis to, to understand me, to support me, to have fun with me, to, you know, laugh with me. Those people keep me well in, in so many small and big ways, right?

[00:31:58] And then the other pieces are the daily habits, the making sure I'm getting enough sleep. At night, I wear blue light blockers. These are orange glasses that supposedly filter out the majority of blue wavelength light, nightlight, or nighttime. And so sleep is a big part of my life. I really try to do a lot to protect it. I'll tell you one other thing. My husband tends to wake up if my son is awake in the middle of the night or early in the morning. And so that's one strategy that we've sort of got in place to help protect my sleep, which is really meaningful.

[00:32:38] Food, you know, eating a variety of foods. I tend to have sort of a Mediterranean diet over the course of, you know, the day and really, find that important. Exercise… protecting my energy. So, you know, big events, for instance, where I'm spending a lot of time talking about myself, my journey in a conversation like this, it, it tends to be really meaningful and important and also deplete my energy.

[00:33:07] And so I have to be really mindful of how I structure my weeks. So if I know I'm having a conversation like this, I'm going to try not to schedule too many other things in the next week or so. Right. And that gives me some time to sort of rest, decompressed, refill that cup, that energy cup and, and sort of be present and able to do what I need to do in the rest of my life.

[00:33:31] And so just being really aware of what's happening for me mood wise, energy wise. Am I feeling that tension in my shoulders? Like, what can I do differently? Like if I have any red flag symptoms, like let's say I'm starting to feel a little bit on edge or irritable with folks.

[00:33:46] One of my tells is I tend to respond too quickly and with too many messages on WhatsApp. And remember, my family lives sort of abroad, and so that's a big mechanism of contact. But if I'm doing that, that is often a tell that I'm starting to feel a little bit elevated. And just knowing what it is that I need to come bring to bear in those moments to try to reverse where I'm going mood wise and come back into sort of my baseline mode.

[00:34:14] So it's a lot of kind of those maintenance mode things that we spoke about, but also recognizing red flag symptoms and then having a toolkit in place to intervene, whether that's up or down. And that looks different for different people.

[00:34:28] LM: I mean, that is such good self awareness. I particularly like what you said about the energy allocation. You have this busy life, you're a pediatrician, you're a public health leader, you're writing, you're speaking. You're parenting, you're learning from your own two year old. I think women are, I mean, we are just, I think beyond capable and we're interested in so many different things, but I think, you know, that resonates a lot with me too, is this sort of notion of an energy budget.

[00:35:00] Yes, we can do it all, but like, like with everything, there are trade offs, right? So I think that it's important that you're aware enough about yourself and your tank, where you are, of energy to sort of allocate it appropriately. And I wonder if you find like certain relationships you've had to sort of change or if you, or if there are boundaries that you've had to set.

[00:35:22] I know that as I have gotten older, I just turned50. That I'm a real empath. I love being around people. I also know when my energy is being drained either by a certain situation or a certain set of people. And it's not their fault. It's just, that's just the way my mind and body work together. And so I'm sort of more aware of who, what, where I can tend to over-expend energy and then when I need to pull back. I wonder if boundaries and relationships are something you think about yourself.

[00:35:51] DB: A lot actually. And you know, it's one of those things that we as women are socialized to be very other oriented, to worry about other people's feelings, sometimes at the cost of our own health and wellbeing. And it's a lesson that I think I learned in my late thirties—I’m 37 now—to really honor my needs, my emotional needs, and sort of to know that with certain relationships. That there do have to be some boundaries in place and at the beginning when I first learned about this concept, you know in therapy, I thought, that's kind of I don't know how that's gonna work in an Indian family. Like we're so close. It's a very communal situation even when we're many miles apart.

[00:36:38] There's this like very open expectation that you will be there and vice versa in lots of ways and the concept of a boundary felt culturally potentially inappropriate and what I realized was that I'm putting this boundary in place not to shut this person out of my life, right? Not to have this relationship wither and die, but actually to have a better relationship, where I'm not resentful of them… of something that they are asking of me that I'm not able to do. I realize like it's been such a powerful, game changing thing because I have closer relationships with those same people now because I'm aware of my own emotional needs and triggers and sort of what those boundaries really need to be.

[00:37:24] Sometimes it's something simple like When I see them, I'm going to see them for this amount of time, and there won't be a chance for, you know, necessarily that build up. But it's been, yeah, it's been huge for me, as I imagine for you too, and for many of us who are listening.

[00:37:39] LM: I mean, I think a lot of what you're talking about pertains to the human condition in general. I mean, I think certainly when you have bipolar illness and certainly when you figure out your kit of coping tools, that's essential. I also think for most of us, we need to be careful about our sleep, our exercise, our relationships saying no, kind of recognizing our internal sort of thoughts and feelings and who drains us and who energizes us and meeting our needs, especially as a physician, as a mother, I'm socialized and trained to be empathetic and I am, I think, intrinsically empathetic, maybe not all the time, but I think I am.

[00:38:20] It is hard. It feels culturally inappropriate in my own family and as a physician, as a woman, to say no and to say, I'm so sorry, I can't do that. But I've also learned, like you, that I'm a better mother, sister, daughter, person when I am meeting my own needs, which is not selfish. It's the way I need to be healthy.

[00:38:42] And, you know, sometimes you get it wrong, right? Sometimes you get it, like, sometimes you get it wrong. Sometimes you say no because that's what it felt right. And then you realize, oh, wow, that was actually... at my own expense, but I think that's something that we as women need to practice and I think it is part of a mental health coping kit is to recognize that our needs matter and then to try to practice establishing boundaries and saying no, and you know, we all know that feeling of when you're talking to somebody, whether it's a loved one or a patient or, and they're asking you to do something that doesn't feel quite right.

[00:39:14] And you're thinking no, but then you end up saying yes, and then you're resentful and you can get angry and it's not their fault. We need to own that power and own that ability to say no.

[00:39:24] DB: Absolutely. You know, I'm reading a friend's book right now… Real Self-Care by Pooja Lakshmin. Yes. So I just finished the part about boundaries and two really insightful things that she has in there. One, don't over explain a boundary when you're giving it to somebody because then it seems like you're asking for permission, right?

[00:39:45] And then number two, to your point, allow there to be a pause between the ask of you, and your response. And in that pause, you will figure out does this feel like the right thing to do? Does this feel like a yes but, or you know, a yes and situation? Or do I have more questions? Do I need to negotiate a different situation, right? Or do I need to say no? And you won't know that if you very quickly respond “yes” which is our gut instinct as women again, and taking that pause is where the boundary can actually emerge meaningfully.

[00:40:19] LM: I think that's right. So what I'm hearing from you, Devika, is that your wellness is external. It's about sort of environmental, everything from your nightshades to your medications, to your therapy, to an internal kind of, checking in with yourself on your energy, on your relationships. It's about connection.

[00:40:42] It's about feeling loved. It's about, it sounds like it's about feeling safe. And I mean, I think those are essential parts of health for all of us and it doesn't have to be fancy or expensive. We don't have to buy fancy leggings and show up with a personal trainer and have exotic supplements and be on a yoga retreat in Bali.

[00:41:04] Although, you know, invite me with you if you're going to go, I think it really is about an internal sense of what we need, what we deserve and what, and how we relate to other people that is at the root of our mental health. So I want to just close by reading one more quote which I love from your LA times.

[00:41:23] You said “by sharing my story, I hope to dispel stigma and internalize shame and to help anyone struggling, know that they are not alone. If you feel comfortable, consider shining a light on your story. Stigma festers in the dark and scatters in the light.” So, for anyone who's listening, who feels like writing, or talking to their friend, or their dog, or just their journal, about their story, I think it's important that we acknowledge that we all have vulnerabilities, we all have grief, we all have loss, we all have fears.

[00:41:56] Some of us have mental illness, some of us have... You know, real relationship struggles. And I think that when we talk about them, we can then start to figure out the path forward. And so I just want to say, thank you so much, Devika, for sharing your story, for being such a role model and for teaching us the ways in which you stay well.

[00:42:13] DB: Thank you so much, Lucy, for having me here and for the wonderful work that you do in your sub stack for the whole community. Really appreciate you.

[00:42:28] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.

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It’s hard enough for adults to navigate anxiety, lack of privacy, and social relationships in the digital era. How can we expect young people to do it?

On this episode of Beyond the Prescription, media expert Dr. Devorah Heitner presents practical strategies for parenting in an era of perpetual connectivity.

She offers a refreshing perspective in her bestselling new book, Growing Up In Public: Coming of Age in a Digital World. Instead of panicking about social media’s role in young people’s lives, she argues that parents should accept that it’s here to stay and focus on the benefits of technology. Instead of blaming social media’s role for the uptick in adolescent anxiety, she argues to uncover and address the root causes of young people’s distress.

She offers practical advice to help kids set boundaries, maintain digital hygiene, and learn how to make mistakes—even while everyone is watching.

Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, and review the show!

The transcript of the show is here!

[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.

[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter. At lucymcbride.substack.com, and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.

[00:00:57] So let's get into it and go Beyond The Prescription. Today on the podcast, I'm speaking with Dr. Devorah Heitner, who is a bestselling author, speaker, and expert on raising kids in the digital world. In her various capacities, Dr. Heitner offers practical advice that's backed by science and research. She's providing tools that people can use to start conversations with their loved ones about how to use technology in our lives in a healthy way.

[00:01:25] Her most recent book, out in September, 2023 is titled Growing Up In Public: Coming of Age in a Digital World. It's an essential read for parents. In short, Dr. Heitner thinks we're worrying about the wrong things. We see the panic inducing headlines, yet social media can be an excellent way to help learn about our kids and help them learn about the world we live in today.

[00:01:48] Devorah, thank you so much for joining me today.

[00:01:51] Dr. Devorah Heitner: Thank you.

[00:01:53] LM: So, I talk about inputs with my patients every day. I talk about things that we put into our bodies and brains, like alcohol, caffeine, food, of course. And then I talk about screens, because screens are something we ingest. They're ubiquitous. And it's not just about how much screen time we consume, it's about our relationship, sort of like relationship with food or alcohol.

[00:02:17] What I love about your work is not only are you exploring people's relationships with screens, you're taking a somewhat counterintuitive stance that there's a lot of research out there to suggest that screens are destroying a generation of of youth. That it is the cause for the emotional and mental health despair.

[00:02:38] So, there's a lot of data to suggest that screens are the biggest evil for our kids, that they are the reason that kids are experiencing emotional and mental health problems, but you take a different viewpoint. You take the view that screens are indeed ubiquitous, but they also can be used as a tool. They can be used as a tool to help us shepherd kids through this complicated part of their lives. So talk to me about how you see screens as a boon, as a way to help parents understand their kids. And not just as something we need to be terrified of.

[00:03:20] DH: Yeah, I think we've been really pushed this idea that screens are the big bad that are really tanking kids’ mental health has been really pushed on us and we ignore a lot of other factors and also like, what are the screens bringing our kids? So as you said, it's not just about the quantity, the minutes.

[00:03:36] The minutes are important, too. We want to live in balance with screens and be able to do other things. But we also want to think about the quality of the experience. If your kid is a creator and is making things online, for example, or collaborating with other kids, or has started a business, or is composing music, or is writing a really interesting blog, or fan fiction, and getting a lot of creative juice and community out of that, it could be a really positive thing in your kid’s life.

[00:04:04] So we first want to look at: what is the quality of experience? What is your kid engaging with? Are they finding community there? Are they connecting with people in a positive way? Is it leading them to other interests? And sometimes, especially in the last few years, when so much of our novelty has come from YouTube or Netflix, and we maybe have forgotten about other kinds of novelty. As parents, we may want to look at our kids screen based interests as a clue. Like, oh, they're watching this kind of content on TikTok. What else might be interesting? My kids are very into strategy games on the computer, but we've also gotten into risk and some other deep strategy board games.

[00:04:41] And part of that was like recognizing these multi layer, multi hour games, you know, with strategy and complexity are really interesting. What can we do as a family that might also be related to that? And then we also want to think about the ways kids are connecting with other humans and how this is supporting their friendships. So there's a lot that's going on socially here and we worry about the negative pieces, but we should also look at the positive ways our kids are finding affinity with other kids. Our kids are finding community and finding people who share the same interests.

[00:05:12] LM: I hear you loud and clear. I think headlines that scream: watch out parents. Your kids have a separate life that you don't know about and it's only nefarious and screens are doing harm and only harm are sensationalist and really put sort of fear in the driver's seat of our roles as parents.

[00:05:32] I do think there's a lot to be worried about. I mean, kids are looking at images that you and I never had access to as children. And I think that kids can certainly get lost in a screen addiction. Just like you can be addicted to marijuana or alcohol, you can get addicted to screens. You can develop a relationship with screens such that you're using it to “medicate social anxiety” or fear of failure or you can be bullied online.

[00:06:02] Of course, I think we all know about the harms. The way I practice medicine as a physician is that I try to be a realist. I recognize that alcohol is ubiquitous in our society. I'm not going to be able to take it away from everybody, nor should I. We have to reckon with these phenomena. We can't just mop up risk and make it zero.

[00:06:21] We have to reckon with the realities of our everyday life and screens are not going anywhere. Screens are, if anything, becoming more and more woven into the fabric of our society. So I think what's important as you're saying is to recognize that there are opportunities here. There are ways that we can use screens as a sort of window into our kids lives.

[00:06:46] And that policing them may do harm in and of itself. I mean, what do you make of this idea of restricting kids access to screens until they're 18? I think there's a new law in Utah, for example.

[00:07:00] DH: I think the Utah law is a particularly harmful example. Like I do think when school districts and other folks are trying to push back on the big companies and say, “hey, when we report bullying, we should get a response right away.” Or when we report that our kid started an account under age 13 when they're supposed to be 13 and you don't take it down or you're not doing anything to even pretend to try to age verify and any eight year old can start an Instagram account if they can do the math to change their birth date, then I think it's important to say, yeah, we do want to push back on these companies. So I'm excited to see some states and school districts pushing back on the big companies. Utah's saying, let's put this all on parents. Like parents don't have enough going on and parents should be in charge of their kids social media up to 18.

[00:07:44] I think that's a problem for a lot of reasons. One reason is that not every kid is lucky to have enlightened, wonderful parents. So, what if I'm a gay kid in Utah and my parents don't know and if they find out, I'm going to become unhoused? It's not safe for me to post on social media if my parents have access to my social media up to 18.

[00:08:04] I think 18 is particularly glaring in a state where kids can work at 16 and drive at 16. I think to say that driving and working a job are, are less responsible than posting on social media is a problem. I think when we look nationally at what's going on, where there are states saying we want kids to be able to work dangerous agriculture jobs with pesticides and work in meatpacking plants at 14, but they shouldn't be able to post on TikTok till they're 18.

[00:08:30] I think we're a little messed up as a society if we're saying that, because if we actually wanna protect kids, yes, I think none of us want our children to see pornography, for example. We don't want our children to see extreme violence, but the companies need to take down some of that content when it's getting reported.

[00:08:47] But putting that on parents and saying parents need to be checking their kids' messages and reading their kids' posts up to 18. I went to college when I was 16. I moved away from my house and went to college. I'm not saying that was necessarily the best thing in the world, but that's what I did.

[00:09:04] And to sort of say that, and many kids start college at 17 because that's when they finish high school. So to say that a college freshman in Utah, their mom should still be reading their direct messages is just a little extreme. And I think we really need to get out of that idea of big brother and think about we need to teach kids to swim, putting the electric fence around the pool is not helpful and kids entire focus will just be saying that they don't live in that state or that they're going to change their age in some way when they sign up and many parents will not be in a position to make that not happen. And again, it also assumes that every kid has a well meaning thoughtful parent on their side.

[00:09:39] So there are tremendous problems with that. What if a kid needs to use social media to report abuse in their home?

[00:09:44] LM: So do you think that the headlines about the harms of social media on kids and adolescents mental health are overblown? Or what's sort of your take, in general, on that sort of frenzy,

[00:09:54] DH I think they are overblown because it's an easy thing to blame, but some of the problems that we're seeing in kids, we have to look at the pandemic. We have to look at school shootings. We also, when we see more kids reporting mental health issues, we have to look at access to mental health care as a plus.

[00:10:09] When I was growing up in the early 90s, and there was a smoking lounge in my high school, and many peers were using substances to self medicate. Very few kids would have self identified as depressed or anxious because they didn't necessarily have that language. I would argue that there are kids who are learning the language of mental health from places like TikTok or Discord and are using that language to describe the way they feel, but I don't know that those problems are new to this generation of adolescents. But I think we're seeing increased access to both language around mental health, and hopefully in many communities, actual mental health care. The thing I would worry about is I don't want kids to get their mental health support from TikTok and Discord. It's one thing to identify, like, maybe I have an issue, and learn about it, or have a YouTuber who talks about ADHD and say “oh, I think maybe I should get neuropsych testing.”

[00:10:56] What we don't want to do is self diagnose from YouTube or TikTok, and I'm sure you see that as a physician all the time. Like, that, Is concerning, but the fact that more kids are self identifying with mental health issues, I think is partly that we as a society have shifted to destigmatize that conversation and I actually think social media is part of that in a positive way for kids. But it sounds scary to adults to hear like this many kids say that they're depressed or anxious, but it's not that kids in the past were not depressed and anxious. I think they were self medicating in the smoking lounge at their high school.

[00:11:28] I think adults were turning a blind eye to drug use and other things and alcohol use. So I think we're in a really different place as a society where we're looking harder at adolescents. And there are many reasons adolescents are feeling anxiety. For example, if your kid is looking at their social feed or at the news and information about school shootings, that's distressing, but taking away Instagram doesn't take that distress away. They're going to get that news another way. Their phone may be, in fact, the source of where they're getting that stressful information, but that doesn't mean that if we just take away the phone, they're not going to be worried about it anymore.

[00:12:07] So I think it's really important that we look at, is this a vehicle for getting access to stressful information? When we see the apps themselves encouraging things that are stressful, like the apps themselves may be a problem when they encourage us to location share and we can see that our friends are out without us. And that is a problem that I blame more on social media, versus, you know, that's not just getting information. That's kind of random. That's like, hey, this app is really encouraged us to do this very human thing, which is to want to know where the people we care about are, which is very human. But it's kind of trading on that brain what we want to do.

[00:12:41] And it also trades on parental anxiety when parents put Life360 on their kids devices to track their kids all over town. But that may also not be great for our relationships. There may be ways where that undermines trust and undermines relationships. So I think there are times where what we in the tech world call affordances, but it's basically like what the apps let us do become a problem. And that's where I think we should be looking at do we want to change our own behavior or do we want to make some feel really empowered in relation to an app? Like, yeah, I want to use Snapchat, but I'm going to turn off Snap Maps. I don't want that feature. Or I'm going to turn off location sharing on another device, or I'm not going to use Life360 unless someone actually has disappeared and I haven't heard from them way past curfew.

[00:13:20] I'm not just going to use it to see if my kid might have relationships or errands to do that. I don't know about right now to kind of resist, in other words, the possibility of what apps let us do and make choices about how we're going to use tech that might be healthier for us mentally. So to come back to the headlines, I really don't think we should panic about the ways kids are using social, we need to also just look at our own kids. Like if you have a kid who's predominantly using discord to connect with their three best friends to play a game every day after school, then my worry is, are they getting their homework done? Are they getting enough sleep? But I'm not worried that social media is making them depressed because it's clearly functional for them.

[00:14:02] LM: Right? I think as parents, the screen landscape can make us feel very out of control. Kids in their adolescence are naturally kind of differentiating themselves from their parents and they are behind closed doors a lot of the day and we don't always know what they're looking at. But that's always been the case. And that's part of growing up. That's part of developing our identity is being around our peers. And sometimes that's online. So what do you say to a parent who has, for example, an adolescent who's kind of less accessible verbally, who's spending a lot of time on screens, who you may be worried that they're spending too much time on screens.

[00:14:44] How do you even begin to sort of query whether or not you're doing a good enough job as a parent vis a vis this child and their screens? They don't want to talk about it and they don't want to share with you what they're doing online and you feel completely anxious. And then you look at the headlines and you think, Oh my God, I'm the worst person alive. What do you say to that parent?

[00:15:02] DH Well, it depends on the kid and what your specific worries are, but I do think you could have especially a younger kid who's newer on some apps, like walk you through some of the things they're doing. Like, “hey, can you show me some of the things you love?” You know, like my 14 year old will absolutely show me, you know, things that he thinks are funny from YouTube sometimes and like just getting a sense of like, oh, I can see you're diving into some political satire here.

[00:15:24] I see you're diving into some remixes of the culture and things that you're interested in and movies that you like over here and just getting a sense of like, what is the content? You can decide if the bedroom is a place for screens. Certainly with sleep, I would strongly recommend not having connected devices in bedrooms overnight, especially for younger adolescents who will really struggle to self regulate, or tweens, or younger kids.

[00:15:47] And the challenge is sometimes kids are getting phones so young that they're still little and compliant. You know, your 5th grader, if they get a phone, might be super compliant and put it away at night. But you gotta think ahead to that 8th or 9th grader in love and think about, do I want them texting their sweetie all night?

[00:15:59] Do I want them, you know, on social media late at night? And so it may be that the bedroom is a place where tech doesn't go or it doesn't go during sleep and overnight. And I think that's important to think about. So some of their tech use hopefully is around the house for younger kids. If they're gaming with friends, I would suggest not having headphones on all the time.

[00:16:17] It may be annoying. It was definitely annoying for me living in a small apartment through a lot of remote school in the pandemic. And my kid was gaming without headphones. It was extremely annoying, but I knew what the friends were talking about. And when some things came up on Roblox, where they ran into some content that was a little bit of a surprise, as in, like, naked blocky people having sex in Roblox.

[00:16:38] When I heard them start to talk about that, I was like, walking over to the computer, like, what's that? And so I think that's, that's a helpful way. It's a little bit less big brother-y than using your device to kind of spy on or get your kids data later, but just being in a place where you're adjacent, you can overhear some of the activity can help you know.

[00:16:57] As kids get older, their privacy is going to be more and more appropriate, but you can still check in with them when they're in the car. We have a no phones in car rides rule for under a certain amount of time. So, you know, my kid can't like put on a podcast and listen to it with his headphones for a five minute ride if I'm driving him somewhere.

[00:17:14] If we're going on a road trip to another city, podcast and listen together. And some of his time might be in the backseat. with music on or something. But shorter rides, we have to talk to each other. And some of that is like, he gets to pick the topic because he doesn't like to share about school, but he has to tell me about something, right?

[00:17:32] And it might be the video game he's playing, but we have to talk to each other. And family meals are important. Finding a time that actually works. And with busy teenagers who do a lot of activities, that might be late at night. And that's when your kid's ready to spill and you might be ready to fall over, but if your kid is ready to tell you about things, that's a good time to be listening.

[00:17:52] If there's a specific where you have, like, say you think your kid is. checking out pornography or something where you're like, this is a specific worry. I do not want you doing that. Then I would address it directly. A lot of us are uncomfortable there, but if you have evidence that your kid has looked at pornography, I would definitely talk to them directly about it and talk to them about why this isn't where you want them to learn about sex and consent and relationships.

[00:18:14] And we can do that in a non-shaming way. We can normalize and humanize that human beings have been preoccupied with the body and sexuality and art for a long time. This is not new. For an adolescent to be curious about sex and what that looks like and what people do is very typical and normal.

[00:18:30] But this isn't a useful way to get information and it can actually be misleading. It can offer misleading ways to get information about what partners might actually like. It's very misleading on the consent front. And so I think we, and we want to make sure they get alternative information. The older your kid is, the more I would want them to read… certainly younger kids should get have books about puberty and sexuality.

[00:18:52] Hopefully you live in a place where they can also get good sex ed in school, but we know that's not the case everywhere. So we know kids need to be able to talk to their pediatrician and other things. But we need to make sure that they have good information. And then for older kids, like reading a steamy love scene in a young adult or even an adult novel is preferable to me by a lot.

[00:19:12] I mean, there's a lot of books I would want my kid or be comfortable with my kid reading as opposed to seeing pornography. And I think that's really important to make sure that kids do have access to information. And we need to know that it's not just boys looking at porn. Girls will look at it too. A lot of kids are accessing porn for, for sex ed purposes, or that's what they think it is.

[00:19:30] LM: Yeah. And one of the other specific worries I think that comes up for parents of girls in particular, not that boys are immune to this, is the focus on bodies and thinness and diet culture and comparison culture. And I think it's really hard to avoid those, the constant barrage of images of… and now that we have AI where these faces can all of a sudden look perfect and you can see your real face compared to what your face might look like if you had plastic surgery and you were on the red carpet in Hollywood. I mean, that is a pervasive phenomenon and it's concerning as a mother of a daughter and sons, this constant sort of focus on appearance. But again, as I think you're saying, lwe cannot take screens out of their hands.

[00:20:19] We cannot make risk zero. We can do what we can as parents to help our kids kind of have a relationship with screens. So, I was counseling a patient last week who's a mother of a teenage girl who's struggling with her eating. So she's got some binge eating and some restricting behaviors and she's on screens all the time and Focusing on her appearance and the girls, her friends are in bikinis and she's not included in all the events where the girls are wearing bikinis and it's just, you know, it's torture as a mother to watch her daughter kind of go through this and you think to yourself, Gosh, I could just get rid of the screens and everything would be okay.

[00:20:57] Let's acknowledge that wouldn't be the case. And let's acknowledge that's not realistic. So my advice to her was to have a conversation with her daughter that's led with curiosity and empathy. So instead of saying, you really need to get off your screens, that's bad for you, ask the question: “honey, I wonder what it feels like when you're sitting at home and feeling uncomfortable about maybe your body or your social life and you see your friends looking perfect because they've got this curated image of themselves and you're not there. What, I wonder what that feels like.” I mean, and you might offer even an example of what you might feel like. Like it might make me feel awful. You know, when I was a kid and I knew my, my friends were hanging out together and living this so called perfect life, it, it hurt. I wonder what that feels like to you. So curiosity is always a good way to lead a conversation. And then also with empathy and say I just feel bad for you guys that this is such a hard thing to have to navigate. You can't avoid looking at these images.

[00:21:54] You can't avoid comparing yourself to other people. And then sort of open the conversation like that instead of going at it as you really need to get off screens. You need to not look at these images. You need to just stay away from that friend group or stay away from that social media feed. These are their friends.

[00:22:07] These are their lives. But I think it's very hard to know how to have those conversations as parents. And I think the world we live in as parents consuming social media seems to suggest that there's the right way to talk to our kids and the wrong way to talk to our kids. That we have to read the right parenting book.

[00:22:25] We have to follow the right expert on Instagram. We have to listen to the right podcast and that our kids are so fragile and so vulnerable that if we say the wrong thing by just two phrases, then we're doing all this harm when I think that for parents is scary and we need to understand that just by showing up as parents, and just by being empathetic and curious about who our kids are, and showing them that we love them no matter what, that is good enough. Sure, there are parents who are doing harm. Sure, there are parents who need help. I need all the help I can get with parenting, but I also have learned to trust my instincts and intuition, and I need to listen to my kids and meet them where they are.

[00:23:06] There's no parenting book that is going to tell me how to parent child one versus two versus three. So this is a long winded way of asking you, are you saying that parents need to be able to read the room with their kid, they need to be able to understand the person they are talking to, and have a relationship at baseline with their child that involves discussing who they are, what their interests are, and understand that screens are going to be an inevitable part of it.

[00:23:34] DH: I think that empathy and curiosity as you say, is huge and just slowing down, like really saying, what do you notice when you look at Instagram and letting your kid talk. Ideally not even leading with like exclusion or your own feelings, but you can go there and in a conversation, but I would let them what it's like for them and see what insights you can get from there.

[00:23:59] And certainly with body image, as the example you used it can be an exacerbating factor. Like it probably didn't originate with screens, the eating challenges you're talking about, but that doesn't mean that screens couldn't exacerbate. And if a kid is in treatment for an ED, for a substance, for anxiety, for another mental health issue, 100% with that therapist, I would be working on a screen plan with that therapist.

[00:24:25] Especially with a teenager, it's helpful to have someone that's not a parent coming up with, like, if you are going to change the screen plan and your kid is in treatment for an ED or coming home from the hospital even or something. Those are kids who are going to need some support. And sometimes it's apps we don't think of, like Pinterest is actually filled with diet content that is quite toxic.

[00:24:44] If I had a kid with an ED. I would be thinking about, like, how can we encourage them to maybe avoid Pinterest? This may not be a good place for them. If I had a kid who's really into redecorating her bedroom, or a kid who's really into crafting, Pinterest could be fine. So it's not about the app. It's about what experiences and connections and content your kid will seek out within that app. Because I could say the same thing about discord, you know, discord could be totally positive for a kid Who's using it to connect with other anime fans? It could be very negative if kids are doing like how to on an eating disorder or something or self harm. So I don't want to scare people but there are places on the internet and and communities and sub communities that aren't going to be a positive place to be if you're struggling in those ways and asking kids to reflect on their experience, asking kids to consider taking a break.

[00:25:35] Cutting a kid off completely from an app is a pretty big step, but even taking it off your most frequently used device without closing your account can be helpful. And for some kids doing that, even for a few days, just to take that app off your most frequently used device for a weekend and spend a weekend where in order to see that app, you would have to go to your computer and log in.

[00:25:55] I have that suggestion for a lot of kids who are stressing about their grades and actually over checking their grading app. I'll say actually take your grading app off your phone. If you're checking your grading app multiple times during the school day and getting distracted in one class because you saw a test score come in from another class, that's too much. And so some kids are compulsively checking those apps. So I do think in those cases, again, it's not like we never want to see the grading app again. You may need to check it at some point, but like if you have to go to your desktop or your janky school laptop that you don't use that much and check it there, but it's not on your phone, which for 99% of teens is going to be the most frequently used device...

[00:26:32] That's really helpful. So creating those friction moments to make it less automatic and less habitual to go to the places that maybe are kind of death by a thousand paper cuts—maybe it's not like, you know, your phone is hitting you over the head and giving you a substance use disorder and eating disorder, but it's not helping either.

[00:26:51] Maybe that's where change your access. And the more kids feel empowered about that and the more… I talked to several kids who were intentionally following size positive models, people who made them feel good about their bodies. So going in the other direction, using the algorithm intentionally. So for Growing Up In Public, I did talk to some kids who felt like it wasn't great for them.

[00:27:11] And they started using those apps more just for messaging and not posting pictures as much and kind of feeling like they had to post. And again, the people who are curating first, you know, either size positivity or following athletes that they felt like were more body positive and not giving them kind of kicking off or catalyzing feelings that were more negative was so important. But that's a lot of sophistication. Even adults often don't recognize this content is adjacent to this content. But for any kids, I would say fitness content is always going to be adjacent to diet content and diet content is not safe for children. I think it's toxic for all of us, but definitely for kids, you know, if you're looking at your eating or anything with fitness, like talk to your physician. Do not get that from TikTok because it's all very dangerous on there.

[00:27:57] LM: Absolutely. And there's a sort of moralization of human behavior that happens that's just hard not to internalize. I love what you said about suggesting these breaks from screens. I mean, I find it hard as an adult to do that myself, right? When I'm standing in line at the grocery store and it's taking too long, I'm tapping my toe, you know, I'm kind of like scrolling through Instagram to pass the time and it becomes this habitual thing you just go to your phone when you have time to kill and there's a downside there. And so what I sometimes will ask my patients, I will ask myself this too, is what does it feel like internally, and how do you feel sort of mentally and physically when you take a break from, say, Twitter or Instagram for a weekend?

[00:28:38] When you take it off your phone, you don't delete your account, but you take the app off your phone, do you feel less tense in your jaw, less tense in your back? Do you sleep better? Do you find yourself drinking less alcohol because you're less kind of outraged or kind of overstimulated? Do you find yourself gravitating to the book that you put down six months ago? So I think it's not just about restricting the apps. It's about noticing how you feel mentally, physically, how are your behaviors different? If you could give up some apps that you frequently use or gravitate to for a week, what does that feel like?

[00:29:13] So I think what we're talking about really is control. Are we in control of the screens and our utilization, or are they controlling us? It's the same thing I talk about with alcohol.

[00:29:23] DH: I always say that to kids. Yeah, I always say that to…

[00:29:25] LM: It's the same thing I talk about with alcohol, you know, sugar, like, are we deciding how to use it? Or is it deciding for us? And when it is deciding for us when there's a Twitchiness in our brain that gravitates to the phone when you're standing in line at the grocery store or you're lying in bed and you can't fall asleep and you pick up your phone just to kill more time, that may be a sign that is controlling you. And so that's a moment to decide, let's pull back, not because we can't come back into our lives at some point, but let's recalibrate that relationship. Let's put us in the driver's seat of this relationship because it's such a slippery slope, even for grownups.

[00:29:59] DH: Yeah, what I say to kids is you want to be running your devices, not letting them run you. And that's, I absolutely feel that way. And that could be my inbox some days. It's like, wait, I need to set my priorities and not let my inbox set my priorities, right? I need to not just be reacting. I need to be planning and prioritizing and doing things in a way that makes sense like most of us check email too often too frequently throughout the day. So it's really important to talk with kids about that. And when I talk with kids about running our devices and not letting them run us I talk a lot about distraction and even what are the intentional things I do as an adult and as a writer like when I go Speak at schools or is like she wrote books like I'm like, oh, yeah like that's so easy because most kids find writing hard and guess what?

[00:30:38] I do too. I have to give myself rewards for every 500 or 1000 words I write. Like, it's not easy. And if I have to do an edit, which is even a next level challenge, often I will print it out and do it offline because of distraction, because I would much rather check the news or I mean, check the weather or scroll Facebook and see somebody's cute baby, whatever, then do that edit. And so I talked to kids about what do I do to set myself up for success? And when we as parents see our kids going down that rabbit hole, I mean, A) we have to look at how did we spend our time as teenagers? Did we always spend our time in the highest and best way? We did not.

[00:31:14] Like you probably spent some time sleeping very late. You probably spent some time, you know, like I spent time like playing songs on the radio for my friends over the phone. Wasn't like the highest and best use of, you know, our time. Like I wish I had been more like Greta Thunberg. We'd be in a much better place now if my generation had been environmental activists instead of playing songs for each other on the phone.

[00:31:35] But that kind of downtime and like watching a TikTok video with friends isn't necessarily bad for kids. They need some of that. But if you feel like it's a huge rabbit hole for a kid, your kid, and they're losing time that they need on other things like sleep or homework or, you know, any physical activity, chores around the house, Then we can talk to them about how can you choose your time? Especially when you have something with no ending cues, like a TikTok or an Instagram. How can you decide I'm going to do my hardest subject homework first. And then maybe I am going to scroll Instagram for a few minutes. And then I'm going to do another subject.

[00:32:09] And then maybe I will look at TikTok, but I'm going to set a timer on myself. Because there's no end to it. And the algorithm is really good. They're going to give you something you like. Like if they know what you like, they know what you like. They've got your number.

[00:32:21] LM: Yeah, I think at the end of the day, it's incredibly overwhelming, as you know, incredibly stressful for parents to think that we can put our arms around this behemoth of social media. And we really can't. And so I think what you're saying, Devorah, is to know our kids, to have those open lines of communication, to lead with empathy and curiosity for who they are, how they spend their time, what social media means to them, and then to recognize the good of social media, the good, the practice it can offer kids, setting boundaries and setting limits, and where to spend their time. It sounds like you also think that we can kind of tap into their interests.

[00:33:02] If you notice your kid on, you know, baking shows, then hey, maybe it's time to take a cooking class together. I mean, that would be sort of... The dream is that your teenager would want to take a cooking class with you, but I think we can use it as a road.

[00:33:14] DH: Even they could just make dinner. I mean, honestly, like if you're, if your kid is watching cooking shows, like have them make dinner. I want to eat those cupcakes. I want to, you know, eat that homemade pasta and truly like your kid will be the most popular kid on the floor of their dorm if they can make a good meal or even just some nice cookies.

[00:33:30] And so, and, and even if they're watching like how to make slime, like I want to see some slime. Like I don't want endless how to content filtering into a kid's brains without them putting it out. And the other thing we really want them to remember is there's other human beings on the other end. So when they are connecting with kids, those people have feelings too. If you're going to make a snarky comment on somebody's YouTube, that's a real person. And not only is it to that person, but you're also dealing with the people who will read it. So if you can't say something nice, it's not a good thing.

[00:34:00] You don't want to put that out there. And if someone is really bringing about your ire and your rage, and there are people on YouTube that bring, and Twitter and other places, that bring out my rage and my frustration, but my frustration is best channeled finding people I agree with and doing something to solve the problem.

[00:34:14] If somebody's being a racist or misogynist mouthpiece on YouTube, responding to their YouTube with a comment criticizing them isn't going to fix it. They're not going to say, “Oh, well, Devorah in Chicago thinks I should change my ways. I'm having a mea culpa moment. Here I go. I'm going to go down a new road.”

[00:34:31] Instead I want to do, think about like, what can I do in my own community to fight racism? What can I do in my own community to build an accepting school district for LGBT plus students? What can I do in my community to fight misogyny? And make safe spaces for women and girls? So I think it's really important to focus on what we can do to make the world better when we see things that enrage us and not get into like an outrage cycle online. And I think unfortunately that is another thing that the algorithm is really good at is like churning us up in that way. And that's something we want to resist.

[00:35:03] LM: That's right. And being in control of our own emotions. Recognizing that it wants us to be afraid and outraged. Fear and outrage is how they, how the social media algorithms work. So if we can say, look, I'm of course entitled to be afraid. I'm of course entitled to be outraged, but I'm going to calibrate that to my understanding of the facts and not calibrate it to what the social media algorithms are serving up.

[00:35:28] Now that's a tall order for kids. It's a tall order for adults, but I really like what you're saying again, just to frame it is that we as parents need to understand that there's good, there's value in social media. We have to feel that way because it's not going away, but it's true. There is good. There is value.

[00:35:47] In fact, during the pandemic, I was grateful in many ways for social media, for my kids to be able to connect with their peers and classmates, despite being out of school. So let's end with this question. What do you think a healthy relationship with social media looks like? What is the sort of definition of healthy social media habits?

[00:36:06] DH A healthy social media relationship is one where you're using it if you want to, because you want to, and you're getting pleasure and distraction and entertainment from it. You're getting maybe ideas and inspiration from it as well. And you can have a sense of humor about it. You know, everybody's posting about living their best life, because nobody wants to see you unloading the dishwasher.

[00:36:28] But the reality is most people's lives are a lot more about cleaning the cat box and unloading the dishwasher and running around and getting things done or if you're a kid like doing your homework or whatever and that very little of your time is on top of the mountain with the sunset or at the party.

[00:36:43] And so it's good to remember that it's a performance and to just have that sense of humor about it. I mean, I try, even though, of course, like my publisher wants me to be famous and get likes as well. Like I have that pressure as an author and a speaker, but I also have to have a sense of humor about it and say like, okay, this time, I'm not going to do the reel and chase the numbers, or this time I'm going to do it, but I'm going to try not to keep checking my phone to see how many likes I got, because I know that's the app getting me where I'm the most human, where I want to be seen and regarded. And that's where we all are.

[00:37:12] So if we can let our kids know that we have empathy for them, and that we see them, and make sure that they have things that they're doing outside of social media that bring them real self esteem, which is being helpful at home and in the community. to balance out that sense of chasing that algorithm or the numbers or the followers or the likes, I think that's a healthy relationship with social media. So use it for what it's good for.

[00:37:34] LM: I love it. I love it.

[00:37:35] DH: And be able to take some space.

[00:37:38] LM: And as we've talked about earlier, acknowledging that it is. An input, just like food, water, screens are now, you know, sort of part of our sort of nutrition, sometimes good, sometimes bad, but we have to metabolize it and we have to be aware of how it affects our bodies and minds.

[00:37:56] DH When it makes you feel bad, definitely put it away. That's I mean, That's definitely time. When it makes you feel bad, that's the time. If you're watching other people do stuff without you and it's making you feel terrible, put it away.

[00:38:05] LM: So Devorah, thank you so much for joining me today. It's been a pleasure and I've learned a lot.

[00:38:09] DH: Thank you so much. It was great talking with you.

[00:38:16] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com. The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.

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What gives you meaning and purpose? How do you measure success? What does it mean to be healthy?

Suneel Gupta is helping people grapple with these essential questions.

His new book, Everyday Dharma: The Timeless Art of Finding Joy in What You Do, is about reconciling what we do with who we are. Gupta describes our “dharma” as our calling—or what Gupta’s grandfather called our “essence.” Gupta recognizes the central tension between outward markers of success and finding this internal sense of purpose. A successful entrepreneur and bestselling author, Gupta has also grappled with depression and self-doubt, fueled by the natural tendency to measure success with external metrics instead of asking ourselves the “Why?”

On this episode of Beyond the Prescription, Gupta explores the harms of hyper-vigilance and the power of vulnerability. They discuss the “Arrival Fallacy,” the false assumption that once you reach a goal, you will experience enduring happiness. He shares parts of his own process of self-discovery that allowed him to pursue his inner purpose and help others do the same.

Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, and review the show!

The transcript of the show is here!

[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.

[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.

[00:00:57] So let's get into it and go Beyond The Prescription. My guest today is the ever dynamic. Suneel Gupta, who's passionate about helping people achieve success in a healthy, sustainable way. Suneel is a beloved speaker, a visiting scholar at Harvard Medical School, and best selling author of two books. His new book is just out. It's called, Everyday Dharma: The Timeless Art of Finding Joy in What You Do. It's really a practical guide to finding your dharma, your inner calling, and learning to integrate ambition, work, and well being to create a balanced life. The book combines Suneel's own stories with history science, Eastern philosophy, and Western methods. Suneel, thank you so much for joining me on the podcast today.

[00:01:49] Suneel Gupta: Oh, Lucy, I'm so glad we were introduced and it's good to be here.

[00:01:52] LM: So let's talk about Dharma. There's something about it that resonates with me as a physician who's in the constant quest tohelp patients pull the curtain back on their story. So what is Dharma?

[00:02:04] SG: Yeah, I mean, I wrote this book really for the same reason. I think that we are experiencing an overwhelming sense of emptiness right now and society sort of speeding up. All right, we're using artificial intelligence, we're using automation to continue getting faster and more productive. But I think as individuals, we're kind of in a lot of ways moving in the opposite direction.

[00:02:28] We are starting to feel like we are disassociating with our work, we are quietly quitting. And I think the result of all of it is that we are losing an emotional connection to what we do, which I think is a shame because we spend so much of our time either at a job or with the work that we do.

[00:02:45] And to not feel that connection is, I think, I think it's devastating, right? It causes, I think, a lot of the symptoms that you talk about on this show. And so the reason that I wrote this book is because I wanted to to talk about how do we bring that emotional connection back to our work in a way that really feels real to us? And dharma is an age old philosophy really about that connection and one of the underpinnings of dharma is that while it may be tempting sometimes to try to find happiness and bliss outside of your work, there also is another path which is finding it through your work, right?

[00:03:22] And Dharma is really the alignment of who you are and what you do, because when those two things are lined up, you feel creative, you feel energized. My grandfather called this your essence, right? And when you are expressing that essence, you're lit up, you're energized. But when you're not, you feel depleted, you feel burnt out.

[00:03:43] And so I think the question for us is, how do we now start to come back to this essence, right? And it's something that's available to I think all of us. It's not the kind of thing that you get to luxuriate about when you've hit a certain level of status or wealth. I think it's it's available to every single one of us no matter where we are in our career the the challenge though is that most of us don't know what our Dharma is and even if we do understand to a certain degree, what our Dharma is, what our inner calling is, we don't necessarily feel like we have the time or the space or the money sometimes, or even the courage to pursue it. And I wanted to write this book because I wanted to go directly into those struggles. Not to write a book about what purpose is sitting behind a desk, but how do you take this thing that you feel that you need to express, right, it needs to speak, and how do you once and for all start to bring that into your everyday life?

[00:04:39] LM: I love that I commonly talk with patients about this gap that exists in all of us between our best intentions and the execution of them. Meaning, like, we know we want to eat healthy. We want to exercise. We want to be more purposeful. We want to be more intentional. We want to put our phones down. We want to be happy and pursue things that are joyful, but there's that gap and the river is wide between the intentions and the execution. And you just said it, Suneel, sometimes the gap is filled with financial insecurity. Sometimes it's filled with logistical obstacles. Sometimes it's filled though, with fear and maybe even ambivalence, and then maybe even not knowing what your purpose is. So talk to me about how you might mind the gap. Those are my words, but how you kind of actualize and take control over your sort of sense of purpose and meaning.

[00:05:37] SG: Yeah. So two different things that come together, right? Who I am and what I do, right? And I think the what I do is the execution. Who I am is really sort of getting into like, what it is I care about. Let's start with who I am because I think that's just a natural place where I think a lot of us, I think me, me included would skip over. And the reason I would skip it over is because I would look to what everybody else sort of had, right? I would look to people I saw with nice cars and nice homes and really nice sounding LinkedIn profiles and bios. And I'd say, let me go follow that. And what I found over time is that I was really walking somebody else's path, not my own.

[00:06:12] And I think the work to sort of coming back to yourself and understanding what you want, it doesn't have to be something that you go on a huge meditation retreat. to do, right? I think it comes through starting to ask yourself certain questions. And in the book, I go through a list of sort of questions that really sort of helped me kind of get to this point.

[00:06:31] I call these the chisels. And the reason I call these the chisels is because Michelangelo, when he would look at a block of marble, he would say the sculpture is already inside. All I have to do is chisel away the layers. I don't have to create something from the ground up. And I think dharma, or calling, is very much the same thing.

[00:06:48] I bet that at some point in time, you have experienced your dharma. Like, you have lived up in a certain way. It may have been when you were a child. It may have been last week. It may be something that you're actively doing even at your job right now, but you're just not, you're not in tune with that.

[00:07:03] You're not in touch with that. So what I think of one of the very first things that we can start to do is start to identify the bright spots, whether that be in a past role or in a current role, these moments that really made us come alive. I think the key here that I think that we sometimes miss, I know I did, was that when we think about things like purpose and dharma, we think about a job.

[00:07:23] And so like in the book, for example, I tell the story of a woman named Mila, who really wanted to be a teacher. She was a project manager, but she really wanted to be a teacher, right? And she was frustrated because she couldn't, like, realistically, she had kids, her family relied on her health benefits, like the idea of leaving her job, going back and getting a teaching certificate was just not something that fit her practical life.

[00:07:46] And she was frustrated by that. And I think a lot of people sort of find themselves in a similar position. But when she was able to peel back the layers and understand, well, what is it about teaching that I love, right? When I dig below the occupation and into the essence of teaching, what ultimately arrived for her was that she loved to help people grow.

[00:08:05] And there was this emotional conversation she had with her mom, where her mom's like, Yeah, you've always loved helping people grow. Ever since you were a little kid, you were the kid who helped the kids on the other, on the block, like, learn how to ride bikes. It's the thing that's always been a part of you.

[00:08:19] And once she sort of reconnected with that essence, all of a sudden, all these different ways of expressing that began to open up for her, right? Teaching was obviously one of them, but she could start to coach people at work. She could step into a lateral shift into HR and start growing people inside the company.

[00:08:35] And all these options started to pop up for her. When that happens, Lucy, it's liberating because how many of us right now are like, Oh my God, like if I just took that other fork in the road in my career, then I would have ended in this job that would have been perfect for me right now. And I would be so much happier.

[00:08:52] Well, the reality is that over 90% of us right now are looking for jobs, right? In 2023. Over 90% of us right now are looking for our next job, and what the data almost overwhelmingly shows is that we're going to jump to the next job, and within a few months, we're going to feel exactly the way we feel right now, right?

[00:09:09] So I think with Dharma, with who I am, we're peeling underneath the occupation layer, and we're going into the essence layer. When you tap into that essence, you can start to figure out how to express that, and your world kind of opens up.

[00:09:21] LM: It's amazing the way you describe it. I love the Michelangelo image, right? The block. And he says, I'm just repeating it back to you, but he says the sculpture is already there. It's just that you have to pull back the layers and that's exactly right. I think when people are able to do that, as you've described in your book.

[00:09:40] LM: To me, that's the definition of health. I mean, health also includes having nice cholesterol levels, not having a heart attack, doing your cancer screenings, but health at its core is about awareness of our stories and how they live in our bodies, awareness of medical data, our own data, and the way our data is contextualized in the literature and then accepting the things we can't control, so other people, our genetic predisposition to breast cancer, and then finding agency where we can, because we can't control other people. We can't control certain genetic predispositions. We can't control the fact that we may be financially bound to stick with a job we're not fully actualized in, but people often have more control than they think.

[00:10:28] And I think what you're saying, Suneel, is that part of the control and the agency we have, which is ultimately. To me, a part of definition of health is simply querying our own bodies and minds and asking ourselves, like, what is my passion? What am I here for? How do I feel when I'm doing something that gives me joy? And can I recreate that in other spheres of my life, whether it's at work or parenting and ultimately that feeds back onto our health. I mean…

[00:10:55] SG: It does.

[00:10:56] LM: During the pandemic, for example, I saw people every day who were experiencing physical manifestations of emotional distress. And some of it was burnout from caring, caregiving and parenting and living through a pandemic, just being a human.

[00:11:08] But even now, I mean, people are wired and tired and they don't feel well. And so it's reassuring to me to hear someone like you talk about, to me, what is really the essence of health in your book.

[00:11:24] SG: Dr. Tal Ben-Shahar, who you may have crossed paths with at Harvard, really sort of, I think, Explains this nicely, which is like he has this phrase called the arrival fallacy and the arrival fallacy is basically this idea that like we're going to hit this moment where we've attained enough wealth, enough status in order to feel this lasting sense of joy on the inside.

[00:11:47] And until then, we're willing to suffer. Until then, we're willing to sort of grit it out, grind it out, do whatever we need to do because we believe we're going to hit this moment where it's all going to have been worth it. And at some point in time, I think we all get wiser to this idea right? And I would argue that We're starting to realize that earlier in our lives.

[00:12:05] I think Gen Z is asking difficult questions that older generations sometimes don't like because they're like we didn't ask those questions when we were your age, right? And they're, I think, very understandably saying, yeah, but you don't seem very happy. And we want to do things a little differently than you.

[00:12:20] I mean, the country has gotten richer, we've become more productive, but we're also more lonely than ever before. Mental health issues have never been higher, right? We feel disconnected from one another. That's not necessarily sort of the train that I want to get on. And so to ask the difficult questions right now, and to your point, to be inside out about it, right, to peel back the layers, I think it's a very reasonable thing. And then the question I think becomes, well, then once I start to peel back those layers, how do I actually put it into practice, right? Because there's nothing more frustrating than understanding who you are, but showing up every day and feeling like you're walking in somebody else's path.

[00:12:55] And what I try to do in the book is really get into those struggles again, like we may not feel like we have enough time. We may not feel like we have enough money. We may feel like we know exactly what it is, but we're scared of that. And so I wanted to tell like the everyday stories of people who were able to not necessarily even leave their jobs.

[00:13:14] Like one of my favorite stories in the book is, is about a nurse who really wanted to be a writer. And her parents said, no, you can't be a writer. You're first of all, writing is not a profession. It's going to make money. You're not a, you're not a man, right? Like, and, and like, if you're a son, if you're a son, maybe, but like, as the daughter, no, you're not going to be a writer.

[00:13:31] And so she got pushed into a different field and became an outstanding nurse. But one of the things that she realized is that she was able to bring her persona as a writer into her work of nursing. And one of the ways that she did that, it was through her patient paperwork. So, while most people like, try to get through, and you know this Lucy, try to get through the paperwork as quickly as possible, like put the clinical details in, she started to actually expand on those clinical details into like, who were these people?

[00:13:56] What did they care about? Who do they love? What was their life like at home? What was their experience of being a human like? And she would start to pour her heart as a writer into these clinical patient forms to the point that like literally this paperwork was getting passed around the hospital like novels people loved reading it because it gave them a sense of purpose and what they were doing and so she was able to express this dharma as a writer through her occupation as a nurse and the point of it all is that oftentimes we think that in order to live our purpose we have to blow up our lives. We have to leave our jobs, right?

[00:14:30] We have to move to a different place and become a painter or leave everything we have behind. Not true. And there's so many situations and stories in the book. We talk about sort of how Dharma doesn't have to be a separate path, but it can be a permutation of what you have right now. You don't have to leave everything behind. You can start to bring a new persona into where you are today.

[00:14:49] LM: I love that Suneel, I think you're right that life happens in the mundane in a way, right? It's not in the big sort of huge moments. It's really in the everyday moments that sometimes we don't even know exist. It's just a tuning to the present. How did you get to be so wise? I mean, you're young and you talk a lot about burnout and failure.

[00:15:12] I love that story you told about. You told your wife, I'm a failure and she's like, no, you're not a failure. And you're like, well, the New York Times says I'm a failure. And then you showed her the article about your talk about failure. And so like, what is your story? How did you get to the place where you are now writing and speaking and talking about these very soulful topics?

[00:15:36] SG: Yeah, I mean, I think success is a lousy teacher, there's no doubt about that. It's wonderful, I'm not trying to downplay success, like, I think that I've had some success in my life and has been able to provide the sort of, I think, a life for my family, it's allowed me to sort of take care of my kids, and I'm very thankful for that.

[00:15:54] And yet, if I look back at sort of where the learning really came, where the growth really came, it didn't come from success, it came from setbacks, it came from mistakes. It came from change when I coach sort of organizations and leaders today, and I asked them, what was the most important part of your career, right? Most important year of your career. Very rarely do they say like it was the winning year when I had the most profit or it was when I earned the biggest salary. Most of the time it's like something big happened, it was a big change and usually that change isn't positive. It's like it was something that got knocked back on their ass and they had to sort of learn and that changed everything for them.

[00:16:32] But that was really meaningful. And I think I've had no shortage of I think those moments where I felt like I wanted something really badly and I put myself out there and it didn't happen. I think the learning for me, though, sort of came from sitting down and writing about that. Right? So, I think, if I'm being honest, like, I started writing because I was depressed.

[00:16:55] I was feeling anxious. And I realized that I was dumping a lot of that on my wife. I was spending a lot of time talking to her about that, and I realized, and as, like, loving as, like, Lena is, I realized it was unfair for her. She was always listening, but it was unfair to just, like, almost, like, vomit my trauma on her.

[00:17:13] And so I started to use the page, right? Literally sit down at my desk every morning and I started to write about these things that I felt like I was struggling with and searching for answers to that would do it every morning because the page always listened, no matter what it just listened. And I'd say 99% of what I've written in my life has ended up in like a trash bin, nut there were some pearls there were some little pearls that was able to string together along the way and eventually those pearls started becoming blog posts that became published articles. Eventually they became books and that's just kind of the thing like I think if you look hard enough There are these poor these pearls of wisdom.

[00:17:55] I talk about this a lot in the book is like I think I was following sort of an outlook of resilience before right and now I feel like I'm following an outlook of growth and the difference between the two is that like with resilience, there can be a tendency sometimes to just like want to get back up right like pull yourself up by the bootstrap, let's get back up. But I think growth is getting back up, but also taking some time to understand. What did I learn. If my kid was in a similar situation? Well, how would I sort of help coach them through a situation like this? What would they learn from my mistakes? Taking such a taken like a reflective view on that.

[00:18:35] Even just spending some time moments, right, to write about it, to learn about it, even if it's just for your benefit. Nothing you're gonna publish, but just something that you're gonna reflect on yourself I think can be the difference between cycling through the same mistake over and over again, and I think actually using a setback to create genuine.

[00:18:56] LM: I love that. I have a comment and then a question. The comment is about the writing. Like you, I find writing to be very therapeutic. I find that I can really crystallize a lot of my thoughts. I mean, writing ultimately is about thinking. And when you're putting things on the page, it's clarifying to oneself about how you're thinking.

[00:19:17] It also can disarm some sort of scary thoughts. I have found, like, when I've had depression symptoms or I've been anxious, when I journaled, I was a journaler from a young age. Just intuitively, I knew to write. When you look at the words, A day or two later, you realize that with time and with perspective, they're not so terrifying.

[00:19:37] And so, I too find writing really therapeutic and I recommend it commonly to patients who are experiencing depression or anxiety or trauma as an adjunct to other sort of treatment modalities, but certainly kind of writing down our thoughts can help disarm them.

[00:19:52] SG: Yeah. One of my favorite techniques is to write what I call sort of the if true, then pattern.

[00:19:58] LM: Tell me about that.

[00:19:59] SG: going a little bit deeper into the fear can be a really illuminating thing. So if I'm scared that I'm going to blow a presentation, right, I'll write that down. Like that's the thought inside my head, you're going to blow this presentation.

[00:20:12] And then I kind of talk with the fear. I say, okay, let's pretend that happens. If true, then what? And then it's, you're not going to get the deal or you're not going to get the, you're not going to get the job or whatever it is. Right. And they say, if that's true, then what? Well, then you're, you're not going to have this role that you wanted.

[00:20:27] If that's true, then what? Well, then you're going to blow up your career. And if that's true, then what? And I continue to just sort of go deeper down. And when it starts to make me realize is that underneath this surface level fear, all these sort of deep seated concerns that almost in all probability will not come to happen, but the other thing is that at the very bottom of that list Right when I really dig down to the root of it It always ends with something like well your wife is no longer going to love you, your kids are no longer gonna love you, right?

[00:20:59] And I think to myself Wow, that's the deepest root of my fear and I actually have more control over that right now Then I do whether I get this presentation done like I can go give my kids a hug I can go tell my wife I love her. I can do that right now. What happens inside that presentation, I don't know. But I know the deepest fear, I can deal with right now.

[00:21:21] LM: It's such a powerful point, Suneel, because I think all of us have at our core, the fear of not being loved or being worthy. Like shame and feeling excluded or not loved are like the deepest fears. And I think a lot of those fears come up in our childhood naturally, right? Like I think of life as this set of experiences and we're like a blank canvas when we're born and then you experience loss and challenge and hardship and dings on your self esteem.

[00:21:57] And then we create this sort of network of connections in our minds. In fact, we call it the default mode network. It's a set of neural pathways in the front of our brains that basically are derived from a lot of pattern recognition so that we don't reinvent the wheel every time we come across a new scenario, right? Like, we lose that wonder and curiosity of childhood.

[00:22:20] But we also gain some street smarts, but the downside of that default mode network in the front of our brains is that we can start to make assumptions about things and make connections and thought and behavioral patterns that actually aren't serving us at the time. In other words, you can have an experience as a child where you were terrified and felt vulnerable.

[00:22:41] Maybe you weren't picked for the team or something. And then you wrote a story in your mind about why. And then the next time something happens to you that's like that, even in your adulthood, you might then go back to that sort of I'm not worthy narrative. So, this is a long way of asking you, about your childhood.

[00:22:59] And now we're going to do like go deep here. Like, I love that pinned tweet on your Twitter feed. I guess it's called X now, about your mom. And I'm like, okay, there's a story there. First of all, her story and then your story of her being your mother. Someone says to her, “go back to your country.” And she says, this is my country.

[00:23:17] And then I think the man says, get out of my kitchen. She says, this is my kitchen. And then there she is in all of her glory on time magazine, telling her story. Tell me about like growing up in your family. What was her story? How did that affect your story? And then your telling of it to yourself and then the experience of fear and vulnerability, like you just described,

[00:23:37] SG: So, mom grew up on the border of India and Pakistan, right? When it was all one big country, when it was India. When the country split, during partition, was one of the bloodiest conflicts that humanity has ever known and she was part of that. She was in, she was right in the mix of it and their family fled.

[00:23:56] She ended up in a refugee camp as a kid, very little running water, no electricity, but she decided that she was going to teach herself how to read. And she felt like that was going to be sort of her path out of poverty. And so she did. And she knew she had enough foresight even back then to know that like English was sort of the language that she would have to learn if she wanted to get herself to the United States because that was her dream. And so she started reading and the first book that she read from cover to cover was a story about Ford Motor Company because Ford Motor Company was literally the Google of its day.

[00:24:30] The big, it was the big company. Everybody knew about it, right? If you were rich and you were driving sort of a Ford car, even around sort of certain parts of India and she would see that and that's what she wanted. And she wanted to be an engineer, as well, and she set her heart on that, and it was a very unlikely dream because people from her country, especially women, that period of time were destined for the kitchen, right?

[00:24:53] And I mean, the best case scenario for her as told to her by some of the other people in her village was Find a rich man, find a wealthier man, somebody who isn't in poverty, and that's your path out. She wanted more, like she wanted to express herself. And so she studied hard and people got behind her, her parents got behind her, they saved every rupee that they had.

[00:25:13] She was able to get on a boat to eventually the United States. She got a scholarship to Oklahoma State University. The day after she graduates, she finds herself to Detroit, Michigan. She applies for her dream job. There's a lot there. There's another story there. But she gets it. And in 1967, the reason Time Magazine wrote about her is because she became Ford Motor Company's first female engineer.

[00:25:34] Ford Motor Company had thousands of engineers on staff at that point in time. Not a single one of them was a woman. And so here she is, this woman who tends to dress in saris, and she cooks and eats mainly Indian food back at home, and she is now amongst this, like, sea of mainly white men who are doing this job, and she finds a way to sort of fit in, or I shouldn't even say finds a way to fit in, she finds a way to be herself in a very different environment.

[00:25:58] And, and I think that for me as a kid growing up in almost the opposite situation. I'm an Indian kid now growing up in America. I live in suburban Michigan. Everything is compared to my mom. We lived in a pretty, we lived in a three bedroom house, but like it was a night and day difference from the conditions that she grew up in.

[00:26:17] It was the equivalent of a silver spoon in my mouth and the fact that I could eat every single night. I think that for me, what. I've learned about my mom and what I've learned about, I think other leaders who I spend time studying and I think admiring who have done difficult things is I think that the thing that holds a lot of us back are the words, “I'm not ready.”

[00:26:40] Right? Like, I'm not ready to, to run with that thing. I'm not ready to step into that role. I'm not ready to speak my mind. I'm not ready. And I think the confusion sometimes is in believing that the people who did difficult things, my mom included, is that they were somehow ready to do what they did, but they weren't, right?

[00:27:01] I call this the game of now, in my book, versus the game of someday, right? The game of someday is you wait for courage. You summon up enough courage, and once you actually have enough courage, you take action. And I think that's the way that most of us behave. There is another game, and that's the game of now, which is that instead of waiting for courage in order to take action, you just take action, and you let courage catch up along the way.

[00:27:27] And I think the thing that I've learned is that it almost always does. If you just say like I'm gonna go do that thing courage will come even begrudgingly courage will be like, okay. I'm with you, right? That's the thing I learned about her story is that it wasn't the story of a little girl in a refugee camp who said f*ck it all I'm gonna go do this thing. It was more a story of a scared person who said I want this really badly and I'm scared And I'm going to do it anyway.

[00:27:58] LM: that is a huge lesson. And I wonder how she expressed that. I mean, you told me in so many words, but like. Did she talk about like the lack of courage? Did she talk about her fear and just doing it despite having the courage or did she just model it? Was it the kind of thing you talked about as a kid?

[00:28:17] SG: Not as a kid, no. I think as a kid, I had very surface level conversations with my mom. I marveled at her story, I marveled at who she was, but I didn't really dig into the how. If there's anything that I felt as a kid, I felt like kind of almost insecure because here was a parent and I have a brother who's done amazing things as well and my father's an immigrant too.

[00:28:40] And so I sort of, I felt like I kind of came from this really brave family and I felt insecure because I actually didn't feel all that brave. I just didn't. And, and that made me feel bad because it was just, I felt like, wow, like, gosh, I'm surrounded by all these incredibly courageous people and I'm not one of them.

[00:28:58] But. I began to realize over time, more from the stories that I would dig into, more from hearing about what it was like at Oklahoma State University when she was sitting in her dorm alone, right? What was that sort of like for her because she didn't eat meat and she couldn't go to the cafeteria because she was a vegetarian?

[00:29:17] What was that like for her? And I think when you dig into people's stories and you get beyond this happened and this happened and you just simply start to ask the question of like, what was that like for you? And that's when you start to get insights, but I didn't start asking those questions until I was a teenager or maybe even in college when I would come home and have conversations with her.

[00:29:35] And the thing about it, Lucy is like, I love that question now. Like I host a documentary series where I travel around the world and I meet with all these leaders who've done crazy things. And I almost always dig into less of what they did, but what were they feeling in those moments along the way?

[00:29:54] LM: It's the essence of who people are. Right? Suneel, I can't thank you enough for joining me on the podcast. You are such a bright light and I can't wait to share your book more widely and to reread it. And I just thank you so much for your pearls of wisdom and for acknowledging that you're a work in progress too.

[00:30:13] I think that we're never done. We're never done in the process of self discovery and then bringing our best selves to our relationships, to our work. And so I appreciate the humility that you offer as well. So thank you.

[00:30:26] SG: Thanks, Lucy. It's so good to be here.

[00:30:35] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it, and if you have a comment or question, please drop us a line at info@lucymcbride.com. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.

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Confused about how to handle COVID this fall and winter? Wondering how to think about masks, boosters, and reducing your risk of getting sick?

On this episode of Beyond the Prescription, Dr. McBride talks with Monica Gandhi, MD, MPH, who became one of the most prominent public health experts in the country during the pandemic. Dr. Gandhi is a Harvard-trained physician, expert in infectious diseases, and professor of medicine at the University of California, San Francisco (UCSF). She is the director of the UCSF’s AIDS Research Center and the medical director of the San Francisco General Hospital HIV Clinic.

Dr. Gandhi’s career centers on the principle of harm reduction, born out of her decades-long work in HIV. Harm reduction is the belief that public health policies should consider not only the pathogen (i.e., HIV or COVID) but also people’s basic needs for social connection, intimacy, and a sense of agency—and that public health’s job isn’t to eliminate risk (that’s impossible) but rather to arm people with information and tools to mitigate the inevitable risks we face.

Her new book, Endemic: A Post-Pandemic playbook, published in July 2023, aims to reckon with the country's present condition: comprehending and living with a new respiratory disease and how to face the coming variants and next pandemic with reason, science, courage and compassion.

Listen to hear Drs. Gandhi and McBride discuss where we have been, where we find ourselves now, and how we ought to manage the virus this season, and in the coming years.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, and review the show!

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Manish Agrawal MD and Paul Thambi MD are oncologists who have spent decades caring for patients with cancer. They realized early in their careers that chemotherapy could treat the cancer—but what about the emotional, psychological and spiritual impact of facing mortality?

When they learned about the potential for medications like MDMA and psilocybin to help people gain access to parts of their minds they didn’t know existed—and to address the human experience of suffering—they quit their day jobs as practicing cancer doctors to found Sunstone Therapies, the sole psychedelic-assisted therapy research and treatment center in the Washington, D.C. area.

The data are increasingly clear: these non-addictive substances hold the power to expand consciousness and improve quality of life.

When guided by a trained therapist in the appropriate setting, even one experience with a psychedelic medication can help people unlock closed doors in their minds and to feel safe enough to explore its contents. They can be the catalyst for patients’ ability re-route well-worn pathways of negative and maladaptive thoughts, feelings and behaviors.

It turns out that science and spirituality aren’t mutually exclusive.

On this episode of Beyond the Prescription, Drs. McBride, Agrawal and Thambi discuss the inseparability of physical and mental health; the promise of psychedelic therapy to treat the psychological impact of cancer and other diseases such as PTSD, anxiety, and depression; and their shared excitement about the potential for these drugs to fundamentally expand the standard of care in medicine.

Bios:

Manish Agrawal, MD

Manish brings an extensive background and experience that spans medicine, engineering, philosophy, and ethics to his role as CEO of Sunstone Therapies. Driven by a deep interest in healing, Manish is particularly passionate about whole person healing and the transformative potential of psychedelic therapies. Manish previously held the position of Co-Director of Clinical Research at Maryland Oncology Hematology, where he dedicated 15 years to the care of cancer patients. He completed a fellowship at the National Cancer Institute, National Institutes of Health, and his residency at Georgetown University Medical Center.

Paul Thambi, MD

Paul brings deep experience in oncology care and clinical trial design to his role as Chief Medical Officer at Sunstone. He is a proponent of strong organizational culture and strives to create a compassionate, open and accepting workplace to advance whole person healing in medicine. As a medical oncologist, Paul developed important and meaningful relationships with patients, witnessessing their emotional and physical distress upon diagnosis and throughout treatment, leading him to explore psychedelic therapies to improve the emotional and mental health of patients fighting cancer. Paul completed his oncology fellowship at the National Cancer Institute and, prior to pursuing medicine, he began his professional career in engineering and consulting.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

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Kelly Casperson, MD, is a urologist, sexual medicine expert, and best-selling author. She is on a mission to empower women to live their best love lives.

In her wildly popular book, You Are Not Broken, Dr. Casperson breaks down the common narratives that women have been told about their bodies such as “I shouldn't enjoy sex,” “I can't get any better at sex,” and “It is my partner's job to give me pleasure,” in order to help women play, explore, and normalize their sex lives.

Combining the power of mind, body and relationships, she breaks down the societal barriers that keep women from fully embracing their sexuality and intimate experiences.

On this episode of Beyond the Prescription, Dr. McBride and Dr. Casperson discuss desire mismatch, relationship communication, and tools to help put women back in charge of their health and sex life.

It is time to normalize healthy, enjoyable sex worth desiring, and Dr. Casperson is here to help!

Submit your question about sex (or anything else) for this Friday’s Q&A right here!

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

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Dr. Mary Claire Haver is a board certified OBGYN and women’s health advocate who has helped thousands of women going through menopause actualize their health and wellness goals. Dr. Haver’s goal is to empower and educate women in their mid-lives, and help women advocate for themselves in the doctor’s office.

On this episode of Beyond the Prescription, Dr. McBride and Dr. Haver break down the myths and facts about menopause and hormone therapy. They discuss the harms of fear-based narratives in medicine and the importance of balancing risk to help women live longer and healthier lives.

So, should you or shouldn’t you take hormone replacement therapy? Dr. McBride wrote a longer piece about this decision-making process here.

The upshot?

• Menopause is defined as having gone a full calendar year without a menstrual period. A woman’s midlife decline in estrogen and progesterone levels can cause short-term symptoms (like hot flashes, vaginal dryness, and insomnia) and can increase the risk for long-term health problems (like cardiovascular disease and osteoporosis).

• In general, menopausal hormone therapy (MHT) is considered safe for most healthy women who are within 10 years of menopause or are under age 60 and who do not have contraindications.

• Estrogen itself does not seem to increase the risk of breast cancer for the vast majority of women.

• Unless she has had a hysterectomy, a woman should take estrogen and progesterone together.

• Micronized (aka “bioidentical”) progesterone does not increase the risk of breast cancer; synthetic progesterone does seem to increase the risk, but only slightly.

• I wouldn’t freak out about the new Danish study suggesting an increased risk of dementia in women who take MHT. Why? It was an observational study (not a randomized controlled trial or RCT) therefore it cannot prove causation; the study population used oral estrogen and synthetic progesterone which are not the standard of care in the U.S.; myriad RCTs show the opposite finding: that MHT is likely protective against premature cognitive decline, especially when started early.

• Too many women needlessly suffer through menopause because of false narratives about the safety of MHT and because discussions about quality of life often aren’t prioritized.

• Don’t take it from her! Dr. McBride encourages you to share the latest expert statement from the North American Menopause Society with your own doctor to help guide your decision-making process.

• Women are entitled to make their own decision about hormones, armed with the data, and with an understanding of their unique risks and benefits.

Dr. McBride will answer your questions about menopause and HRT on Friday. Submit your question right here!

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

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Did you know that all children, regardless of genetics, are at risk for substance abuse?

Jessica Lahey is a New York Times bestselling author, mother, and parent educator on teen substance use. Her most recent book, The Addiction Inoculation, is a practical guide to help children grow up to be healthy and addiction-free.

On this episode, Jessica sits down with Dr. McBride to discuss her own path to sobriety, the myths about substance abuse in adolescents, and how to help kids feel comfortable setting healthy boundaries.

This is a must listen if you’re looking for ways to talk with your kids, grandkids—or yourself—about alcohol. Feel free to share this episode with others who may be, too.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, and review the show!

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Juneteenth is a celebration of freedom and liberation. I can’t think of a better person to speak to the importance of self-expression, autonomy, and living without oppression than Nedra Glover Tawwab.

Nedra is a practicing therapist, relationship expert, and two-time bestselling author. She understands that health begins with individual freedom—and that healthy relationships require supporting each other's freedom, growth, and self-identity while maintaining mutual respect and healthy boundaries. Her books, Set Boundaries, Find Peace: A Guide to Reclaiming Yourself and Drama Free are born out of her philosophy that a lack of boundaries and assertiveness underlie most relationship issues. Today, Nedra sits down with me to discuss the physical and emotional health consequences of relationship drama—and the importance of self-awareness and acceptance in order to have agency over our life and health.

I hope you enjoy this very special podcast episode. Listen above! 👆🏼👆🏼👆🏼

Together we are helping redefine what it means to be healthy. To join this community—and for lots of fun extras—consider a paid subscription!

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, and review the show!

Transcript of the show is here!

[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story, to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at https://lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.

[00:00:58] Okay. Buckle your seatbelts. I am thrilled to be speaking today with two-time bestselling author, licensed clinical therapist, and relationship expert Nedra Glover Tawwab. Every single day, whether it's counseling patients in her therapy practice, or talking to her 1.8 million Instagram followers. Nedra is helping people create healthy relationships by teaching them how to implement boundaries.

[00:01:29] She has written two books Set Boundaries Find Peace and her most recent book, Drama Free, both of which are born out of her philosophy that it's a lack of boundaries and assertiveness that underlie most relationship issues. Nedra, I cannot tell you how happy I am for you to be here today. Thank you so much for joining me.

[00:02:02] Nedra: You're welcome. Thank you very much.

[00:02:04] Dr. McBride: As patient-facing providers, you and I both know that relationship stress, relationship drama, can affect people’s health. During the pandemic I witnessed patients coming into my office with headaches, migraines, back pain, high blood pressure, weight gain, alcohol use increasing as a result of a spotlight being shined on a troublesome relationship, or until they had to make hard decisions about parenting, caregiving, living through a trauma.

And so when I saw you on Instagram I knew I loved you at first sight, because you were there talking straight to the audience your 1.8 million followers about the relevance of relationships to our health and then you were dispensing practical guidance to this the drama and lean into the joys of relationships. And so thank you for doing that and thank you for being here.

[00:03:26] Nedra: You're welcome. The only time that, well, one of the only times I'll said, there's two times the only, one of the only times where I felt, oh my gosh, I think I'm having a panic attack, is when I was put in the situation of seeing a person who made me very uncomfortable. I was like, I'm about to have a panic attack… this is how much I don't want to see this person.

[00:03:54] My nervous system is on fire. My body is like run, hi, go. And it's not always, oh my gosh, I need to trust this, but I need to consider it. Right, because sometimes our bodies, our minds could be pushing us away from things we need to do, but there are other times where it's like warning, warning and we're like, okay, I'm going to do this anyway because I have to do it. And for me, in that situation, it was a warning to stay far away from a situation that was unhealthy because of past events.

[00:04:31] Dr. McBride: Another reason I knew we were kindred spirits, if you will, was that I saw you talk about adverse childhood experiences. So ACEs, as many people know, are events or situations or even relationships in childhood that have lasting effects on our health. In fact, there's no shortage of data to show that people who experience childhood trauma, whether it's physical, emotional trauma, experience higher rates of binge eating disorder, depression, anxiety, post-traumatic stress, and even cardiovascular disease.

[00:05:12] And so when I see someone like you who's helping people address the experience head on instead of meeting me when they're 50 and having heart disease, I think this is health, this is prevention. So could you talk to me, Nedra, about how you became a therapist and how the ACEs in your life perhaps informed that decision?

[00:05:36] Nedra: I was trained to be a listener. I listened a lot to my father in particular, talk about very adult topics, complain or, you know, ruminate or you know, do all, and I would just uh huh. I took it on as something that I had to do. I didn't know that this was a profession. I didn't even know this was something I was drawn towards, but it really shaped me into a person who. Was a good listener because with your parent, you're not really allowed to cut them off or stop them from talking. It was just like, oh, I have to listen to this person. And so it became a part of me with my peers, with other people in the grocery store who wanted to tell me random things.

[00:06:22] I'm like, “Uh huh.” And when I went to college, I thought I wanted to be a social worker who worked with children and you know, I got an internship and it was. In a therapy setting. And I realized that I actually like the side of listening where people actually want help. Not just people complaining, not just people ruminating or you know, saying, “Oh, woe is me.”

[00:06:47] It was people who wanted help with their situations. Now they may not all be at the same level of readiness, but they were certainly in the place of seeking. And for me that was a light bulb moment of, “Well, I have the training. I have the parent to fight training to do this. Perhaps this is an opportunity where I can really get into something that feels good to me.

[00:07:14] I felt really good being that person, that hope, [to help] someone think about things differently, because that's really what it is. I never had the opportunity to give insight. I was only a listener up until that point. But then when I was able to give the insight with that and they were like, oh, I never thought about it.

[00:07:31] I was like, “What did I say? I said that. I said that. Yeah, that was really good.” But I just think therapy is a wonderful thing for all people. And I don't just say that because I'm a therapist. I say that because I'm a person that goes to therapy and there is nothing like having a person who does not tell you about themselves for one whole hour a week.

[00:08:00] Dr. McBride: Amen. And I'm a believer as well, and I love that story that you had this firsthand experience of being an empath and listening and observing. I think I agree with you that therapy is a wonderful way of having that space and time to download our thoughts, feelings, and talk about our behaviors and relationships.

[00:08:26] I do think, however, there is a difference between therapy that is simply chewing over the day's news and the data dump in therapy that is, I think, what you do, which is helping people affect change. And having the courage and tolerance for distress, they need to affect change. And I actually, I just talked to a patient today who's been in therapy for about a year, and you and I can agree that it takes sometimes years to make changes, but I asked her because she isn't feeling better vis-a-vis some things in her life.

[00:09:07] Do you think it's possible you're not bringing the whole story to your therapist? I think we all have parts of our lives that are so vulnerable that it's hard to even bring up to ourselves, not to mention to another person. And I said maybe it's like at the museum when you kind of rope off a part of your story that you're not accessing.

[00:09:29] And I don't know if you have thoughts about that, but I'm guessing you do. But I just think that I said to her, I would, I would love to challenge you to bring more out and maybe think about other issues in the relationship with your therapist that make it harder to do that. I push people.

[00:09:46] Nedra: Yeah. I'm excited for the people that I work with who are brave enough to be deeply honest. It requires some honesty to admit the things that don't make you look good. Everybody loves to tell the story of, I can't believe they did this to me, or Can you believe this person did blank? Not many people acknowledge I did this to this person and it wasn't very nice.

[00:10:15] I've recently thought of a story only because something happened to a person in my life where they had this friendship sort of situation where someone did not honor a commitment. And I said, oh, I remember one time, I think I was like 20. I did not honor a commitment and I ghosted that friend after because I could not address it.

[00:10:42] And they were like, “Really?” I was like, yes. I'm like, put it in my obituary that I apologize to this person today.

[00:10:52] Dr. McBride: Yes.

[00:10:54] Nedra: I even tried to Google them. I was like, “let me email them.” I'm like,

[00:10:58] Dr. McBride: That's hilarious.

[00:10:59] Nedra: I've done one bad thing in life. That's it. No, probably tons, but this is the one that is sticking out. And they were really shocked. They were like, “I can't believe you did that.” I'm like, “I didn't want to do it.” I didn't know how to end the relationship. And in my immaturity, I did it in a very explosive and probably damaging to the person way is not something I'm proud of. I would never do anything like that today, but I did do that and it does not make me look good.

[00:11:32] Dr. McBride: Well, I think it makes you human, Nedra, and it's like just the process of being human and sort of sharpening our tools for managing relationships and honoring our needs and honoring the other person's needs. I'd love to talk about acceptance for a minute. So you wrote on your Instagram recently, and I screenshot it—a little secret from a therapist.

[00:11:56] “In relationships, we often think the other person is the problem. If they changed this or that, your life would be better. Sometimes the problem is you not accepting that you can't change the other person and you have to change for the situation to improve.” And then you wrote in bold repeat after me, and this is where I thought, oh my gosh, this is so good.

[00:12:19] “I am not in control of others. I am in control of myself.” One of the things I was telling a patient today or not telling, one of one of the things I was talking to a patient of mine today who is a middle-aged woman, mother of three, and a born sensitive empathic pleaser who is coming in not feeling well emotionally and physically asking me if she should be on more Zoloft when we drill down to the issue is really that she's not erecting appropriate boundaries with her family. They have expected her to jump through hoops in every department of her life to please and satiate their thirst for whatever she's offering, and as a result, she's feeling exhausted and burnt out and resentful. So there's no amount of Zoloft that can help her tolerate that. What I talked to her about is I said, first of all, buy Nedra Tawwab’s book, And she said, which one?

[00:13:20] I said, well buy both because they're both really good. And then I said, let's think about retraining your family and rehonoring your needs in the relationships. And, and I'm gonna make this a question, accepting that painful acceptance of realizing your parents and your siblings may not change. They may not want to ask less of you, but you can hold the line.

[00:13:47] Nedra: You can do less. They can ask whatever they want to, and you can do less. Take it from a person who gets countless amount of dms,

[00:13:58] Dr. McBride: Oh my gosh. I'm sure.

[00:14:00] Nedra: All so many requests. I meant, here's my question for you. Here's this thing I need. I can't respond to all those things and show up in my life. It's not possible in a healthy way. I'm not gonna say it's impossible. It's not possible in a healthy way. It's not possible to fulfill many commitments the way that we do sometimes in a healthy way. We do it while other things are suffering. Can you imagine that here it is, you haven't even had a glass of water and you're doing all these things for other people. You haven't even had your yearly checkup and you're doing all these other things for people. You are last on your list. Your health is suffering. You have things that you need that aren't being honored, and your concern is, “oh my gosh, they’re gonna be so upset at me.” You may not be here at the rate you're going.

[00:15:00] They're gonna be upset at a ghost. They're not gonna be upset at you because you're not gonna be here, you're not gonna be, well, you're not gonna be able to keep this up long term. So stop it now. Stop it before it gets to a point where you know, the migraine is actually really a issue now. It's not, it's no longer just, oh, I'm having the occasional headache.

[00:15:22] You've worked yourself into hypertension, now you have hypertension. Because you're doing these things at this high capacity that is not sustainable. And I think about people who have to take things to be able to get through the day. So there are some people who will take a painkiller every day just to get through the day.

[00:15:43] I have a headache every single day. I have a whatever. Every single day I've watched Dr. Pimple Popper. Oh my gosh. And those people, they'll have this growth on them for 20 years, and I often think, what have you been doing that long that you couldn't get yourself to the doctor? 20 years? That looks like something that should have been removed after two months. But there's all of these other places, all of these other things that we have to do other than taking care of ourselves, which is the most important thing in life for us to show up in these other spaces.

[00:16:24] Dr. McBride: Why do you think it's so hard for women in particular? I think it's true for men as well. Why do you think it's so hard for humans to center their own needs? I mean, what are the themes you see in your practice that people come up with?

[00:16:41] Nedra: The voices of other people dictate what we choose to do on our lives. People are going to think it's selfish. I'm not being a good this. That's not kind, that's not loving. I think about the statistic that married women die sooner than married men. Not sooner, but they don't live as long as unmarried women.

[00:17:07] So unmarried women because they have less responsibilities and probably less stress. They live longer than married women. And I see that manifested in my family where both of my grandfathers outlived my grandmother's, and it's just, I remember my grandmothers being such hardworking women who didn't even, you know, when it was time to sit down to eat, they weren't even hungry anymore because they'd done so many. It was like, I don't even have an appetite.

[00:17:38] I've done all this cooking. I've been cleaning, I've been folding, I've been doing all this stuff. I don't even have space to eat anymore. I just need to sit down. And I remember being a little girl, grandma, how can I help you? Can I sweep the kitchen? Can I… because you see it and it's like, Oh my gosh, the modeling.

[00:17:56] And so we think that's womanhood. We think that's love. We think that's being compassionate and what it is, is being overworked. It's being run dry. It's being, I don't wanna say taken advantage of, because if you don't know that you shouldn't be doing it, you're not being taken advantage of.

[00:18:17] But it's certainly being disregarded in a way that other people don't even have to consider. It is not healthy for us. It's not healthy for women or men. You know, if a man is in that situation, I don't want you to work that hard, especially when you're not the only person. You're not the only person in the household, and so for any of us working alone, it is a lot and we have to rely on other people. We have to have some communal support. We cannot be the only person doing the things.

[00:18:55] Dr. McBride: What do you think your grandmothers would say about your sort of exquisite ability to have healthy boundaries in your own life. I ask because one of the common things we say to each other, myself included, when we try to have healthier boundaries, like saying no is saying yes to something else… is you're worried about what other people will say or think, particularly if they are used to getting a certain behavior from you.

[00:19:27] Did you ever get any pushback from your grandmothers when they were alive, or did, would they be proud of you that you are paving the way towards improved self-awareness and care? What would that be like in your family?

[00:19:39] Nedra: I think I'm an evolution of myself. When I see video footage or hear stories about me as a kid, I've always been outspoken. I am the youngest grandchild, so I got a lot of passes, the almost get in trouble type person like, you're gonna get in trouble. But I never quite got in trouble because I was little.

[00:20:02] It was like, “okay, whatever grandma, you'll forget.” Right? I see. You know, videos of myself and I'm like, wow. I said that. You know, I remember as a kid often being told, you can't say that to your mom, or, why are you talking like that? Your mouth is smart. But I would just challenge things. I would ask questions if I knew something was maybe wrong. If my mother said, you know, you have to eat liver, it's healthy for you. And I'm like, why? It's so nasty. How is it healthy? So like what part of the vegetable is a liver?

[00:20:38] Lucy: So you were always a curious and sort of self advocating person, like you didn't just take things for what they were. It sounds like you always wanted to know why.

[00:20:49] Nedra: Yeah, I've always been curious why, what is this? How and in some relationships, not all, there are some where I've just like, be quiet, you're gonna get in trouble. But in some relationships it was certainly allowed and I'm very grateful for that, that I was allowed to, you know, have some very early boundaries and I would even set boundaries with myself to test out my discipline, I would test my discipline. I remember I stopped eating red meat in high school because I just wanted to see if I could do it. I'm just going to do it. Like, I just wanna see if I can, and I did. I just wanted to see how courageous can I be for myself?

[00:21:35] Lucy: Nedra, when you're counseling a patient about erecting healthy boundaries with family, for example, and the relationship is challenging and you're trying to give them some space and distance from their family without cutting them off. How high does that boundary need to be? I think about Hurricane Katrina. It can rain and storm and the levees can hold, but at some point the levees break. And so maybe what you're trying to do is build the levees a little higher, a little more robust, so that it can still rain and storm, but the person doesn't fall apart, the levees don't break. How do you know how high to build that moat? And how do you know when it's time to really kind of cut off a relationship? What is the appropriate height of the wall that you're building to protect yourself and still have a relationship with other people?

[00:22:34] Nedra: That's always a tough question because I think it's really based on the person. Everybody's wall is built at different levels, and there are some relationships that no matter how hard they are, some of us will not end them. So it's really about the least amount of impact. It is not about letting the relationship go.

[00:23:00] What I deem as intolerable for me may not be intolerable for you. It could be some… that's just the way that person is. Okay, well if that's how they are, how do you deal with it? If you have a family member who's always commenting on your weight, how do you just live with them, commenting on your weight and they just won't stop it, and you wanna keep this relationship with them? Sometimes those are choices that we make, but we have to recognize it is a choice. We are in this relationship because we want to be in it. I want to be in this relationship with this person, even though I don't want this, other behavior from them. I want to be in this relationship. It's important to me.

[00:23:42] Dr. McBride: Yeah, I think what you're talking about, if I may, is sort of. at the entire picture of the relationship and then accepting the parts you're willing to accept. You're right. I mean, some people would leave a spouse who is a substance abuser. That's just the line in the sand for them. Maybe they've given their spouse or partner three tries, and fourth time you're out.

[00:24:08] Other people would've left a long time ago. Other people would stay with them, even if they're actively substance using. And I think it's our job not to judge or to tell people what boundaries they should have, but rather to decide what you're willing to accept and make peace with it. And then lean into the parts of the relationship that maybe are good and joyful and where you feel like you have your needs met.

[00:24:35] I don't know, because I think when is it time to just cut someone off? When is it time to just think about maybe you have accepted things that you shouldn't have had to accept. I mean, I guess this is why you have a job, Nedra, is to go through these things with a fine tooth comb with patients.

[00:24:50] But I just think it's so important to not be black or white about relationships. I think, as you have said, life and relationships live in that gray area and we are always evolving. We are always changing, and hopefully we are always evolving for the better. I wonder what the hardest thing that someone brings to you? Is it abuse? Is it neglect? What are the hardest cases you see in your current practice?

[00:25:19] Nedra: I think many of them are hard when there's a person on the receiving end of suffering. I'd hate to say that. Well, abuse is worse than neglect…

[00:25:29] Dr. McBride: right. There's no suffering. Olympics, right?

[00:25:32] Nedra: Yes. I don't wanna weigh the two. I think that. You know, for the receiving person, not having a healthy relationship with their mother who might be, you know, in competition with them is the worst thing in their life.

[00:25:49] And that's, maybe some people will say, well, that's not as bad as being cheated on by your husband, or, I don't know… I think bad is relative. I don't wanna see anybody suffer with anything. Not a paper cut, not abuse or neglect. It's just like all the things are hurt.

[00:26:12] I don't want to weigh those things. I do want to think about how it's impacting you because what might cause another person to feel anxious is not all going to be the same. It's not, we don't have all the same anxieties or the same things that make us depressed. Everything is different in its own way, and I feel as if my job is to leave room for that and to allow people to have their own experience with their levels of dysfunction.

[00:26:45] Dr. McBride: I think that's so true not to rate our suffering and not to judge it. And I wonder what you find are the hardest or sort of the most common barriers to people building appropriate boundaries. What are the things that hold people back? Is it fear? Is it, they just haven't practiced it? Is it that this is a new concept culturally for them? What are those sticky points?

[00:27:11] Nedra: It's new and we want people to like us. If we do this thing, they may not like it. They may be disappointed. What will they do if we don't do it? If they asked us to do it, maybe we're the only person that they've asked. And so if I don't do it, who will do it for them? You know, all of these thoughts run through our heads and we don't have proof that anything is true. We just say, oh my gosh, it must be true because I'm thinking it when, you know, thinking is not the proof. Thinking is just the process. It's not the proof.

[00:27:41] Dr. McBride: You said it. I commonly talk to patients about fact checking their narrative. I completely believe that our stories live in our bodies. As you were talking about in the beginning, that when you had this experience of being in front of someone who was challenging for you, you had this panic attack.

[00:27:58] Similarly, we can have these stories that live in our bodies that aren't rooted in reality. Like the story that you are the only one who can make your parents happy or meet their needs, that you are the only person who can come to the rescue, and that if you don't do that, that they're going to not love you or not be able to be healthy. Is there a time in your life when your dad, for example, needed you and you said, “sorry, I can't do it. I could do it next week,” and then everything fell apart? Or did he call the next person? So, I think it's important that we are honest with ourselves about these stories that we bring with us through life that sometimes are actually not true.

[00:28:41] Nedra: Yeah, sometimes our stories aren't true and we've just been telling them for so long that we have started to believe them and we have this vivid recollection of this one thing happening. And we think it's. The way, and it will always be the way, but a way to really challenge the story is not to only fact check, but to talk to other people about it and see what they remember about the situation.

[00:29:05] Nedra: We are not always trusted storytellers because we're telling things from our perspective. There was this show that came on a few years ago called The Affair, and they would tell it from three sides. And it was always interesting because one person would think that they said things in this way and it was like, nope, it was said in this way.

[00:29:27] And it was just like, oh my gosh. To think that that is how life is playing out. Even someone will say to me, “why did you say that like that?” I'm like, “say it like what? I think I just said no thank you.” And they're like, “no, you said NO, thank you.” I'm like, “did I? Oh my gosh. That's not how I said it in my head, I didn't think it came out that way,?” but you know what we perceive to be happening all the time, it might not be accurate. I think the better judge of what's happening is what's happening with this person and other people. I think that's a better judge. Like if there's a person who you find to be problematic. Do other people find them to be problematic? Are they able to have healthy relationships with other people? If so, you know, you may wanna look inward and say, what? What is going on in our relationship where it's just me?

[00:30:21] Dr. McBride: I think that's true. A little humility. I had a patient many years ago who told me that she had moved house four or five times in the past eight years because of the neighbors. The neighbors here were doing this, the neighbors over here were doing this, the neighbors over here were doing this, and I thought, I wonder if it's the neighbors. Do you know what I mean? I mean, I think we need to look inward and think maybe I am responsible for some of this conflict or some of this drama. And as you said earlier, Nedra, I think that is one of the hardest things to do, is to consider ourselves flawed and to be honest about the things that we have done that potentially harm other people.

[00:30:59] Dr. McBride: And I also think it's true that we all have a story that we carry with us and then families have stories, and for some of us, as you've talked about, you know, a lot, our family of origin is a solid foundation that feeds our confidence and helps us navigate life challenges. For some others, the family of origin is a source of pain, hurt, and conflict.

[00:31:27] And I wonder if you could comment on sort of generational trauma and what that looks like and how you might counsel a patient to be sort of a cycle breaker. I don't wanna use that word too much because it feels so kind of trendy, but it fits right. It's a cycle of—I don't know how you describe it—but I would describe generational trauma as sort of a cycle of sort of hyper vigilance, a trying, a vigilance about protecting ourselves from pain that accidentally backfires. Mental health-wise, behavioral health-wise, relationship-wise, and then we learn those behaviors from our parents and then we pass it down to our kids. I wonder how you think about generational trauma, particularly in this country, particularly around race, and then how you counsel patients to be a cycle breaker, to have the courage to not carry that with them in their own body and then in their own family.

[00:32:27] Nedra: With people who are cycle breakers, I find that the most challenging thing is for them to find community because they often look for that community within the cycle. So it's like, oh my gosh, like, you know, this pattern exists in my family, but I'll go to my family where everybody has this, this pattern and say, “why aren't you guys accepting me? I'm breaking it.” And it's like they're still in the cycle. So some of the community and the support you need around this is going to be from your chosen family is going to be from you know, friends, coworkers, community support. therapy, all of these other spaces and maybe a few people in your family, but it may not be everyone.

[00:33:08] So the biggest thing with cycle breakers is helping them find community and not trying to be the therapists and their family. Often when you are the person who's made some of these shifts, it's very hard not to want the other people to come with you. It is—most of us will make it our new job to make everybody else as well as us. You know, I read Set Boundaries, Find Peace. You must read it and process everything in the same way that I do. But you'll, you'll be surprised how many people read a book and they still see things differently. They're thinking about boundaries at work. When you're thinking about boundaries with them. They're like, “wait a minute, this was about me?”

[00:33:53] We get things in different ways because we're getting what we uniquely need, and it may not be what you think I need or what cycle you think I need to break. I may break a cycle that you didn't even know I had. So it's really interesting with cycle breakers that you take really good care of yourself and you allow people to maybe access the information if they want it, but you don't make yourself accountable for their healing.

[00:34:23] Dr. McBride: I think that's so well said, and I think it's common also to see people who are cycle breakers be triggering to people in the system in which they came. In other words, the healthiest, emotionally healthiest person, the person who has erected the most appropriate boundaries or has done the most work, which again, doesn't make them morally superior, can be thought of as a threat to a system that hasn't caught up. And I think that is something that we have to acknowledge can be a thing that holds the person back from actually breaking the cycle.

[00:34:58] Nedra: Absolutely.

[00:34:59] Dr. McBride: It’s so easy to be, as you know, it's so easy to be angry, afraid, ashamed, and to perpetuate a narrative that we are not enough, that we are not worthy. It's like, why is that so easy? It's harder to say No, I'm, I wish I could, I can't, you know, sorry. With a full period, you know, we all do that. Sorry. But you know, I just really was upset about it and I really just, I didn't mean it, but you know, the, sorry, with a million explanations after it or the, I wanna talk to you about something, and it's gonna be just a few minutes and it might be kind of awkward, but let's talk about it anyway, just to be direct, be clear.

[00:35:37] And be warm and firm in the same space. I think that is not something we're born to know how to do. I just don't. I think we are, you know, we teach our kids how to read and write and we prep them for college and we worry about them driving and in relationships and we haven't taught them about healthy boundaries. And this is why your work is so important Nedra, I just think you have like, Captured this moment in such a beautiful way. And I don't mean that in a hyperbolic, I'm fawning on you because I want to be on your podcast, which I do. I'm just being honest because I just think that we need to reconceptualize health as more than the absence of disease.

[00:36:15] It has to be about these kinds of concepts, which isn't selfish, it's not egocentric, it is simply to name our humanity. And I think it's just a wonderful thing you're doing.

[00:36:29] Nedra: I think it's a wonderful thing that you're doing, having people look at health in this broader sense, and not just coming in for sick visits, but also maintaining some level of wellness and of total being.

[00:36:42] Dr. McBride: I thank you for that. My patients know that I'm interested in mental health, such that one of my sweet patients whose dad had died the year before. And we had talked through her grief and she was doing some therapy. She was in college at the time. She came in for her annual checkup a year later, and she was wearing this necklace that had a little carrot on it.

[00:37:01] And she said, what is the carrot about? And she looks at me and she goes, Dr. McBride, it's just a carrot. Like she just didn't, it didn't have any sort of meaning or metaphor. I'm gonna let you go Nedra, but I just wanna close with your great quote. End the struggle. Speak up for what you need and experience the freedom of being truly yourself.

[00:37:27] Nedra Glover Tawwab, thank you for your work. Thank you for your honesty. Thank you for your clarity in speaking directly to audiences, and thank you for being you.

[00:37:40] Nedra: You're welcome. Thank you very much. Have a great day.

[00:37:43] Dr. McBride: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line@infolucymcbride.com.

[00:38:05] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician beyond. The prescription is produced at Podville Media in Washington, DC.

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Pain is an inevitable part of life. But did you know that pain is not just about body parts?

Dr. Rachel Zoffness is an Assistant Clinical Professor at UCSF and leading global pain expert who is revolutionizing the way we conceptualize pain. She explains that hurt (pain) and harm (damage) are not the same—and that pain is never purely biological. Similarly, treating pain is never just about pills. It’s about addressing the social-emotional context around it.

On this episode, Dr. Zoffness sits down with Dr. McBride to discuss how thoughts and feelings inform the experience of pain. And how treating pain must include treating the brain.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, review — and enjoy — the show!

Transcript of the podcast is here!

[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.

[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at

and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go Beyond the Prescription.

[00:01:02] I'm delighted to welcome to the podcast my friend Rachel Zoffness. Dr. Zoffness is a PhD, pain psychologist, assistant clinical professor at UCSF, and an author of a new book called The Pain Management Workbook. She believes like I do, that our bodies and minds are inseparable and that we need to think about pain in a much more nuanced way.

[00:01:25] In other words, when I was trained in medical school, we thought pain was about the body part and that pills were the solution. When actually, as doctors, we describe pain as a biopsychosocial phenomenon. Rachel, I am so happy you're here today. Thank you for joining me.

[00:01:42] Dr. Zoffness: Thank you for inviting me on, Dr. McBride.

[00:01:45] Dr. McBride: What I love about you is that we agree that mental and physical health are inseparable. When I was training in medical school in the 1990s and early 2000s, we were taught that pain was about the body part itself, and that we used medicines to treat pain. We used Tylenol, Advil, opiates, and we were taught to get ahead of the pain and to get people more opiates than we thought they might need because it was cruel to deprive people of pain meds, which of course it is in many ways.

[00:02:16] But we now know just how addicting these medications are, and we also know that pain is about more than the limb that is hurting. So could you describe for me how you talk about pain, this bio psychosocial model? Because it's a big word and I'd love to break it down.

[00:02:34] Dr. Zoffness: Yeah, it's sort of frustrating for people who have been living with pain and also for healthcare providers who treat pain because medicine, as you know, has been rooted in this antiquated, dinosaur era biomedical model, which teaches people that everything to do with pain is just anatomy and physiology.

[00:02:54] But neuroscience has known for many decades that that's not actually true when it comes to pain. And one of the reasons we know this is because of this syndrome called phantom limb pain. And phantom limb pain is when someone loses a limb and arm or a leg, and they continue to have terrible pain in the missing body part.

[00:03:14] Now, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain does not just live in your leg, and it does not just live in your back. And what science says is that, of course the body is involved in pain production, but ultimately pain is constructed by the brain.

[00:03:38] And the reason that's so profound, at least for me as someone who treats pain and has lived with pain as many of us have, and all of us will because everybody, everybody is gonna have pain at some point, is that there's lots of parts of the central nervous system that process pain. It's not just there's one pain center, and that's how that goes.

[00:03:56] There's lots of parts of the brain that contribute to the pain experience including the brain's emotion centers contribute to the pain experience, and what that means is how you're feeling emotionally in any given moment, whether you're stressed or anxious or depressed affects intimately the pain that you feel.

[00:04:15] So we know from neuroscience that pain messages are amplified during periods of anxiety or during a global pandemic. That's not gonna surprise anybody, and we all know this. We all know that our bodies feel worse during times of duress. So it's really not that shocking. And we also know that, say if you stub your toe at work on the day you get fired, that exact injury feels completely different than if you stub your toe on a day at the beach when you're hanging out with your friends in the sun. So context matters, emotions matter, thoughts matter. Everything matters to the brain when it's deciding whether or not to make pain and how much, and that's always true.

[00:04:54] Dr. McBride That's a great example and the phantom limb pain is, is, I'd love to talk more about the phantom limb pain because I mean there couldn't be a better example of the construct that pain is—not to say it's not real— it's to say that it's more than just about the limb. So take that example for a second. How do you treat someone who has phantom limb pain? If it's not about the limb?

[00:05:18] Dr. Zoffness: So there is this frustrating thing that happens in medicine where people with chronic pain are often told it's all in their head. Especially if there's no known etiology for the pain. If you've had a lot of scans and tests and you know, people just aren't sure, the doctors are like, we don't know.

[00:05:31] We can't find a thing. So people get told often that pain is all in their head, and that is not what I'm saying. So I want to be very clear. Pain is never all in your head. If you have pain, your pain is real. The important thing to know about pain is that it's the brain in conjunction with the body always working together.

[00:05:47] The interesting thing about phantom limb pain, again, we've said you can have pain in a leg that's no longer attached to your body. And we've said that's because your brain is implicated in the processing of pain in your brain. You have what's called homunculus, and a homunculus is literally a map of your entire body that lives in your brain.

[00:06:06] So if I said to you, Lucy, without doing anything or moving, sense into your foot, can you feel your foot on the ground? Notice if your foot is warm or cold. Can you feel if your foot is moving or… you can do that. And the reason you can do that is because you have a map of your whole body that lives in your brain, your homunculus.

[00:06:23] So sometimes if you lose a limb, you've lost the limb, but you haven't lost the leg part in your brain map. So with mirror therapy, what we do is. We hold a mirror up to people who have phantom limb pain and they go through a series of activities and structured exercises to help the brain become unconfused and realize that pain, which is your body's danger detection system, doesn't need to send you any more danger or warning systems because the damage has already occurred and there's no warning signals that need to continue. So that's one of the treatments for phantom pain.

[00:06:58] Dr. McBride: It's such a great example and I love the way you described it because I think for a lot of people, doctors included, we have a hard time wrapping our arms around this concept of suffering you can't measure or you can't see it, but everybody who's listening right now can think about their toe or their foot and know that you're directing your attention to it, and there's a reason for it's in our brain. So that is great. That's a beautiful way of opening this conversation about pain being more than just physiological.

[00:07:31] Dr. Zoffness: Exactly right.

[00:07:32] Dr. McBride: Talk to me about—breakdown biopsychosocial, because when someone hears pain is biopsychosocial they may think, oh wow, it's more complicated than I thought, but they don't necessarily know what that means. So what is it?

[00:07:45] Dr. Zoffness: Right. So I happen to really love big words, and this big word in particular has helped me make sense of a lot of different things, not just pain, because it turns out anxiety is biopsychosocial, and depression is biopsychosocial and diabetes. So I'm going say what this word means. So biopsychosocial, what we know now about pain, is that it is never a purely biological thing. It's never just to do with your bad knee or your aching back. Never. It is more complicated than that. Of course it is. And so with this word, biopsychosocial means, and we know that that's what pain is. It means that there, of course, are biological components or triggers for pain contributors

[00:08:25] So the bio components of pain are genetics and tissue damage and system dysfunction and inflammation, and things like diet and sleep and exercise. Those all are biological contributors to pain. They're very, very, very important. However, what we know about pain is that there's other things that contribute to your experience too, and they're just as important.

[00:08:48] It's not that they're less important. So in the psych, we have bio, we have psych, and we have social or sociological. And the psych domain of pain has so much stigma around that. And I am a pain psychologist, and let me just tell you all day long, all I do is try and explode the stigma around these quote unquote psychological contributors to pain.

[00:09:08] So I want to very clearly say, When you say that pain has psychological components, that's not, again, that it's all in your head. What it means is neuroscience shows that emotions intimately affect the pain we feel, and that negative emotions are going to amplify pain volume and positive emotions and feelings of calm and relaxation are going lower pain volume, turn pain volume down so that lives in that psych bubble.

[00:09:35] Also, in that psych bubble, we know that thoughts and beliefs intimately change the pain we feel. This is supported by many decades of science, for example. We've all heard of the placebo effect. The placebo effect means, Lucy, I'm gonna give you a sugar pill. I'm going to tell you as a pain doctor that this is gonna lower your pain volume, and low and behold, you actually feel better.

[00:09:59] That happens a lot of the time, and the reason that happens is not that the placebo pill is nothing, rather the placebo means you change your beliefs and your brain understands that these danger messages are not needed anymore. So your pain volume is lowered. Beliefs and thoughts change the pain you feel.

[00:10:19] That doesn't mean you can think your way out of pain. It's more complicated than that. But thoughts and beliefs matter. We also have in this bubble coping behaviors. What do I mean by that? People with pain often, understandably believe that they need to stay home, stay inside, not move, not go outside, stop going to work, stop their activities, stop moving.

[00:10:40] Reasonable. However, what science shows is that that ultimately is also going to amplify pain volume and that to treat chronic pain, we have to get out of bed and back to life very slowly and in a structured way, and I'm not telling people to go outside and do things, but behaviors, how we act, how we handle our pain also changes the pain experience.

[00:11:01] Then I said, we have this third domain of pain. It's the social or the sociological domain of pain and what science says is that social factors matter all the time. When it comes to pain and health, humans are social animals. We know that the worst punishment you can give a human being is not Thanksgiving traffic, and it's not your in-laws, it's actually solitary confinement. And what happens when we are lonely and isolated and alone, which happened during the pandemic to a lot of people, our brain amplifies pain volume because a lot of brain chemicals change. So in the presence of others, our brains produce all these chemicals that literally make us feel good.

[00:11:42] Dopamine, serotonin, oxytocin, and endorphins. Endorphins are our brains’ natural painkillers. They are our endogenous opioids. So in the presence of other people, brains produce painkillers. There's other sociological factors that matter also. It's community, it's context, it's environment, it's even race and race and ethnicity, and even racism.

[00:12:07] It's poverty and it's access to care, it's trauma. There's so many, so many things that live in this sociological domain, so, All of it together contributes to the thing, this experience that we call pain. And what's happened in medicine is that we’ve distilled it down to just the biological, the bio bubble. And what that means is that what we've been doing in medicine is missing two thirds of the pain problem. And part of the reason I do things like this and come on podcasts, is to try and change the way we're thinking about pain so that we can change the way we treat pain.

[00:12:41] Dr. McBride: It is so important, Rachel, because as you just said, we have reduced the patient to a set of lab tests, a set of complaints, and because doctors don't have time and they aren't trained—we are not trained in pain management like we should be—People who are in chronic pain are often thought to be nuisances, thought to be malingering or thought to be making it up, because we don't have sophisticated ways of treating pain and because it takes time to access the 360 degree version of the person we prescribe pills. Now, I love Advil for a headache. I love Tylenol when I have a fever. But I think what you're saying is that we need to look at the whole person. We need to look at their emotional health, their mental health, their physical health, their story, and address the various complex parts of this person because they're integrated and they show up in pain.

[00:13:40] Dr. Zoffness: That's exactly right.

[00:13:41] Dr. McBride: Can you give me an example, Rachel, of a patient who had intractable pain, who was treated inappropriately by the medical establishment and then got better with this model.

[00:13:52] Dr. Zoffness: It's really interesting. I'm in private practice and I see people with chronic pain and I happen to love working with teenagers in particular. They're sort of forgotten in medicine, especially in the world of pain. We have pediatric pain and we have a lot of adult pain and older adult pain work. It's not being done right in my humble opinion. But we do have a lot of attention and money being thrown at it. And then we have teenagers who are sort of in this messy middle, like they're not quite children, they're not quite adults, but meanwhile, all they want is an adult who will talk to them as if they're an adult.

[00:14:21] They want that sort of respect. They don't wanna be talked down to like a child anymore. And teenage pain is very confusing for a lot of doctors, in part because they fall into this messy middle category and people aren't sure, do we involve parents, do we not? So one of the patients I was thinking of who came through my program was a 16 year old who had been diagnosed with chronic daily migraine that was so debilitating that he couldn't get out of bed. He also had been diagnosed with abdominal migraine, so chronic stomach aches, stomach pain, and he also had diffuse, amplified body pain of no known etiology. So no one really knew where it was coming from or what was going on.

[00:15:00] And when I met him, He had been in bed for about four years and had missed four years of school. And when he showed up in my office, I want to describe him to you because I will never forget this as long as I live. He came into my office, he had long unwashed hair and he was pasty and pale, and he was heavy because he hadn't been moving his body and hadn't been exercising, had truly been bedridden.

[00:15:25] And he started rocking himself back and forth on my couch with the pain. And I remember thinking like, he's been through Stanford, he's been through UCSF. Who am I to do that? I almost called his neurologist to say I can't do it. Thank God I didn't. But it's just funny. I think as healthcare providers, we all have a little bit of this imposter syndrome—can I do it? And so when I take a history, I don't just ask about the pain and when it started, I want to know everything. Because as we all know now, there's always a pain recipe. There's always bio ingredients and there's always emotional ingredients. There's always contextual and environmental ingredients.

[00:16:03] There's family ingredients, there's trauma. There's coping behaviors—all of that is baked into a pain recipe. So I asked him about his emotional health. He had been paralyzed with social anxiety for most of his life, untreated. He was depressed. He was suicidal, which is not that surprising actually, when you're 16, you have no life, You've been in bed for four years. He had been on 40 medications. He had seen 14 specialists and experts. It's understandable to me that a 16 year old might feel hopeless and helpless and in fact, that's true of a lot of patients who come to me. I am the last stop on the train. Nobody wants to see a psychologist for pain.

[00:16:42] Nobody, and I understand why I also would not want to. So, I realized pretty quickly that there were a lot of parts of his pain recipe that were not being treated. So when we started the program, we did get his parents involved for a number of different reasons, and one of those reasons was that he needed support doing some things to help his social anxiety go down, help his mood improve and help us pain improve, because all of those things are intimately connected all of the time.

[00:17:10] My mantra is that the brain and body are connected 100% of the time. They're never not. Ever. So of course your emotional health affects your physical health. So one of the things we needed him to do in order to help his pain and his mood was start moving his body. And you can't ask someone who's been in intractable pain for four years to go outside and hang out with friends.

[00:17:30] That's not how that goes. So week one, he went out onto his porch and stood in the sun for 10 minutes a day, every day for a week. Week two, he walked the corner mailbox and his mom would give him mail to put in the mailbox. Week three he would walk around the block and he would stop at the corner store and order tea or coffee or whatever, just to have human interaction. And by the way, this was paralyzingly difficult for him and part of our pacing plan, because that's what this was and I'm happy to explain what that is. You go slowly to increase activity, whether it's social activity or physical activity. It was really hard for him. And he would have pain flares. Absolutely.

[00:18:11] And we built that into the treatment strategy. So he would take breaks, as many as he needed. He could take the whole day to get the walk around the block and the stopping for coffee done. Week four, he walked his dog to the dog park and had a conversation with someone. Week five, he mixed in a little bit of jogging and texted a few friends. So as you can see, there was a gradual increase in activity, both social and physical. It was targeting his anxiety, it was targeting his depression. We know that behavioral activation is very critical for depression. We know that social exposure is very critical for treating social anxiety and slowly, slowly, slowly, his mood improved.

[00:18:49] Anxiety started receding, pain volumes started going down. At some point, his neurologist called me and said, “What magic purple pill are you giving this kid?” And I sort of had to say—suppressing my frustration—yeah, that's the whole point. It's not a magic purple pill. And he gradually got back to school and he rejoined his soccer team and he started playing soccer again and his pain went away and he went off to college and became captain of his swim team or whatever. And listen, just to say, this is a kid who's still, he's an adult now who still has migraine, but his migraines do not debilitate him and they will never again dominate his life. And he will never again be in bed for four years because now he knows he has to look at his whole pain recipe. He can't just take medications forever. And I am not. Saying that medications are not helpful, thank God for medications. What I am saying is that it's a bigger picture and humans are more than just a body part.

[00:19:50] Dr. McBride: Amen. Hallelujah. I mean, this applies to really any suffering I think that you cannot measure in a blood test whether it's depression, anxiety, PTSD, chronic fatigue. Patients who don't fit in the mold or, or who don't have a diagnosis that we can see on paper get so easily dismissed by the medical establishment and also get, there's self-stigma, right? When people don't have a, when there's nothing you can hang your hat on from a lab abnormality, it can eat away at your sense of self. And then what's worse is when doctors are not counting your story and you don't then have access to your whole interior world, which is of course essential to how we function in the world every single day.

[00:20:44] And you're right—there's no partition between head and body. It's not like there's a neck down kind of version of humankind. What is your advice to people who are listening who have chronic pain, say from hip injury, a herniated disc, migraines who are thinking to themselves, Huh? I have some imitrex for my migraines. I have some Advil for my back pain. I know how to stretch and move. My life is stressful, but I'm managing it. What else should I be doing?

[00:21:17] Dr. Zoffness: So I'm one of these people who believes that appropriate pain care should be affordable and accessible to everybody. So I published a book during the pandemic called the Pain Management Workbook, and in there is everything to do with pain science. Very digestible. It's like neuroscience that anyone can read, and it also has a ton of strategies in there.

[00:21:39] And I think the most important thing, if you're living with pain or if you treat pain and you're not sure what to do next, is to figure out how to put together a pain recipe. And that's in the book, the Pain Management Workbook. And I'm gonna say what that is and what it means. Every single person has a pain recipe, everyone. So for me, my pain recipe, for example, is sitting for too many hours without getting up and moving, not exercising, eating poorly, not taking care of my body, poor sleep, fights with my family or my partner or whatever. A lot of stress at work. I know that if it's a high stress day, I probably will not have a good pain day.

[00:22:22] And also my level, managing my level of stress and anxiety, so whether I'm actually actively incorporating self-care, like am I going for walks? Am I going outside in the sun? Am I making sure that I'm scheduling time to be in nature or go to pleasurable activities? So that's my pain recipe.

[00:22:42] And as you can see in that pain recipe, there are bio components, there are cognitive and emotional and behavioral components, and there's social components always. And so when you put together a pain recipe, the cool thing about it is, there's always a high pain recipe. Like I like to ask people like, you know, do you like to cook or bake?

[00:23:00] Because I do not. But as you know, if you like to cook or bake, there's always a recipe that will get you to the end point that you're seeking. And the same is true for pain. Like just as there's a recipe for brownies, there's a recipe for pain. And so I just gave you my high pain recipe. The cool thing about a high pain recipe is that a low pain recipe is the exact opposite. A little bit more nuanced than that, but there's always this high pain recipe, low pain recipe sort of thing. So for me, sitting for too many hours without taking a break is part of my high pain recipe, and the reason that's great valuable information is because I know that to manage my pain, I need to set my alarm every hour and go for a walk outside, even if it's literally two minutes, five minutes, or my next phone call, I take it on a walk around the block, whatever.

[00:23:49] Whatever I have to do to structure in these things that I need to get to a low paying recipe. That's what I do like scheduling pleasurable activities and walks in nature on the weekend and making sure to see friends and making sure to put boundaries around toxic relationships and not spend time with certain people, because guess what? You're allowed to do that. So whatever ingredients are in your high pain recipe, figuring out that recipe is the way to lower pain volume. So that's one of the strategies in the pain management book.

[00:24:16] Dr. McBride: I love it. I think at the root there, Rachel is, is a self-awareness. Giving ourselves permission to look inside and to think about, as I say, our stories and how they live in our bodies. To take time to look at the narratives inside, some of which are rooted in fact, and some of which are not rooted in reality.

[00:24:34] For example, the patient who says, I've been in bed for four years. I am a broken person. I'm an identified patient in the family, I'm a problem. You know, if you, if you organize your thoughts, feelings, and behaviors around a narrative isn't fully fact-based, then that's only gonna exacerbate the very problems you have.

[00:24:56] So, making sure, obviously someone who is suffering is entitled to feel like they are a patient or a challenge. But if we can look inside and access our stories and then ideally rewrite some of those narratives like I can and I will and I'm able, I mean the agency there. I think a little bit of what you're talking about is sort of making your own recipe, making your own kit so you don't feel so helpless and a victim of yourself.

[00:25:28] Dr. Zoffness: And I think that goes back to this thing where there's cognitive components to pain and beliefs matter a lot. This particular patient I was talking about believed that there was no hope for him and understandably so. And the first thing I told him when he came to my office was that I was going to help him. And of course, I didn't know that for sure, but I knew for sure that he needed to believe that. So I said, I can help you and, and I knew that he needed to believe in me for any of this to even work.

[00:25:53] Dr. McBride: The other thing is the trust you're describing. I mean, for me to help someone—I'm sure it's the same for you as a clinician—to help someone who has an intractable problem, whether it's obesity or PTSD, heart disease, to feel like they have hope and possibility. They have to really, really trust the messenger and the guide because if you feel hopeless, if you feel like there's nothing out there for me and you've been treated like a bag of organs and not a person, that alone is a barrier to care. And so just aligning with the patient and leading with empathy and curiosity in my mind opens the door to that partnership, which sounds almost corny and hokey, but there's an incredible therapeutic benefit to the patient when you can align… And it's like, believe the patient, they are not making this up.

[00:26:49] No one wants to make up a story of, I'm in so much pain, or I have experienced something that is unique to me, no one's ever experienced and I'm alone. No one wants to feel that way. And so just giving people permission to be human and then by a doctor or PhD, Rachel's Zoffness, that's a meaningful intervention.

[00:27:10] Dr. Zoffness: Yeah. I was also thinking about what you were saying before about how, and it's so true, how chronic pain patients are such a challenging population for doctors to treat, and there's a bunch of papers actually that have come out on this that show that one of the reasons for this is that there's a lack of pain education in medical school, and there's this crazy statistic that sort of blows my mind, which is that 96% of medical schools in the United States and Canada have zero dedicated compulsory pain education. And all these subsequent papers that came out where physicians were interviewed, like, how comfortable do you feel treating pain? And it's what you were saying before, there's this lack of comfort, understandably.

[00:27:47] How are physicians supposed to feel, or any of us as clinicians supposed to feel comfortable treating a thing that we haven't truly been taught about in part because it's not really well understood. It happens to be well understood, but it's not really, the education is so poor. Like as a patient. Do you ever get taught about pain if it's not really being taught in medical school, it's not being taught to, to the lay public. So how do we treat a thing unless we really understand it?

[00:28:14] Dr. McBride: Exactly, and then doctors don't have time. It's not the doctor's fault, it's the system's fault. We don't have time to elicit the whole story and the whole landscape of that person's interior world, and then we have to know what to do with it. And that takes time. And that's just not what modern medicine is designed to do right now.

[00:28:32] Dr. Zoffness: No it's not. It's a profit driven healthcare system.

[00:28:34] Dr. McBride: It's awful. What do you see as the relationship between chronic pain and addiction?

[00:28:41] Dr. Zoffness: So it's interesting. I started teaching at Stanford a couple of years ago and I'm teaching the Addiction Medicine Fellows, and I remember when I first went down this rabbit hole in pain science, realizing that addiction, medicine and chronic pain have started to become synonymous, and I am a nerd, and the way I make sense of the world is by reading everything.

[00:29:05] So I started reading every single paper I could find. Here's a heartbreaking statistic. 80% of people in America who have become addicted to heroin started out as pain patients. There's this disconnect, I think until recently that we, and there's also a lot of blame, like people with addiction are blamed for their addiction. But 80% started out as pain patients. That means they went to their doctor, this person they trusted and they were like, help me. I have pain. And the doctor, totally, understandably because doctors were lied to for forever [and told that this] medicine is the thing you need to give. It's the treatment for pain. They gave this medication that hijacks the brain and hijacks your central nervous system.

[00:29:46] Dr. McBride: You're talking about narcotics and opiates.

[00:29:49] Dr. Zoffness: Correct, oh, did I not say that? Sorry. Yeah.

[00:29:51] Dr. McBride: No, but that's, I just wanted to tell you because I mean, that's what we were taught in medical school.

[00:29:54] Dr. Zoffness:Yeah. Oh, no, no, absolutely.

[00:29:56] Dr. McBride: That's what we were taught. Get ahead of the pain opiates, Oxy five, 10 milligrams Q4 to six hours, more than you think they need.

[00:30:04] Dr. Zoffness: Right, of course. And, and that's because there was great marketing. Everyone who has seen dope sick knows this now. Yeah. And there's a book called Drug Dealer MD by Anna Lemke that all of this has just been really blown open over the last couple of years. And of course now pharma is paying a 26 billion payout in reparations, but in my mind, that is absolutely not enough.

[00:30:28] The number of lives lost and the way that pain medicine has been completely hijacked is pretty gnarly. And I also want to be clear to say I am not anti-opioid. Thank God for opioids post dental surgery. If that's something that your body can tolerate, you don't have a history of addiction, like I am not anti-opioid, But the issue for me is the way we've framed pain as a biomedical problem that requires a purely biomedical solution. And we know that that's not true, and we know that that's actually wrong. And we also have known for a very long time that opioids can be very dangerous for people. So the fact that that's sort of become the de facto treatment, especially for chronic pain, is so heartbreaking.

[00:31:08] Rachel: I treat so many patients who have been in pain for a really long time and now they have two issues. You asked, like with a relationship, there are all these dual diagnosis clinics now around America where the dual diagnoses are chronic pain and opioid addiction. Like what are we doing to people with pain? It's so unacceptable.

[00:31:28] Dr. McBride: It's completely unacceptable. And then when you think about the mental health world and the false dichotomies there—I know you talk about your frustration and anger about the way. People are treated in the current medical industrial complex. My particular cross to bear is the way we talk about mental health, which is as if mental health calmness, serenity, and the ability to be happy when mental health is really the ability to have an appropriate emotional response to the setting and to have agency and tools to manage the inevitable potholes on the road of life.

[00:32:15] And then we talk about the mentally ill, which as if there's some kind of distinctive line in the sand where you go from mentally healthy to one click over, oh, mentally ill broken person, totally healthy person over here. So just like you do with your own patients, when I'm talking to my patients about their emotional health because it's relevant to their physical health, surprise, surprise, I don't say, are you anxious or, are you depressed? I say, okay, given that everyone has anxiety, where are you on the continuum of anxiety and what are you using to manage the anxiety? Where are you on the continuum of mood given that you're located somewhere on the mood continuum? What's your depression recipe? What, I don't say that but what is the thing that, what brings your mood down? And then what brings it up? And if it's recreational drugs, then maybe we should think about an alternative plan. If it's nature and being with your loved ones, maybe we need to lean into that avenue. And if your mood is pulled down by a toxic relationship, maybe we need to put a fence around it. I believe in Prozac. I believe in Zoloft. I believe in psycho-pharmacology. I also believe in treating the person and not just the pathology.

[00:33:34] Dr. Zoffness: So you said it exactly the way I would say it. And I do teach about a depression recipe. And of course there is one. During the pandemic, calls to suicide hotlines went up 8000% in some parts of our country. Now, was everyone mentally ill during the pandemic or was there an external situational trigger that made us all anxious and fearful about our loved ones or whatever?

[00:33:59] However you responded to that thing or made you feel depressed because you couldn't do all the things you wanted to do. You couldn't go to work, you couldn't go to the movies, you couldn't go to restaurants. You couldn't see your grandparents in the hospital. Of course there's a depression recipe. And depression again is biopsychosocial also always, all the time for everyone. It's not just a chemical imbalance. And by the way, a paper came out recently by Joanna Moncrieff showing that, we've all known this for a long time also, but there's no such thing as a chemical imbalance. That is an effing lie. That is a lie. If you look at all the brains of people who are depressed and not depressed, there actually is no evidence to support that people who are depressed have less serotonin than people who are not depressed.

[00:34:40] Actually, that has no evidence and no traction in medicine. So the one issue with that is, if you believe the lie you've been sold by big pharma, that depression is a biological problem that requires a biological solution, All you'll ever do is take a pill, and it's the same as true with pain, but depression is just as bio psychosocial as pain is.

[00:35:02] Dr. McBride: That is exactly right. It is not true that depression or anxiety or PTSD is a result of a chemical imbalance. That is a narrative that has been pushed out for whatever reason. And, and as a result, we end up treating patients with pills and pills alone, not uniformly. I wanna make it clear though, that's not to say that Zoloft Prozac, all these SSRIs cannot and do not help people with depression, anxiety, PTSD, and that they are appropriate for some people in the context of the biopsy psychosocial model. In other words, when that paper came out, which illustrated what we've known for a long time, it just needed to be said again, that chemical imbalance is not accurate. Patients of mine were calling and saying, well, does that mean that I shouldn't be on my Zoloft? Does that mean I shouldn't be on my Prozac?

[00:35:52] Meanwhile, as I say to my patients, Zoloft is one piece of the larger puzzle of your health and wellbeing. If it is helping you tolerate the anxious thoughts and feelings and the cognitive distortions that then allow you to get more out of therapy, that allow you to activate on the recipe for feeling better, then that is an entirely appropriate medication. It doesn't mean you're mentally ill if you take medicines and you're mentally well if you don't take medicines. It's just a piece of the puzzle, just like being in nature and exercising. So I think it's important to be clear that just because it's not true that these phenomena are chemical imbalances, it can still be true that medications can help. This is where the nuance gets lost. Because if you're someone who believes in the middle ground, where biopsychosocial elements intersect, you run the risk of people misunderstanding and thinking that you are anti-medication and that everything in our world is fixable with willpower, thoughts, and behavioral modification when that's not true.

[00:37:04] Dr. Zoffness: Yeah, I think that's why it's so important to say like there's always a bio component to everything. Of course genetics matter and you know, of course neurotransmitters matter. But I think the message, the take home message here is that whether it's depression or anxiety or diabetes or migraine, there's always a recipe of factors that are contributing every single day. And we know that because what I like to say to my patients is like, if you tell me certain times over the course of the day that pain goes up and pain goes down, or if you monitor your pain over the course of the week, you know that there are certain times that pain goes up and pain goes down.

[00:37:37] Rachel: And what that means is that if pain is always changing, Pain can change. If pain can change, then pain can change. And what that means in any given moment or hour of your day or your week, there's different bio psychosocial factors that are contributing to your pain recipe. So times when your pain is low might be you're distracted, you're with friends, you are watching a funny movie and shoving ice cream in your face and during that period of time, those two hours, your pain volume is a little bit lower. Your pain volume might be higher when you're driving to the doctor's office for a procedure that's upcoming and you're feeling really worried and you feel your heart is racing and your body is tight, and of course we know that those are gonna contribute to a higher pain volume. So it's always all the things working together. It's never just one thing.

[00:38:24] Dr. McBride: This morning I was talking to Lisa Damour about anxiety, and I think there's some parallels here with pain. Insofar as some anxiety is helpful and productive. In other words, if we didn't have anxiety, we would walk into traffic. We would not turn in our term paper. We would not veer away from the bus that's coming at us. Anxiety is a problem potentially when it's out of proportion to the actual threat and takes on the life of its own. Pain too has a function. I mean, it's a warning signal. It's telling us that, you know what, you've stepped on a thorn. You have arthritis in your knee, that maybe means it's time for an evaluation of your surrounding muscle structures and maybe you need a new knee. So how do you describe to patients, when pain is okay or enough and when we should tolerate it and when it's not enough? Because a pain-free existence is impossible.

[00:39:20] Dr. Zoffness: Yeah, so I like to always talk about pain as the body's danger detection system. It's our warning system, right? So as you said, you put your hand on a hot stove. If you don't get those danger messages, you'll leave your hand on the. Dove and your skin will melt off. Or you go for a run and you break your ankle and you don't stop running and seek help and rest so your bones can repair, you're screwed. You're going to further damage your body in bones and tissues. So pain is a very important danger message. And I remember when I was an undergrad at Brown, I had this wonderful professor, Mark Bear, who I talk about all the time now because his neuroscience textbook changed my life. And he would talk about how some people are born without the ability to feel pain like this congenital insensitivity, this high threshold.

[00:40:04] And I remember thinking, gosh, that sounds so. Lovely. And then he went on to say, and they don't live very long because again, if you imagine you, you damage your body, but your brain doesn't give you any of these warning messages or these danger messages. You're not gonna live very long. So pain is important and we have to pay attention to pain.

[00:40:23] So acute pain is pain that's three months or less. And acute pain is like the pain of childbirth or like you get a virus and you have muscle pain and then it goes away. Or the pain of a broken bone or torn ligament—that's acute pain. Chronic pain is pain that lasts three months or longer or beyond expected healing time, which is very nebulous and the definitions are just not that great, but pain that lasts beyond expected healing time.

[00:40:52] And we know that there's a difference between these two things. And one of the ways I like to talk about this, when people come to my office, they say, well, I've been in pain for seven years, 10 years, why is my pain chronic? How did this happen? And there's a number of ways by which pain can become chronic.

[00:41:13] But one of the processes that underlies chronic pain is called central sensitization. And what that means is we talked about the location of pain construction and how that happens in our brain and we know that our brains are like the muscles in our body. The more we use certain pathways in our brain, the bigger and stronger those pathways get.

[00:41:34] So for example, for me, I played the piano growing up. I didn't really like to and I didn't really want to, but my mom would say, Rachel, sit down and practice. It's the only way you're gonna get better at it. And over time, of course, she was right. The more I practiced, the bigger and stronger the piano pathway, which isn't a real thing, but the piano pathway in my brain got bigger and stronger with time until I could sit down at the piano and my fingers would just know what to do. Right? Not magic. That's just your brain changing with time and experience and exposure. And there's a word for that, and it's called neuroplasticity.

[00:42:13] Neuroplasticity literally means your brain over the course of your life is always changing, always, even into adulthood. It's morphing every time you have an experience. It's the reason you can learn a new language, even when you're 62. So just as practicing the piano made the piano pathway in my brain big and strong, the same happens when we have pain all day long, over and over for many months and weeks and years. What happens is the more we accidentally practice pain, the bigger and stronger the pain pathway in your brain gets. And I wanna say that carefully because there's no actual pain pathway. There's a lot of different ways that pain is processed by different parts of the brain, but we know that of course circuits in the brain and neural networks get stronger with use in time.

[00:43:03] So pain pathway for the sake of this metaphor, gets bigger and stronger with use. The more and more we use it. And when that happens, we say that your brain has become sensitive to pain. And I think about that word all the time. What does sensitive mean? So if you have a dog, and it's the 4th of July, we know that of course dogs are much more sensitive to sound than we are. So when all the fireworks are going off on July 4th, all the dogs in America are hiding under our beds. We give them thunder shirts or whatever, thunder jackets so that they'll calm down and it's because their brains are very sensitive to sound. And the same is true with our brains when we become sensitive to pain over time.

[00:43:48] Small bits of sensory input from the body to a sensitive brain sound and feel very big. So for example, an example I'd like to use is for my fibromyalgia patients. You go for a picnic with a bunch of friends and you're sitting under a tree in the sun, and we can all agree that that is not dangerous. But your brain might give you very amplified danger messages anyway. So things that are not dangerous can result in a very loud danger alarm. And when, when, when that happens, we know that the brain has become sensitive. And that's a chronic pain process. That's not true of acute pain.

[00:44:26] Acute pain and chronic pain are different processes, and they're both biopsychosocial. There's bio, cognitive, emotional, behavioral, sociological factors that play into both, but it's really important to think about how to desensitize a sensitive brain once pain has become chronic.

[00:44:44] Dr. McBride: Rachel, I think we need you on every corner of America because as you opened with pain is an inevitable part of life. And when we medicalize it and put it in a box and prescribe a pill, we're really depriving people the opportunity to have access to their internal world and then have agency. And I just wonder, how are you're gonna get this message out there even more than you already are. You were on the Ezra Klein show. You've written this phenomenal book. You're talking to me today. You are making a difference every day with your patients, but like I want you to have a megaphone because this is so important. It's so relevant.

[00:45:31] Dr. Zoffness: It's so relevant. I also think about this distinction between like, like you were saying before, it's like pain patients to the left and like providers and everybody else to the right and like. That's not how pain works. Pain is coming for everybody. There's no one that escapes the human experience of pain, whether you had it in childhood or you have an injury now, or you know, pain later in life. So it seems so critically important to me that we all are the holders of the truth. Like I'm just tired. Like you were talking before about, gosh, why were we all sold this big lie that depression is due to a chemical imbalance. The answer is that was a pharma marketing device. That's why that we all, we all got that message cuz it was literally plastered.

[00:46:15] I remember I lived in New York City growing up—I mean I'm a New Yorker born and bred—and there was this huge 20 foot ad on the side of a building and it said depression is not a flaw in character, it's just a flaw in chemistry. And I remember thinking, God, that's so brilliant. It's making you feel like, oh, it's not my fault, it's just my chemistry. So like if your chemistry is broken, of course the only fix is a pill. It's brilliant marketing, and we all have been sold this lie for very many decades about pain, about depression, about anxiety. It is a lie. That's not the solution. The solution is never just a pill ever, ever, never.

[00:46:53] Dr. McBride: Which is ironically not anti-pill.

[00:46:56] Dr. Zoffness: No, I'm not at all anti-pill.

[00:47:01] Dr. McBride: We could talk about big pharma all day long…

[00:47:04] Dr. Zoffness: It's just not the only solution. It's much more complicated. As humans we're just more complicated than that. Right. We're not just chemistry, we're more than that.

[00:47:11] Dr. McBride: To close. I want to ask you about you. You told me a little bit about your pain recipe and what you do to manage discomfort, psychological, biological. What are the sort of biggest insights you've learned from your own patients, who I find my best teachers. What have you learned from your patients about how to care for yourself?

[00:47:34] Dr. Zoffness: Two different answers to that question. The first thing that comes into mind, just what have I learned from my patients has been this, I don't believe necessarily in magic or miracles, but when I see teenagers get out of bed and go back to life, like I told you about this patient that I had who had chronic pain all over his body and chronic migraine and went back to soccer and went back to school. And what I didn't tell you, he got asked to prom when he went back to school, not by one girl, but by two. And watching this kid, he invited me to his graduation and at his high school graduation, he got on stage and said, if you told me four years ago I'd be graduating high school, I never would've believed you.

[00:48:17] And this magic miracle is just science. I don't have a magic wand, it's just disseminating this information about what pain really is and how pain really works. And I see it every day as my patients get out of bed and back to life. And it's it's what galvanizes me to do things like this. I actually am a library mouse and I do not like public speaking, but I can do it here with you because it's just you and me, so it's fine. It galvanizes me to go out into the world and just spread the message. You have to bridge the gap between physical pain and emotional pain if you want to treat pain because it's this lie in Western medicine that either your pain is physical and you see a physician or your pain is emotional and you see a therapist, and that's never how pain works ever. Emotional pain is physical. Anyone with anxiety can tell you how physical. That pain is, you have chest pain and you know there are times your body hurts and your sweat. There's so many physical parts of emotional pain and physical pain is emotional. People with chronic pain have 50% higher rates of depression and suicidality. Physical and emotional pain are connected always. So the biggest message I get from my patients is that this is real and we all need to be practicing it.

[00:49:35] We can't just be talking about it theoretically. We all need to go back into our offices or to our doctors or to our patients and reframe this thing that has been broken and put it back together, and it is doable. It's absolutely positively doable. And the most important message I want to convey is that chronic pain is always treatable. Anyone who tells you that it's not doesn't understand pain. Chronic pain is always treatable. There is always hope for treating pain. Always.

[00:50:04] Dr. McBride: So tell me, Rachel, where can people follow you?

[00:50:06] Dr. Zoffness: I am on Twitter. What is I think actually how we initially connected, I think I commented on one of your posts. I'm @DrZoffness on Twitter. I also do a lot of pain education on Instagram. I'm @therealdoczoff which is very funny cause I picked that initially as a joke. I joined, I think, maybe at the end of 2019 and didn't actually do anything there and just planned on following some of my friends. But now I really am using it to disseminate information about pain. And I also have, uh, websites, just my last name, zoffness.com and there's a ton of free resources. It's super important to me that pain information and treatment is affordable and accessible to everybody. I'm so tired of this lack of insurance reimbursement and it's really, it's unacceptable. There's an entire resources page with books and videos and websites and just a to a ton of free stuff.

[00:50:59] Dr. McBride: And then there's your, there's your workbook, which is just such a great resource.

[00:51:02] Dr. Zoffness: yeah, the Pain Management workbook is on Amazon and it's on my publisher's website, their new Harbinger. It's just called the Pain management Workbook. I figured go simple!

[00:51:11] Dr. McBride: It's great. It's great. Rachel, I want to say thank you so much for joining me today. You're an inspiration and I wish it wasn't true that you're a rare bird in this medical system, in this country, but I think it's pretty rare. And I think that's why I reached out to you. It's why I connected with you. It's why I've been so excited to have you on the show because it's really a crying shame that this is unusual information when it's basic human 101.

[00:51:40] Dr. Zoffness: I Totally agree.

[00:51:41] Dr. McBride: and you do such a good job of explaining it. So, Rachel, thank you so much for joining me. It's been a pleasure.

[00:51:49] Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com.

[00:52:11] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.

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If you’re anything like Dr. McBride or her patients, you want to live a long life. You want to be healthy! Yet when you try to execute on your best intentions—whether it’s cutting back on alcohol, starting an exercise routine, or taming your phone addiction—you end up defaulting to factory settings.

Well, you are not alone.

The pandemic laid bare how wired and tired we are—and how desperate we are to feel better. We scroll endlessly online for wellness advice and health hacks. We grab quick hits of dopamine through sugar, shopping, booze, or whatever gizmo social media is offering up. We are sleepless and irritable and don’t know what’s wrong.

The U.S. medical industrial complex is failing people. The wellness industry is fleecing people. How do we get ourselves “unstuck” when we don’t know what questions to ask or who to trust?

Dr. McBride argues that first, we must first redefine “health” as more than a set of laboratory tests or a single visit to the doctor. To her, health is a process, not an outcome. Health is about having awareness of our medical data, acceptance of the things we cannot control, and agency over the things we can control.

She calls this the “Three As.” She argues that articulating our Three As allows us to more accurately tell our story. An honest reckoning with the Three As can put us back in the driver’s seat of our health.

In this week’s (short!) solo podcast, she explains this in more detail. She defines each “A” and suggests a way to move through this process on your own.

Spoiler alert: getting healthier isn’t particularly sexy. It’s often not very fun. It usually isn’t usually quick, and it never involves a “fix.” In reality, staring down the facts, accepting hard truths, and then challenging our beliefs and our everyday behaviors is arguably the deepest and hardest work we do.

Our stories live in our bodies. What’s yours?

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, review — and enjoy — the show!

The full transcript of the show is here!

Dr. McBride: Hello, and welcome to my home office. I'm Dr. Lucy McBride, and this is Beyond the Prescription. Today, it's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as a process of self-awareness, acceptance, and agency.

[00:00:28] In clinical practice for over 20 years, I have found that patients generally want the same things. A framework to evaluate their risks, access to the truth and data, and tools and actionable information to be healthy, mentally and physically. We all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today. Let's go.

[00:00:55] So today it's just you and me. I am pretty excited, because I get to talk to you the way I talk to my patients. Specifically today, we're going to talk about how we might approach the process of getting healthier. If you're anything like me or my patients, you want to live a long life, right? You want to be healthy, you want to feel good, and you probably know that there's some things you could do to be healthier, but you find them hard to do, and you default to factory settings on a day-to-day basis.

[00:01:30] Well, you're not alone. Many of us aspire to get more exercise, to eat better, to get more sleep, to manage stress. In other words, we all want to do what our doctor tells us to do, but when the rubber meets the road, it's actually pretty darn hard. So how do we actually get healthier? How do we mind that gap between our best intentions and the execution part?

[00:01:53]So let's first talk about definitions like, the definition of health. Unfortunately in the US, we kind of think of health as the sum total of our lab tests. If we have normal cholesterol and a normal weight, we're healthy. But health is not just an outcome. It's not just about the absence of disease or pain, it's also not about pleasing the doctor or winning your annual checkup.

[00:02:19] After all, as humans, we're not just a set of boxes to check, a bag of organs to fix. We are the integrated sum of complex parts, and the US healthcare system just does not do a good job of countenancing the whole person. There's such a focus on extending life, which is of course good, but at the expense of thinking about our quality of life.

[00:02:41] And unfortunately in this country, by the time most people are seniors, they have a doctor for every body part, a pill for every symptom, and no one is talking to each other. No one is talking to the patient and asking them simple questions like, how are you, Mr. Roberts? What is your story? Are you okay?

[00:03:00] What are your goals? What's your North Star? What gets you out of bed in the morning? What do you live for? And by the way, how do you define health yourself and how can I as your doctor help you get there? In fact, a lot of people, regardless of age, are walking around feeling completely disenfranchised from the medical system and disenfranchised even from their own bodies.

[00:03:26] In fact, 80 million Americans don't even have a primary care doctor. So what is health? How do we define it? Health, to me, is a process. Health is about our everyday thoughts, feelings, and behaviors. It's not just about that single point in time in your doctor's office standing on the scale in a gown. It is about the 364 days a year you're not in the doctor's office.

[00:03:53] This is where I get really excited, this is why I'm here, and I can't wait to tell you about what I call the three A's. The process of becoming healthier from the inside out. It's not easy, but it's necessary for health. In my opinion, health is a process of laddering up from awareness to acceptance to agency.

[00:04:19] So I'm going to say that again and then we're gonna break it down. Health is the process of laddering up from awareness to acceptance to agency. So what do I mean by that? First, let's start with awareness. Awareness is step one. Awareness specifically is of the facts, awareness of the facts and data. When I say facts and data, I mean metrics, physical, quantifiable information that we can measure and see.

[00:04:50] I'm talking about your cholesterol levels, your blood sugar, and your diabetes testing, your weight. I'm talking about the results of your mammogram, your colonoscopy, the PSA test if you're a man, your genetic testing when you went to the geneticist because of your family history of breast cancer. These are the things that we can hold onto because these are the things that we can see, that we can quantify and that we can measure. And this kind of traditional medical data is essential to know for our health.

[00:05:19] But guess what, it's not sufficient and there's actually more data we need to collect. Quantifiable information that often gets missed in the doctor's office. Things like, what is your family structure? Are you a middle child? How were you raised? Were you raised in an urban or rural setting? What were your environmental exposures as a kid?

[00:05:40] Were you raised in poverty? What was your socioeconomic status? What about your job? What are the facts of your employment situation? What are the facts about your children, your parents, and your family's system? What is your cultural background? What are your religious beliefs? What about your educational status?

[00:05:58] How many pets do you have? What we need to gather are facts about you historically and currently that are unequivocally true. So this is step one, gathering facts and data, finding out what is true and putting these facts in a box. Now modern medicine is happy for you to stay here, for you to measure your health as the result of your lab data.

[00:06:22] Medicine is happy not to consider the other contextualized facts I just went over about who you are, what happened to you, and what are the realities, factual realities, of your life. In fact, modern medicine is delighted for you not to climb the ladder any further and to keep you stuck in the lobby.

[00:06:42] But let's not stay stuck. Let's do it. Let's ladder up and let's talk about acceptance as the next rung of the ladder. So this is where it gets hard. This is where people push back. This is the common sticking point where people have a hard time, and this is where we get into some of that magical or even delusional thinking that guess what, we all do.

[00:07:05] This is where the rubber meets the road, and it's where we have to acknowledge facts that are unpleasant, that are ugly, but are true. And this is where we have to cope, or else we get stuck on the first rung of the ladder. When I am talking about acceptance, I mean making peace with the things we cannot control, accepting the things we cannot change, and that is hard. For example, let's talk about your biometric data.

[00:07:36] You might have high cholesterol readings despite being an avid runner, eating vegetables and a vegan diet, you have no body fat. Yet your cholesterol levels just won't budge. And you may be really ticked off that you can't exercise your way out of this fixed reality. You might even have to take Lipitor because of your family history of premature heart disease.

[00:07:59] And in the meantime, you might be like one of my patients who's trying to exercise their way out of this fixed genetic reality. Running yourself ragged, blowing out your knees on the running trail, popping a bunch of Advil, when what you really need for health is less running, some physical therapy for those knees, and a dose of acceptance about your genetics.

[00:08:23] So the first part of acceptance is really looking at all that data and the awareness box. Shining a light on those dark corners, looking at things we don't necessarily want to see but that are true, and we have to cringe and we have to swallow our pride, and we have to recognize that we do not have control over every aspect of our bodies, minds, health and life.

[00:08:48] We just don't. There are things that were given to us like genes. There are things that happen to us like trauma or neglect or bad breakups or hard times. And then there are environmental factors, family dynamics, birth order, special needs kids, aging parents, things that we are exposed to that we cannot change and we cannot control.

[00:09:11] And it's when we start to accept the things that make us human and the sometimes unpleasant realities of our lives—that is the birthplace of health. So here's where I want to say very clearly that acceptance is not about giving up. Acceptance is not about throwing in the towel. It's about making peace with the things we cannot alter and change in our lives.

[00:09:36] Acceptance is not about being passive. It's about taking active control over the finite resources of our body, mind, and spirit. And so whether it's things that are innate, that are biologically fixed or that are emotional, behavioral, social, or even structural in nature, acceptance is about reclaiming the energy and brain space that is occupied by trying to change the things we cannot change, and then moving that energy into a more positive, productive place.

[00:10:12] It's about taking charge. It's about being in the driver's seat of our health. Now, no one is saying that acceptance is easy. In fact, like I said earlier, this is where most people get stuck. And we don't often even know that we're stuck. But this is where we all get stalled out. Accepting things that we don't want to accept and that we desperately want to change, whether it's about ourselves or what happened to us or about other people or our environment is an extremely hard thing to do.

[00:10:46] It's a process. It can be painful, and we're also never really done with the process of acceptance. But I will say it again, that acceptance is a necessary process of becoming healthier from the inside out. It's essential for minding the gap between our best intentions and the execution of them.

[00:11:08] Acceptance is also part of this laddering up process to be able to more accurately tell our story to ourselves, to the people around us and then to our doctors. All right, so let's move up to agency. Agency is the next rung of the ladder. Agency is where it gets fun. It's a little sexier. It's where the action is, there's movement, there's momentum.

[00:11:31] But remember, we can't get to agency before we have worked on acceptance. Why? Because we've jammed up all of this real estate in our brains by trying to control the things we cannot control. So here's the cool thing. Once you have put all of those facts and data into the box and you've accepted the things you cannot control, everything else is fair game.

[00:11:53] Everything else is changeable. You can actually change the way you think, the way you feel, the way you behave. You can actually rewrite your story. You can tell a more accurate version of your story that is rooted in facts with all the junk and waste cleared out of the way. So what is agency? Agency refers to our capacity to exert control over our thoughts, feelings, and behaviors.

[00:12:21] We all wanna live in that agency space. We all wanna make changes, be better. New Year's Day is a perfect example of aspirational, almost delusional agency at its finest. It's when people newly sign up for the gym, they drop the booze, they commit to yoga, I'm gonna start meditating we all say to ourselves. We're trying to get from point A to point B.

[00:12:43] We're trying to make changes to be healthier. But if we haven't taken the time to understand the facts, the realities of our lives. And the medical data that is actually part of our health makeup, and if we haven't gone through the exercise of separating fact from fiction and accepting unpleasant parts of ourselves that we cannot change, then agency is gonna be uniquely challenging.

[00:13:07] We are going to set ourselves up for failure, and by the time February rolls around the wheels come off the bus. And despite our best intentions, we default to factory settings, trying to get things done, and we're wondering why the hell don't we feel well? So that's normal. That is human, and this is what I see every day.

[00:13:24] This is what I do myself. Instead of being intentional all the time, I'm reacting to what's happening in my external and internal world, and I spend a lot of wasted energy trying to control the stuff I can't control instead of leaning into the parts where I do have control and understanding where I have agency.

[00:13:41] Let me give you an example of a patient I recently saw, and I'll tell you how we walked through the three A's. So, this patient is a middle-aged woman who's overweight, she has an arthritic painful hip, and she comes in to see me and she says to me, “Dr. McBride, I really wanna lose weight, but I can't. I can't exercise.

[00:13:58] It's driving me nuts and I don’t know what to do.” So we go through her data. She has high cholesterol, she has pre-diabetes. Her BMI is in the obese range. On her x-ray, she has bone on bone arthritis. Some of her data is favorable. She has healthy lungs, she has a healthy heart. She has a stable job, a supportive spouse, and really good health insurance.

[00:14:21] Other facts and data that we gather are that she has a very busy job, a long commute, and a gym that is very far from her home and work. She's also a parent, and notably, her mom had a hip replacement for severe arthritis that went badly, and her mom ended up seriously ill and quite depressed.

[00:14:41] As an oldest child she likes control, and she worries a whole lot about her health, and finds herself overeating at night because of worry. So those are some of the facts about this patient's health. In order to get to acceptance, the next rung of the letter, we need to take all of those facts, put them in a box, and then take a hard look at each piece of data and figure out what we need to accept because we do not have control over it.

[00:15:07] For example, we have to accept the sad reality that her mom had a bad outcome from a surgery that my patient herself needs. But we can look at the facts of her mom's situation. We also have to accept the fact that her weight and her relative inactivity because of her hip, are driving her high cholesterol and her diabetes testing.

[00:15:27] In fact, when I knew her 10 years ago and her weight was more normal and she was exercising more regularly and eating more intentionally, her cholesterol and her blood sugars were normal. So we know that these biometric pieces of data are dynamic and they're dependent on her level of movement and diet.

[00:15:45] In other words, we are not going to accept that she is destined to have heart disease and diabetes. However, we need to accept the fact that this arthritic hip is not going to get better on its own. That there's no amount of Advil or waiting it out that is going to get it better. So it's time to accept the fact that this is now a surgical problem.

[00:16:04] We also need to accept that she has this habit of overeating when she's anxious. We can accept that. But what we can do is work on the anxiety and the fear itself. Let's move into agency. Now that we have accepted these realities of her life and these parts of her health that are unpleasant, and we've decided not to accept that she is destined to have high cholesterol, diabetes, and a limp for her whole life, and she's not destined to become her mother, we can lean into the agency and put her back in the driver's seat of her health.

[00:16:38] And then we're going to talk about how to rebuild trust in orthopedic medicine and how to find her a physician who will listen to her concerns, and help her get the treatment she needs. We're also going to go back into her laboratory data from 10 years ago, and we are gonna look at the facts around her habits when her cholesterol and her blood sugar were normal, and we are going to forecast her being able to move and live her life the way she wants to, to be able to bring those numbers down over time.

[00:17:08] But in the meantime, given her age and her family history and her predisposition to heart disease, we are going to add a small dose of Atorvastatin to bring her cholesterol down under 100, which is the standard of care for someone in her situation. Now I remind her that when she gets that new hip, when she is able to go back to her swimming, her dance class that she loved so much, and when her cholesterol levels come down, we can always pull that cholesterol medicine away.

[00:17:39] In other words, let's meet the fixed unpleasant realities of her life that she cannot exercise right now. And let's treat the medical issues using evidence-based medicine, and let's follow up and change that recommendation as the conditions change. And as for her natural anxiety about having to have surgery, about her anxiety about her health, I'm going to recommend that she start journaling, prioritizing sleep, and consider seeing one of my great psychotherapists, to help her reroute those hardwired, almost reflexive patterns of thought, feeling, and behavior.

[00:18:12] Like, I feel scared. I am scared. I'm gonna go eat something I regret later. And to help her rewrite her own story so that she is in control of her mental and physical health in tandem. The overarching goal here is to help the patient rewrite the story that she has told herself. That she is broken, that she is obese, that she is incapable, and that she's going to become her mother.

[00:18:36] That story, it’s a story she's told herself again and again, and that can be rewritten when we go through the process of the three A's. As I talk about a lot, our stories live in our bodies, and it's when we are able to do an honest retelling of our stories, and fact check the stories we've been telling ourselves, that's when we can start to work on accepting things we can't control and where we get to open up the door to more agency.

[00:19:05] Okay, so what's the take home? What is the upshot for you, dear listeners, after you've listened to this diddy about the three A's? Here's my advice. Grab a pen and an old fashioned pad of paper. Think about a problem you have in your health or in your life, and then write down the narrative you have about it.

[00:19:26] Write down this story in your mind about the reasons you cannot solve this problem. Write down in a very honest, sober way, about what are the facts about this condition? Have you gathered all the facts? And then go through this exercise. Find the facts, whether that involves your doctor or asking your parents about your genetic history, or asking your spouse or your kids or yourself about the facts of this condition.

[00:19:53] Maybe it's a heart condition, maybe it's arthritis, maybe it's depression, maybe it's alcohol overuse. Whatever it is, and bring it to your doctor and see if an honest telling of your story helps you squeeze the juice out of the medical system, and helps you get a little healthier from the inside out. Over the next couple of weeks and months, I'm going to be fleshing this out a bit more.

[00:20:18] I want to talk a lot about the acceptance part and why that is so hard. How do I help people learn to accept the things they can't control? Where do people get stuck and what is all this magical, delusional thinking that we all do? Let's hash it out. And then let's talk more about the agency part. Let's talk about how we mind that gap between our best intentions and the execution. And why we can't get to the other side.

[00:20:42] So I'd love to help you. I'd love you to stay tuned. In the meantime, join me on my Substack at lucymcbride.substack.com/, and I would love your comments about this podcast. Drop me a note below. Tell me what you think. Tell me what you'd like to hear more about. I will see you next time. Thank you so much for joining me.

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Why are expectations about being a woman—specifically a mother—so unrealistic?

Mother, author, and New York Times opinion writer Jessica Grose has a lot to say on this subject. Her latest book, Screaming on the Inside: The Unsustainability of American Motherhood, is inspired by her own shortcomings as a mother. She interviewed hundreds of women as part of the research process while writing the book. In it, Jessica shines a light on the current state of motherhood, and the historical context around the impossible standards for American mothers.

In honor of Mother’s Day, Jessica and I sit down to discuss the narrative and messaging to parents that “they’re doing it wrong.” Jessica urges parents to learn to trust their instincts and to show up to parenting as their authentic, imperfect selves.

Join me every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, review — and enjoy — the show!

Transcript of the podcast is here!

[00:00:00] Dr. McBride: Hello, and welcome to my office. I’m Dr. Lucy McBride and this is Beyond the Prescription, the show where I talk to my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for more than 20 years, I’ve realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies. I’m here to help people tell their story, to find out, are they okay, and for you to imagine, and potentially get healthier from the inside out.

[00:00:45] You can subscribe to my weekly newsletter at lucymcbride.substack.com and to the show at Apple Podcasts, Spotify, or wherever you find your podcasts. So let’s get into it and go beyond the prescription.

[00:01:01] Dr. McBride: Today I'm interviewing Jessica Grose. She is a mother, she is an author, and she is a New York Times opinion writer who writes a lot about parenting. Her most recent book is called Screaming on the Inside: The Unsustainability of American Motherhood. I was immediately drawn to this book because it was inspired by Jess's own perceived shortcomings as a mother, something I think a lot of us women can relate to. The book combines in-depth interviews with mothers and a historical context on motherhood to help explain why our expectations about being a mom are so unrealistic.

[00:01:37] I think there's a narrative that a lot of us women and mothers absorb that if we only read the right book, if we only had the right parenting expert on speed dial, that we could be the perfect mother when it's not that simple, and frankly, we need to be better able to trust our instincts to know that by showing up, by being a good person and by leading with empathy and curiosity about who our kids are that we are good enough. Jess, I'm thrilled to have you today. Thank you so much for joining me.

[00:02:07] Jess: Thank you for having me. I just wanted to mention, we actually recently dropped the on parenting. I will still talk about parenting. I think my last column was about parenting related issues, but I wanted to have a chance to broaden my aperture a little bit, write about all sorts of issues, mostly cultural, but it's been exciting and I'm really looking forward to this year.

[00:02:30] I mean, an example of that was I just did a big piece about midlife and millennials at midlife. I am one. I am an ancient millennial. I just turned 41.

[00:02:39] Dr. McBride: What's the newsletter called now?

[00:02:41] Jess: It's just my name, just Jessica Grose.

[00:02:43] Dr. McBride: Okay, awesome. How cool is that though, Jessica, that you got to move from being a reporter, which I know you loved to giving your Opinion. I mean, anyone who knows me will tell you that. I love data. I love analysis. I love pouring through primary sources. I also have a few opinions and I love delivering them.

[00:03:04] Jess: Well, I don't think that my approach has actually changed really radically. I do what I like to think of as reported opinion. It's unusual for me to just riff on an idea without including data or including interviews. Occasionally I will actually, my next column is just about Brook Shields' new documentary. And so that's more just thoughts about what it’s like to grow up in the public eye for a kid. And it’s unsurprisingly not great. It was really difficult for her to develop a sense of an identity. But typically I still do a lot of reporting. What it allows me to do is draw more aggressive conclusions from that reporting. And anyone who knows me in real life knows I have a lot of opinions, so it feels really nice to share them.

[00:02:52] Dr. McBride: Well, I think that's right. It's the same thing in medicine. I have a lot of opinions, but it's rooted in my understanding of the medical literature and the understanding of the patient in front of me. So I'm never going to just say, do this because I said so. The fun is taking the data and the data in your case on motherhood and the historical context around it, and then giving parents and mothers permission to be less perfect than their Instagram highlights might suggest they should be.

[00:04:23] Jess: Yeah, I mean I had just the genesis of the book was really just in having so many questions about where ideas that I had about motherhood came from. Because when you start to unpack them, they sound crazy. So one example that I often give is I was very sick during my first pregnancy. I had hyperemesis, so I was throwing up constantly. I could not keep food down. I got incredibly depressed and anxious. I honestly think in large part because I had hyperemesis, just as you cover, the body mind connection is very deep. Not being able to nourish yourself, it's tough to feel good in any way. And I had the question, why is there even the expectation that one should feel good during pregnancy?

[00:05:16] Because I've known a lot of pregnant people in my life, and most of them do not feel great. Maybe they have moments where, during the second trimester, they're not enormous yet. They're feeling a baby kick. They're not sick anymore. Maybe you’ve got like two months of feeling pretty good, but often, there are many ways in which you can feel not your best self, and so every chapter of the book started with a question about an ideal that when you think about it for more than five minutes, makes absolutely no sense.

[00:05:49] Dr. McBride: Yeah, it's interesting about the hyperemesis, and I heard you say in an interview that you leaned into the toilet, that was your lean in. So I had a patient recently in my office who is pregnant with her second child. She's in her second trimester, and so, so sick, like on her knees, in her bedroom. She's a congressional staffer and can't even really go to work most days because she's so sick. And she went to her gynecologist and she was explaining how sick she was to her gynecologist, her obstetrician, and my patient asked the question, “can I take Zofran or something for this nausea?” And the doctor said to her, and the patient's crying telling me this story, she said, “well, if you really can't function, I guess you can take some Zofran.”

[00:06:31] That's a tough standard to hold ourselves to. If you're in the fetal position, then you can treat yourself to a medication that's exceedingly safe, particularly in the second trimester. Why are women so conditioned to suffering and why are we depriving them of the permission to experience highs and lows of pregnancy and motherhood, I don’t know.

[00:06:55] Jess: Well, we're working against thousands of years of conditioning, right? I mean, the idea that mothers shouldn't be martyrs and sacrifice themselves, put themselves last in every situation. That is in all of our in some ways all of our religious texts of the major religions, it is there if you want to pick it up. I mean, in terms of pregnancy and the benefit risk analysis, I think particularly in the United States, and Emily Oster is obviously the guru on this topic, we have just over-rotated on risks and perceived risks because statistically speaking, many of the things we think of as scary and we shouldn't do them, are not damaging really at all, except in extremely unusual circumstances.

[00:07:45] And so I think medication is one of those things, and particularly things that are seen to be non-essential. And it's always a question, well, it's like, well, non-essential for whom, and one of the big mental health related medications, it's even more for, where it's like Prozac in particular is that there's so many studies on SSRIs in pregnancy. So, so, so many and perinatal psychiatrists will tell you that the risk profile for those drugs is pretty good. Everybody needs to make that calculation for themselves. I am not pro or anti-drug. I'm pro making an accurate risk benefit assessment in every individual

[00:08:31] Dr. McBride: You sound like my friend Emily Oster, and you sound like, and you sound like me, because Emily's a good friend and she was on the podcast and we've talked extensively about the level of scrutiny that we expect women to look at these risks with is exceedingly high. Eating blue vein cheese during pregnancy, having a thimble full of wine. Those carry risks, but so do being anxious and being depressed.

[00:08:59] Jess: So does getting in your car every day, which [00:08:00] is probably the most dangerous thing that you do as a pregnant woman. That's typical. But we don't think of it that way because of complicated reasons. And I do think it's affecting not just how we feel in our own bodies and how we experience the pregnancy and postpartum period, but I think it's affecting how we parent and it's making us more anxious parents than we need to be. And to me, the joy of being a mother is watching my kids become who they are and watching them go out into the world and navigate it. And excessive anxiety about things that have risks but low risks really impedes relationship building that joy of watching them become their own people.

[00:09:50] And that just makes me incredibly sad because it should be joyful. Not all the time. That's a big part of my book. Parenting is not joyful all the time, but there are parts that are incredibly joyful and validating. And so I think having too aggressive a feeling about risks and a scary world out there impedes the joy that we could feel.

[00:10:15] Dr. McBride: Yeah, I think we learned in Covid that people in general do a pretty bad job of assessing risk. And then thinking about risk benefit ratios, we tend to overestimate risk when we're thinking about our children and we think about women.

[00:10:31] Jess: Yes, and I don't blame anyone because the avalanche of information that all of us are getting all of the time, no one can parse that. You don't know who to trust. I feel lucky that I gave birth to my older daughter in 2012 when the social media ecosystem was not—I guess I would describe it as broken today. There were problems with it, but it wasn't, there just was less social media. There were no Instagram stories. TikTok didn't exist. It was not what it is today, and I made a concerted effort knowing myself that I tried and really didn't look for parenting information online. I did not follow any parenting as much as I could. I had one book, and the only book was the Mayo Clinic's Guide to Your Baby's First Year. And if I had a question, I would ask my pediatrician or I would ask my mom, and that's unfair to expect everybody to do because my mom is also a retired physician.

[00:11:31] Dr. McBride: You have an advantage.

[00:11:33] Jess: I have a home court advantage in terms of trustworthy, you know, people in my life. But I think paring down that is one thing I tell parents all the time. Pick a few trusted sources and just try to block everything else out because otherwise you're gonna drive yourself bananas.

[00:11:53] Dr. McBride: I think it's great advice, because of all the information coming at us like a open fire hose, and because there's so much fear-based messaging and because we're predisposed to being more anxious about our children and society has made women more anxious about themselves for whatever reason. How do you guide people on deciding who to trust and who not to trust? What's the anatomy of trust in your mind?

[00:12:16] Jess: So, I mean, number one, and again, expertise does not always equal trust, but always look at the credentials. Look at their credentials. See as much as you can. If they have a particular narrative on any topic that they are trying to push, see if they have any conflicts of interest in terms of payment through a certain company. All of the things that… it's sort of a journalistic way to look at the sources that you trust. And then the sort of X-factor is more just vibes. Are they making you feel bad about yourself? That's huge. So many advice givers on social media are invested in negativity.

[00:13:01] Actually, there was just a great article in Vox about this, not specifically targeted at mothers, but saying, because negativity plays better in the algorithms telling you that you're doing it wrong will rise to the top and that's just not how I wanna be talked to about my parenting. Like, “you're doing it wrong and this is the right way to do it.” Well, piss off! My spirit is very contrarian. And so if anyone is telling me like, you're doing it wrong, I have just an immediate gut [reaction]—I'll do what I want. I've talked to so many people through my reporting days that they have the opposite reaction, which is like, I must be doing it wrong and I feel terrible. So if something's making you feel terrible, listen to that voice.

[00:13:45] Dr. McBride: I think women walk around with that narrative on their own. They don't need help in many cases. I think so much of our messaging to women the historical context around this is about you're doing it wrong. You could be better. You're not enough. Your kids are messy, your kids are loud, your kids are emotional, your kids are this. And then of course we feel anxious. Of course we feel like we're not good enough. And so we have this narrative often that is, we are not doing it right, we're doing it wrong. And that is a narrative that dies hard for so many people and does inform the way they show up in my office as patients with insomnia, alcohol overuse, distress and malaise. The pressures we put on the American mother are enormous, and it's not like it is in other countries. Other wealthy countries don't have the level of scrutiny on mothers like we do in this country.

[00:14:41] Jess: And I think there's been cross-cultural studies done on this, and parents in our peer nations actually look to experts less for advice because they feel more supported in their own communities and they feel more confident in their own instincts. And I think that there's a lot of complicated reasons why that is.

[00:15:01] Dr. McBride: Could you talk about why you think that is?

[00:15:03] Jess: Well, I mean, I think, you know, they orient their entire societies around children being more part of the day-to-day and having children behave as children do is just understood. It's not demonized. It's not, you're not worried all the time, that's everybody's gonna give you nasty looks in a restaurant.

[00:15:29] It's like children are just sort of more welcomed as a baseline. And I do think that. There's a relationship—it's not a one-to-one relationship—but there's a relationship between that attitude and having more child-centered public policy. So everything from paid leave, which we are the only wealthy country in the world, that doesn't provide it for our citizens. More subsidized child care to things like even urban design, having more parks and green spaces, having more walkable areas for, and areas for children to exist and play and be more a part of society.

[00:16:10] I did a piece about this adorable Japanese show that's on Netflix called Old Enough, and when I was researching that piece, the show depicts toddlers, really little kids going on their first errands alone, which, just would never happen for a million reasons in the United States. But part of the reason that it is easier for Japanese children to be more independent is because of the built environment in Japan. And there's a great article in Slate about that. So, those are things that are sort of subterranean. We don't even see them. We don't think about them. We obviously are not all so well traveled that we know what the built environment looks like in Japan, but those are some of the reasons that I think American parents do feel such a sense of scrutiny and need and desire to seem perfect or keep their kids perfectly in line when they're out in public.

[00:17:11] Dr. McBride: Do you think there's something to the idea of women in America not trusting their instincts as much, or not being allowed to trust their instincts? I mean, what I see since I became a parent, and it's the same problem in the wedding industry, is that there's a whole professional industry around parenting. I'm so glad I got married in 2000 and not today because we didn't have one of these produced proposal moments. It was just a casual moment in the woods. Similarly, when I was a parent for the first time, I didn't have Instagram and all the parenting gurus out there. I just had to trust my instincts. But I think because we professionalize these phenomena, women can start to feel less than, or like they have to read this book and then they'll be okay when actually we are born to be parents if we want to be. So I don't know if there's something about that, but it does feel to me like we often don't give ourselves permission to just listen to our intuition.

[00:18:19] Jess: Yeah, I think the sort of commercialization of everything is connected to the fact that there are no sort of communal supports and rituals. So, for example, in many countries after you give birth, Somebody from the National Health Systems will come and visit you. A nurse will come to your house and…

[00:18:37] Dr. McBride: Can you imagine that happening in the us?

[00:18:40] Jess: I cannot, I would have loved that. They will come to your house free of charge. They will make sure you're doing okay. They'll make sure the baby's doing okay. They'll help you with nursing. They'll do all of that built in support in that way. There are mothers groups that will be organized through the community and I think when you don't have that, then figuring out how to solve your problems is an individual issue, and then you feel isolated and that leads to that sort of stress and anxiety and desire for individual solutions that ultimately might not help us feel good or feel accepted. And so it all sort of is so connected to so many different aspects of how we raise children in this country.

[00:19:32] Dr. McBride: I also wonder what you think of the idea of caution as a virtue we saw in the pandemic that we really moralized human behavior. If you didn't get vaccinated, certainly you were sort of deemed a pariah of society. If you didn't mask long enough, diligently enough, there was something wrong with you.And I think when we looked at the data on Covid and kids, at least when I looked at the data, it was clear that kids, healthy kids tended to do generally pretty well with the virus, which is not to say that we wanted kids to get covid. It's not to say that kids haven't tragically died from covid, but there's something about the moralization of motherhood and behavior and children in this country that is, to me, seems unique. I don't know what you think about that.

[00:20:27] Jess: I think that's right. There's just this pervasive attitude. It's like if anything goes wrong, it is your fault, it's your responsibility, it's your fault. You should, you have to be there to pick up the pieces. No one's there to help you. You should have done X, Y, and Z differently, but it’s not working.

[00:20:44] Dr. McBride: It's not working because Jessica kids get covid. Kids do stupid stuff on the playground to each other. Kids are messy and imperfect and so are we. And so this notion that caution as a virtue is inherently flawed because there's only so much you can be cautious about and risk is ubiquitous.

[00:21:04] Jess: Yeah, I think a lot about the fact that my older daughter broke her arm during Covid. She broke her arm in May 2021, and it was because she was playing soccer in our courtyard and she fell. And there was nothing that was… we were lucky enough to mostly remain healthy during that time, but it was just like I was literally a hundred feet away from her. Things happen in children's lives. I didn't feel guilty. I felt bad for her. Obviously seeing child in pain stinks. It was a thoroughly un-fun experience for all involved, but I didn't feel responsible for it. I, but it occurred to me as I basically witnessed it happen. It was just like, there's nothing I can do. She's biting it and her arm looks really messed up. [Unless we] start placing her in bubble wrap and never letting her leave the house, this was unavoidable.

[00:22:09] Dr. McBride: That's right. I just had a thought as we were talking about risks to kids. I was remembering the article you just wrote for the New York Times about the reporting on the CDC data on adolescent mental health. And I thought it was such a great article because in my office I have parents and older teens as patients who are having mental health challenges, whether it's anxiety, depression, substance use disorders, eating disorders. I also have a fair amount of parents who are anxious about the headlines alone and anxious about the data. And then I have fair amount of teens who feel like, “oh my God, this is inevitable that I am a mentally ill person because this is what everybody's talking about.” And so what I loved about your article is that you are trying to take away the catastrophization, if that's a word…

[00:23:03] Jess: Yeah.

[00:23:04] Dr. McBride: You’re the the writer! and to frame the data and recognize let's look at the facts and look at the way the data was collected and the timeframe. And then let's also recognize the historical context around over worrying perhaps about girls having emotional health, not to dismiss the fact that kids are suffering, not to dismiss that kids are losing their lives to mental health problems, but rather to recognize the biases we have culturally that make us kind of mentally masturbate, if you will, on girls having feelings. So can you talk about that a little bit more because I thought it was brilliant.

[00:23:40] Jess: Yeah. Oh, thank you. It was a struggle to write because I really wanted to be very careful and not… the fact that suicidal ideation is up, the fact that suicides are up is awful. Full stop. We need to help those kids. Any kid dying before they're 18 is a tragedy. That is awful. And my heart absolutely breaks for parents whose kids are really struggling, you know, exactly as you say, with eating disorders, substance use, self-harm is up, cutting all, of that. So. I never want to seem like I am diminishing the seriousness or pain of that.

[00:24:24] At the same time, since I was a teenager… I graduated from high school in the year 2000. All we've had since the year 2000 is more awareness and more discussion of mental health, and I just don't want teenagers in particular, who, and being, because being a teenager is really hard. I remember being a teenager and you could not pay me to go back there. I don't want them to pathologize the normal ups and downs this period of rapid change. And I don't want them to necessarily label themselves as, oh, I'm an anxious person. I'm a depressed person. I am X, Y, and Z. Well, it's like, maybe, but maybe you're just having strong feelings and that's part of life, and that's part of being a person and you're learning how to handle them and you can handle them.

[00:25:24] You can handle these big feelings and you don't need to necessarily label yourself as having a broken brain, which is how a philosopher that I quoted describes it. She calls it the broken brain hypothesis. Oh, my brain is broken and it needs fixing. And is that narrative helpful for all teens? And I would argue, no. I am the daughter of a psychiatrist. I am pro psychiatry. I am pro psychology. I am pro therapy. But at the same time, does turning inward help everybody all the time? I think most teenagers could benefit from just as they say on the internet, touching grass, not turning inward, turning outward to their communities, to their friends, to their own habits.

[00:26:20] One thing that I had in an earlier draft, which I didn't include and I think is under discussed, there is good data on the fact that teens are sleeping less than they used to, and that is huge. They might just need more sleep. They're just tired and cranky and I mean, I've, there's been, especially when I was a new mom, there were numerous times where I really thought I was losing my mind and I was just completely exhausted.

[00:26:48] Dr. McBride I think it's such a good point, not only do we tend to pathologize normal human emotions, which is distinctly not to dismiss the harms of depression, anxiety and substance use. We also tend to make things more complicated than they sometimes are. Sometimes the solution to my patient’s angst and alcohol overuse in the evenings when she gets home from work and poor sleep and hot flashes is, she just needs to eat lunch. Same thing with what you're talking about. It's not gonna solve everyone's problems, but sleep is an essential part of the human brain and bodily function. So I think you're right. Sleep is huge.

[00:27:33] Jess: But also, I mean in terms of my researching for this piece, my attitude towards all of the ideas around this is yes, and it's not, I don't agree with that. Screens are an issue. They're absolutely an issue. That's part of this. It's how we parent and over parent possibly. I think that's part of it too. It's more just to say, I wanted to take. The temperature down a few degrees because I don't think really panicky headlines are helpful to anyone, honestly, on almost any subject. I think that's making everybody more anxious. And so I just wanted to say, can we talk about different ideas? Can we look at this from a different angle?

[00:28:18] Jess: And I have a dog in this fight. I have two girls, one of whom is entering middle school in the fall. I want her to feel confident and empowered, and I want her to feel like she can take charge of her own emotional life, and I will admit that this is one of the few times where my reporting has really changed the way I think about parenting.

[00:28:43] Dr. McBride: It’s so interesting. I want to talk a little bit more about the taking the temperature down phenomenon, because like Emily Oster, I have been writing, I mean not to the extent she has been, but about fear getting ahead of the headlines about pediatric risk, of covid, about the excessive amount, in my opinion, of rumination, about covid risks in the vaccine era at the expense of thinking about health in a broader way.

[00:29:20] And I'm talking to women in particular. I'm talking to everybody, but I think women as the ones who are largely the primary caregivers for kids and women who are, the ones that I see, at least in my office, tend to be more anxious about risk, not universal, but there's utility in doing that and trying to take the temperature down.

[00:29:42] There's also a fair amount of backlash to that narrative. People don't necessarily want to hear that it's okay if your kid gets covid because by the way they will anyway, and it's not going to necessarily do them long-term damage because that's what the data show us. There's some currency there about. The vigilance and the anxiety. It feels like having its own life, its own place, and that is what's concerning to me that, that it's really hard to let go of. Do you see that? Does that make sense to you? I know that because Emily Oster and I have discussed how we have to go into hiding when we put out these articles for The Atlantic.

[00:30:22] She wrote the article that your kids going on vacation or flying on an airplane is like the same risk as their grandparents or something like that, and she had to go into like witness protection program because people were so angry that she was trying to help people manage risk and calibrate it to the actual threat.

[00:30:38] Jess: Yeah, but I'm sure she at the same time, she also had a lot of people thanking her. I mean, it's easy to think about the backlash.

[00:30:45] Dr. McBride: I think that's right, but I also think that, I just wonder where that anger is coming from.

[00:30:52] Jess: Well, I do think that there is something to, and I'm not saying that this is a conscious feeling, but if you are not worrying about your kid, you're not a good mother. And that has to be part of the equation. And it goes back to if anything goes wrong, it's your fault. And so your worrying will prevent anything from going wrong. But you know, that's not how life works. There's terrible unlucky things that happen and that's part of un unfortunately, that is the downside of living a full life, because if you just avoid anything that is, you know, has a potential risk and even at a potential emotional risk, I think you're gonna be missing out on most of the good parts of life.

[00:31:36] Host: I think that's right. I think because motherhood is intrinsically stressful, I think we can start to associate stress with mothering, where if you're a good mother, by any definition, It's despite being anxious, it's despite being stressed, like I know that I'm doing my best mothering, which, you know, I'm not winning mother of the year anytime soon. But I feel like I'm in my best moments when I'm not [00:31:00] leading with fear or anxiety when I'm like just straight talking. But I think it's easy, like just for anybody, to, anyone who's used to like achieving or. You know, trying to do well, and we're all trying to do well as parents to associate the anxiety itself with the outcome.

[00:32:19] Jess: Right. But I think, and this is actually, I've been thinking about this a lot lately because I see a move in parenting advice towards giving people scripts. And my attitude towards most parenting advice is like anything that helps you get through the day in one piece, great. But I do wonder if we are overthinking the importance of every single word we say to our children and worrying that if you say one wrong thing wrong, I'm putting that in air quotes because who knows what even is the right thing for your individual child. It could have catastrophic blowback, and to me it's a risk of being inauthentic with your children if you are relying on some sort of words that didn't come from you or your brain, it teaches your kid that you're also not really human yourself. I think it's important for your kids to see you as a human. Obviously, they should never feel responsible for your emotional wellbeing, but they should know that you're not perfect. That's good for them.

[00:33:36] And I've written articles where I try to give people scripts when I think it's helpful, so I'm not knocking it overall, but I do wonder what we're losing if we're not just trying to speak honestly as ourselves, because are we pretending that we all want the same outcomes for our children? Like what does that even mean? What is a good outcome? I think all the time about What do you want for your kid in the world? We don't all agree because everybody's different and everybody has different values. So, I just think the challenge for all of us is to sort of live an authentic self as we are also parents. We are not some new kind of person.

[00:34:17] Dr. McBride: That's right.

[00:34:18] Jess: We're still just people.

[00:34:20] Dr. McBride: I'd love to ask you about you as a parent right now and what are your particular struggles? Are their particular narratives you have in your mind that you're trying to undo, and how are you looking to be a healthier parent for your kids?

[00:34:39] Jess: My kids are at a great ages. They're in first grade and fifth grade, and so we're out of that diapers and toddler tantrums phase, which I found. I love babies. I really liked having babies. I struggled with that one. That age between one and two. I think that was the hardest for me as a mother just sheer exhaustion, but with my older daughter who will enter middle school, something that I'm proud of is completely removing myself from any of her friendship drama. And I never got involved in terms of like talking to anyone. Of course not. But I would… she would tell me something. I would not react to her, but later I would be stewing about it. And I have just been like, stay out of it. Do not get emotionally involved because there will be a new drama tomorrow and some other girl is gonna say something to some other girl and obviously if it were a bullying situation, that would be different.

[00:35:44] But just having been a middle school girl, this is very familiar to me. And so when it first started happening kind of at the beginning of fifth grade, I was upset. I was upset, man, it stinks to watch your kid be in this mean girl business. And I don't think she was probably totally innocent and it either, who knows? I wasn't there. I shouldn't be there. And I always let her deal with it herself. I never got involved with it, but I would get really upset. When she wasn't around. And so I think it's a parenting win for me to just have let that just be like, I'm not getting emotionally involved with this. It's only gonna get worse in the next couple of years. I assume maybe I'll get better, who knows? But having been a teenage girl, this is just the beginning. And so I think training myself to not get too involved in any way.

[00:36:38] Dr. McBride: It's really healthy. And what's particularly healthy when I hear you talk about it, that you recognize your daughter may have had a role in it. You're not assuming innocence just because she's your offspring, and you're also recognizing there are harms of, you know, the dynamics that you would hopefully pick up on.

[00:35:53] But you're right, they have to kind of navigate these things themselves.

[00:36:59] Jess: They have to, and they have to learn how to deal with people they're not getting along with. That's life. That's the workplace that's going to go into, there's nothing I can do. Absolutely I can be there for her when she comes and tells me she's upset about something and if she asks me for advice. I'll give it to her. She seems to want no part of my advice about anything…

[00:37:18] Dr. McBride: Welcome to the club. Welcome to the club, my friend.

[00:37:21] Jess: but I found it very distressing when she first would start telling me about the beginnings of these sort of… it's so familiar. I'm sure you found it familiar when your kids started going through it.

[00:37:34] Dr. McBride: A hundred percent.

[00:37:35] Jess: And so it's been, now that she's almost at the end of fifth grade, I feel like I think we both have a better handle on it, let's put it that way.

[00:37:44] Dr. McBride: My last newsletter subject was about this after I interviewed Lisa Damour for my podcast. I love Lisa. She's, oh my gosh, I could just listen to her voice all day long.

[00:37:53] Jess: She has a very soothing voice. That's true.

[00:37:55] Dr. McBride: And I wrote a substack piece about how hard it is to do this, but how essential it is for us and for our children to try not to ride the rollercoaster of their emotions. Because first of all, they want us to, and that that's a little bit of a currency. I mean, they don't want us to really, but they're, they get their mojo from riling us up. But if we can have a little bit of a distance or space from their everyday minute to minute, Emotions. It's good for both parties

[00:38:26] Jess: It is, and again, it's like when I said that reporting, that piece really changed how I thought about parenting. I already felt this way to an extent, but I think not allowing our children to deal with their own problems is so bad for them. It's bad for us and it's bad for them, and we can't just, as my children get older, I want them to feel a sense of agency in their own lives. I want them to be really self-sufficient. It's really important to me. I think it's really important for them. And so, I already thought that, but there are certain things that I have vowed to do a little differently solely based on the reporting about teen mental health, just because I really do think allowing them as much independence, again, emotional and physical independence as makes sense for them as an individual child.

[00:39:28] All kids are different. All kids have different abilities. They have different desires. They have different things that they're ready for at different times. I mean, it's so wild to look at my children. And their classmates because you can see all of these kids are normal kids and they have such a range of physical size, emotional maturity, intellectual, cognitive differences that are, again, all within the range of normal, all beautiful in their own ways. And so every parent has sort of a different way to do it, but I think really giving our kids independence is so important for them.

[00:40:08] Dr. McBride: Thank you so much for joining me. Thank you for shining a light on American motherhood and giving us a more nuanced view of how it actually is and for bringing data and facts and context to it. So I really appreciate your work and I'm so grateful you joined me.

[00:40:24] Jess: Oh, thank you so much for having me.

[00:40:29] Dr. McBrideThank you all for listening to Beyond the Prescription. Please don’t forget to subscribe, like, download and share the show on apple podcasts, spotify or wherever you find your podcasts. I’d be thrilled if you like this episode to rate and review jt. And if you have a comment or question, please drop us a line at info@lucymcbride.com.

The views expressed on the show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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When Caitlin Murray’s 5-year-old son Callum was diagnosed with leukemia in 2016, her world turned upside down. She starting blogging to keep friends and family informed about his treatment, and what began as a medical missive became an outlet for share about life, love, and parenting.

Callum beat cancer, and Caitlin’s star kept rising. As the main character of the wildly popular Big Time Adulting Instagram page and podcast, Caitlin has captured the hearts of parents everywhere with her raw, relatable, and hilarious commentary about raising kids.

On this episode, Caitlin sits down with Dr. McBride to discuss social media for grown-ups; learning to trust your gut; and the heartbreaking hilariousness of being a parent.

So listen, learn, and laugh with Caitlin. She is living proof that humor is healthy.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, review — and enjoy — the show!

Transcript of the podcast is here!

[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is "Beyond the Prescription," the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies.

[00:00:35] I'm here to help people tell their story, to find out, are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at https://www.lucymcbride.com/ and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So, let's get into it and go beyond the prescription.

[00:01:03] There are influencer moms on social media with their perfectly curated family life on display, and then there's my guest today, Caitlin Murray. Caitlin created the wildly popular Big Time Adulting Instagram handle and now has a podcast of the same name. It all started as a way of keeping her friends and family abreast of her son's progress as he was treated for childhood leukemia. And it has grown exponentially over time as an outlet for Caitlin to share her thoughts on, as she puts it, life, love, and parenting.

[00:01:37] Caitlin is arguably the funniest and most relatable mom on the internet. Her content is the refreshing antithesis to the Pinterest-perfect family imagery. Her humor makes her audience of stressed-out parents feel seen and heard. It's her authenticity that has made her wildly successful and someone I really admire. Caitlin, thank you so much for joining me today.

[00:01:59] Caitlin: Oh, my goodness. Thank you so much for having me. I'm super flattered to be here with you because we originally met via the Gram and I reached out to you to be on my podcast. And I found you because I was doing a lot of homework on COVID stuff in terms of the risk analysis of masking children in school, which was really something that I was feeling impassioned by at that time. And I was just so pumped to come across such an accredited doctor who spoke really well from both sides about the reality of the situation. And when you said yes that you would come on my podcast, I was like, "Ooh, I gotta tighten my s**t up right now."

[00:02:45] Dr. McBride: Oh, my God. That's hilarious because when you asked me, I'm like, "Oh, I gotta tighten my s**t up right now."

[00:02:50] Caitlin: So, yeah, but I'm psyched to have developed this online relationship with you and see you a little bit in real life via Zoom.

[00:02:59] Dr. McBride: Well, I feel like I know you. And that's, I think, your gift to your audience, is that you let us into your world, you let us into your interiority. And I think what connects to you and me is the fact that neither of us are willing to put up with a lot of BS, whether or not it's because you are a mom of someone who's had cancer, whether you are just born with perspective and wisdom, or whether or not you're just learning as you go like we all are.

[00:03:28] The appeal in my mind of your content is this relatability, authenticity, and humor that allows people who are watching you to feel like we're okay. And that's the title of my newsletter is, "Are You Okay?" I mean, no one's really okay. Which is not to say we're all mentally ill, we're all broken people.

[00:03:46] It's to say that it's on a continuum how we manage our everyday lives, how we manage stress, how we manage mood, how we manage relationships with food, alcohol, our spouses, our children. My goal as a doctor is to help people be a little more okay tomorrow than they are today. And so, when you see someone like you on Instagram who's real and authentic, it's very appealing and refreshing.

[00:04:09] Caitlin: Well, thank you. I really appreciate that that's how you view it because I'm actually a shallow b***h behind the scenes.

[00:04:17] Dr. McBride: Well, I know that. And I'm trying to just cover it up for my audience, but there you go. Like, that's what you are, you're funny and you're real. And I'm gonna guess that you have insecurities like we all do, and you wonder sometimes like, "Wait, maybe I am a shallow b***h." I mean, Instagram is a weird place, right?

[00:04:36] Caitlin: Totally. Yeah. I think it's a place where people second guess themselves constantly just by scrolling along. And it's this over-inundation of information and ideas and stuff that kind of like what you were saying, am I okay, or are we okay? And, like, no, nobody's okay. But that's also okay. Like, that's fine. So, don't overthink it. Just be yourself, right? Because you only get one shot at this whole thing to just be yourself. And what a gift.

[00:05:06] So, starting my page, becoming really vulnerable in a public way is difficult. It was hard to do that at first. And now I am so much more comfortable with it because my audience size has grown and that's validating in itself. So, I feel compelled to continue oversharing all the time. But it's one of those things where when you let your guard down and you make yourself vulnerable, which I try to do, people really can sense that, the realness of what's happening in life and that you're not preoccupied by the b**t. Like, let's just get to the point.

[00:05:45] Dr. McBride: Yeah. And I think social media has allowed people like you to do that because maybe you have an intrinsic confidence or just sense of self that's stronger than others perhaps. But I think there's a lot of fear about revealing our true selves, certainly publicly and even to our own friends and family sometimes or to ourselves.

[00:06:06] There's a hesitancy to really look inside and acknowledge uncomfortable truths, realities about our lives, about who we are, and then Instagram highlights how perfect people are able to present themselves and then it can deepen any preexisting insecurities. So, I think what I'm hearing you say is that the vulnerability you are presenting outward to your audience is also reinforcing to you of the magic of vulnerability for your own self.

[00:06:40] I'm guessing that you're a little bit like me in this way. The glue of my friendships with women in my life is shared vulnerability, and honesty, and truth. It's not a hey, one-upmanship, it's not a competition. It's, like, it's being real. Because first of all, who wants to be around other women who are like, "Oh, I'm so great, and look at my kid, they won this award." I mean, at the same time, my friends are people who can celebrate my wins with me too, and cry with me at the same time.

[00:07:11] Caitlin: But all that stuff is also like, it's frankly super boring when you just talk about what's, like, great, right? Like, I'm like, "Can you tell me what's wrong? Tell me all about your s**t and I'll tell you about mine, right?" So that's what you were saying. Basically, it has been a super validating experience for me and I think that what I hope the followers who are on my page gain is also their own personal sense of validation through seeing somebody let their guard down on social media because it is a difficult place to do that.

[00:07:41] Dr. McBride: Yeah. And giving people permission to explore their own vulnerabilities and be funny, and be silly, and go get a snack. For anybody who's listening who hasn't seen Caitlin's Instagram handle, she cuts through the BS and then often ends her little monologues that are riveting and relevant with, "So, go get a snack," and you tap the camera. And it's just so refreshing. And then I wanna go get a snack and I do.

[00:08:07] Let me ask you a big question. What is your definition of health?

[00:08:11] Caitlin: Yeah, that's a huge question. I feel like it comes from so many areas, but I guess it starts with, self-awareness, so figuring out what is going on in your body, listening to your body and your mind. Because I'm someone who has health anxiety. And I don't know if that's a PTSD thing from what we went through with my son, but I think I've always had a fairly strong element of that within me.

[00:08:39] I think it's just...it had become much more exaggerated for a period of time, and I'm figuring all of that stuff out now too as I go and learning to take the whole picture instead of focusing on something catastrophic or whatever within my body. So, sometimes I feel like I'm too self-aware, I'm paying too much attention to what's going on in my body with that kind of thing. But, you know, just full picture.

[00:09:04] And this is also something I learned along the way with my son, with the doctors that he would see at Memorial Sloan Kettering, which is a world-renowned cancer center and they have fantastic doctors there. And I really praised the way that they were not alarmists and they kept you sort of grounded with things in terms of...maybe a symptom would arise or something like that but look at the big picture.

[00:09:29] Is this worsening? Are there other things going on? Is this something that I need to really fix or should I relax about this and see if it resolves on its own type thing? So, I'm big into movement. I've got to move my body for not just my body but my mind. Like, I've gotta get...shake my crazies out. And then, balance, balance with food, balance with alcohol, balance with getting enough sleep and doing things you like.

[00:09:58] Dr. McBride: It's a great definition. And I 100% agree with you. It has to start with self-awareness. And sometimes awareness brings discomfort when we realize, "Oh, my god. I'm anxious about every symptom." But if you can recognize, as you have, that some of that stems from a real medical vulnerability with a precious person in your life, then perhaps that allows you to forgive yourself for being anxious and also just try to better frame medical issues as they come up. Can you talk for a second about your son and his diagnosis?

[00:10:34] Caitlin: Yeah. He had just turned three years old, this was December of 2016, and I started to notice he wasn't doing well. He had come down with some kind of a virus, like a cold or a flu. It's that time of year. So, I wasn't particularly worried right away. But then he was not bouncing back the way a child should after say a week of illness. And I noticed he was getting more tired.

[00:10:58] He would want to take a nap. He had dropped his nap. His color looked bad to me, his appetite was bad. So, there were all these… a conglomerate of things going on with him. But little kids are not super self-aware of their bodies necessarily. So, they can kind of distract themselves pretty easily. And you might think for a minute, "Oh, maybe he is okay, you know, maybe everything's fine. He's playing right now or he’s coloring." But deep down it was, like, eating away at me. I knew something was going on.

[00:11:30] So, I had taken him to the doctor after, you know, like, the first illness of a couple of fevers and stuff just to make sure everything was okay. And then we went home and then he seemed to have some other illness or the same, just not recovering from. And then he started getting some fevers that weren't going away. And, of course, I visited Dr. Google.

[00:11:48] Dr. McBride: That's not the wrong thing to do. It just can make people more anxious if they're already anxious.

[00:11:53] Caitlin: Totally. But, like, this time Dr. Google was right. You know your child. Like, you know your child better than anyone. So, I took him back and I actually said to the doctor that day that saw him, "This might sound crazy to you, but he's been sick for kind of a while now and I don't see him improving. And he's had this fever going on. I wasn't a big temperature taker, I wasn't really alarmist like that with my kids when they were getting sick. I knew he had a fever because I could feel him being warm. I didn't know what his temperature was every day or something like that. This is maybe day five or six of him being like this. This is crazy, but could he, like, potentially have cancer? He was up all night coughing, all of this stuff.” And I was very quickly sort of, like, brushed off with that.

[00:12:34] I said, "I'd like to see blood work.”... I'll do an exam and if I see any red flags, and then I'll order blood work. So, whatever. The visit goes on and the doctor is like, "You know, I don't see anything totally out of the norm here. He's probably just got, like, a cold on top of a cold or something like that."

[00:12:56] Honestly, 99% of [00:13:00] the time this doctor would've been right, I don't blame her for that. But I knew that he wasn't all right. So, that's just one of those things where you learn to trust your instinct a little bit. And even if you're wrong, who gives a s**t? Just get the blood work done or do what is gonna put your mind at ease because you do know, you know, be the advocate.

[00:13:18] Dr. McBride: I wanna get back to that point after you finish that story because it's such an important moment of the interface between medicine and humans. But go on.

[00:13:28] Caitlin: Yeah. So, then it was Christmas that weekend. This was a Friday, that day that I took him to the doctor. And Monday was, like, sort of Christmas observed, so skeleton-staffed everywhere, that kind of thing. And, like, the last thing you wanna do is go to the doctor on the day after Christmas where it's just, like, exhausted with little kids celebrating the holidays. But I couldn't even get him to, like, take a bite of cake at breakfast that morning.

[00:13:52] I was like, "Do you want some cake?" Because he wasn't eating anything. So, I was kind of desperate for him to eat. And he wouldn't...he didn't want anything. And I picked him up right there and then. I was at my mother-in-law's house, I was like, "We gotta go. Like, I'm going to the doctor right now." And so, we got there and I said, "I just...I don't care. Like, don't bother with testing or whatever, just order the blood work so I can get this. I just need this."

[00:14:16] So, really honestly, two hours later, pretty much we had to drive up to a hospital, get the blood taken and they called back with, like, very alarming results. Some of the markers for leukemia were way high, way low. And we were sent to go to the emergency room at a local children's hospital that day. And that was, you know, the beginning of our cancer diagnosis journey.

[00:14:41] Earth-shattering experience as a parent, just praying so hard that it wasn't what you thought it was and then thinking you might be, like, in a nightmare for a little while. Like, is this really happening to my kid right now? Just putting one foot in front of the other until you got through it because we were really the lucky ones because he's great today he is well.

[00:15:06] Dr. McBride: And how old is he now?

[00:15:08] Caitlin: Now, he's nine.

[00:15:09] Dr. McBride: And he's healthy, cancer-free, in remission?

[00:15:11] Caitlin: Yeah. He had gone through over three years of chemotherapy and other treatments. And that's a standard protocol for this type of pediatric leukemia, acute lymphoblastic leukemia. And he finished it and has been a clean bill of health ever since.

[00:15:31] Dr. McBride: I have lots of, first of all, empathy for what you went through as a parent and as a patient, and as someone who felt dismissed by the medical establishment. I also have an observation that I would imagine that the path you were on for the last six years has helped you with the perspective that you have that you then bring to your audience.

[00:15:54] But first, I just wanna touch on the moment when you're in the doctor's office and you have a maternal instinct about your child and you're not being heard. I think so many people can relate to that moment, whether they're there for themselves or their child, or their elderly parent. There's nothing like a patient's intuition. You know, patients know them more than the doctor knows them.

[00:16:18] At the same time, we see patients who are anxious, patients who go on Dr. Google, patients who come in with a laundry list of diagnoses that they've made on their own. They're like, "I have the flesh-eating bacteria, and I have ALS, and I have Crohn's disease, and just tell me what to do." And we then develop, as any human does, as physicians, we develop biases and we develop confirmation bias so that when we see someone bringing in a laundry list of Dr. Google diagnoses, we think, "Hmm, this person probably is anxious."

[00:16:51] But what's important for any of us, especially in medicine, is to check our biases and to check our egos at the door, and recognize that patients know them better than we know them. And you're right that 99.9% of the time, your son's fatigue and malaise after a viral infection is fatigue and malaise after a viral infection that will then get better with time, but that moment warranted investigation.

[00:17:17] And you weren't the hysterical parent who was checking his temperature 24/7 even when he was going to school every day and healthy. You weren't being hysterical. Even if you were hysterical, sometimes testing is the tincture, sometimes reassurance is the very thing that we can do best for our patients. Sometimes we do tests because we know something's wrong and sometimes we do tests because we know something's not, and we want to honor the patient's natural anxiety and let them dispatch with it.

[00:17:43] So, look, I'm not perfect at that either, but I think it's important for people to recognize that doctors are human too, doctors make mistakes, doctors make assumptions. But this is all the more reason to then be in touch with your intuition and your awareness of your own body and mind and to know what questions to ask, and then also to advocate for yourself because it's very hard to advocate for yourself in the current medical landscape.

[00:18:10] Caitlin: Yeah. That's really the main takeaway that I have gained from my experience with my son, is the self-advocacy or the advocacy of your children. Because as a young mom, you know, my son, that was my oldest. He was three years old and I had a one-year-old at that time too. You don't know that much about kids at that point really. You're still getting to know what it's like to have children, even though that might seem like a long time to a brand new mother of a newborn or something. It's a constant learning experience.

[00:18:46] So, we do put a lot of faith and trust in doctors, which is the right thing to do. Always get a medical professional's opinion. But don't discount your own inner gut feeling. Don't ever not listen to your gut when it feels like you need to ask for more or get an answer for something. Don't be afraid to speak up about that stuff because you'll never regret going the extra mile for yourself or your children to make sure everything's okay.

[00:19:14] Dr. McBride: One hundred percent. And recognize that it's normal to be anxious about yourself not feeling well or your child not feeling well, or noticing something funky. And we need to notice our own reactions to those bodily cues. In other words, there are people who have an outsized level of anxiety to what is a normal physiologic response.

[00:19:36] I had a patient this week come in who her heart rate was 110 when I was measuring her heart rate. And that's an abnormally high heart rate, but it's because she's anxious, it's because she's caring for her elderly mother who's in hospice right now. And so, she was anxious about it being high and I said, "Look, you have a normal heart that's the accelerator that's being pressed and is giving you a fast heart rate because of the fear and anxiety and grief you're experiencing over your mom. So, let's not medicalize your fast heart rate. Let's address the underlying anxiety and grief that you're experiencing." The wrong thing to do would be to treat her fast heart rate with medication. The right thing to do is to acknowledge the reality of her life right now.

[00:20:16] Caitlin: Let me ask you a question about that as a doctor, Lucy, because I always wonder...I do sense that there's sometimes resistance or just lack of interest from medical doctors to look at the mental health aspect of certain...

[00:20:30] Dr. McBride: Oh, man, girlfriend. I mean, why do you think I'm doing this?

[00:20:34] Caitlin: Yeah. But I think it would solve so many problems. I mean...

[00:20:37] Dr. McBride: I mean...

[00:20:38] Caitlin: Stress is the root cause of, like, so many health issues. And I just...I hate that it's never, "Let's try to work on this and see if it helps that," right? Like...

[00:20:50] Dr. McBride: I mean, my job is actually really, really easy. I mean, it requires a medical degree, it requires experience, it requires paying attention and listening. But that's exactly what medicine doesn't have right now, is time to listen to patients. So, if we acknowledge that we all have mental health. You're born with mental health, you can't opt out of the mental health feature of being human like you can a feature on your car.

[00:21:17] So, if you then acknowledge that you have anxiety, that's how we survive in the wild. It's how we get the term paper turned in, it's how we get the Christmas presents wrapped, it's how we get s**t done. We have anxiety, we have moods. We have grief and loss and vulnerabilities. We have relationships with food, we have relationships with alcohol, we have relationships with each other. All of those things we have, that's a given.

[00:21:45] The question isn't do you have anxiety, do you have moods, do you have relationships? It's how do you understand them and how do you gather a kit of tools to manage the inevitable roadblocks that come your way, whether it's a child with a cancer or a mental health diagnosis, whether it's your own health issues which inevitably come up, or whether it is an inherent mental health problem when, for example, anxiety goes from being, "I'm worried about my son's chemotherapy," which is, of course, in proportion to the level of stress, to am I anxious where every time he has a paper cut, I'm panicked that he's gonna bleed out and this is a recurrent tumor?

[00:22:27] In other words, where am I on the continuum of anxiety? Where am I on the continuum of a healthy relationship with food, where I eat when I'm hungry and I don't eat when I'm not hungry? So, it's a long way of saying, yes, if we could just acknowledge that patients are more than a bag of organs and they are humans, they're dynamic and that our stories live in our bodies, medicine would actually be serving people.

[00:22:58] Caitlin: Yeah. And like you said, every case is nuanced. One patient is not going to respond the same way to the same treatment as another patient necessarily. It can be trial and error or not one size fits all, basically.

[00:23:17] Dr. McBride: One hundred percent. And then let's take it a step further. When you get dismissed by a doctor like you were, when patients every day are being not heard in the doctor's office and medicine has become a cattle-herd style, cookie-cutter style exercise, and we define health as the sum total of your lab tests, what happens to patients? They don't trust doctors. They don't trust that they're being seen, and they're not.

[00:23:44] So, what do they do? They go on the internet, they go on Dr. Google. They look for wellness memes, they look for quick fixes, they look for cleanses, they look for diets, they look for candles and funky stuff. Look, I love candles. I buy crap that's in a pretty package, but I have my expectations managed of what it's gonna do for me. I bought this, like, body lotion at CVS the other day and it was, like, lavender scented it said calming lotion. And I'm like, "If this lotion… can calm for $2.99, that would be amazing." But here's what the wellness industry does, and it's well intended in many ways, is that it actually mismanages people's expectations and it steers people away from the exercise of looking at the hard truths of their lives in many cases. And it's exactly why your content is popular, is because people are not being heard, they're not being seen, and then they go on Instagram, they're looking for that quick-fix-cure fitness instructor and then they find Caitlin, and then they're like, "Ugh, thank god. I'm gonna go have a snack."

[00:24:47] Caitlin: Well, thank you. I think what you said there too, it's like when you said the word the wellness industry, it is an industry. And that's also part of, like, social media industry and buying and selling, and what you're made to think or believe based on a market, and learning how to discern what's actually happening versus what you might be over-perceiving to be happening, or what is really right versus what somebody said was right, or something like that, just listening to yourself.

[00:25:20] Dr. McBride: So, Caitlin, you and I met on Instagram because I immediately was attracted to your vibe, and also because you were advocating for common sense policies when it came to COVID mitigations in kids. You're a mom of a child with an immune-suppressed condition, yet you also were able to see what I see, which is health is about more than the absence of COVID-19. Can you talk about that just a bit?

[00:25:46] Caitlin: My son, you know, he was an immunocompromised child when this pandemic began. And we had, you know, firsthand information from how children...and particularly children on the oncology floor at Memorial Sloan Kettering at the beginning of all of this, real-time information about how those vulnerable kids were faring against COVID. And our doctors were very much, "Don't be worried about this in that way." They were consoling us, genuinely frightened parents of our immunocompromised children that this isn't something that we're seeing having very serious outcomes with children at all. Thank God.

[00:26:27] Dr. McBride: Absolutely. So, I'm really curious, as a content creator yourself, what is it like sort of internally to be putting yourself out there, talking about yourself, like, giving pieces of yourself to other people? What are the biggest upsides and what are the biggest downsides to that?

[00:26:46] Caitlin: The upside is it's a fantastic creative outlet for me. Like, it really fills my cup. I like doing that stuff. I like delivering it in a humorous way. I get a real [bleep] kick out of myself.

[00:27:01] Dr. McBride: I hope you do because I would imagine that you have fun just hanging out with yourself.

[00:27:04] Caitlin: Oh, no. I mean, you know what? Part of this is, like, the isolation of motherhood being home with little kids because I was really locked up with my kids for so long, my little kids. And they are boring sometimes, you know? Like, they're busy and there's so much action, but not a lot of, like, adult mental stimulation.

[00:27:22] So, it was like I was talking to a bunch of people all day. So, that was really fun for me. And I love that. But then there are, you know, moments where I do feel like, "Oh, man, I just said that today about this and that's my kid's teacher who probably saw it," you know? So, within, like, you're in a real-life community, you can be a little bit like, "Oh, god, that person probably saw me shaking my ass in the kitchen this morning, whatever."

[00:27:54] Not that I really care because I don't. Because you can't if you're trying to, you know, build a real authentic brand, audience, community, you have to just sort of put it all out there. But then I also do think about, as my kids get older and more aware and are maybe on social media at some point in the coming years, what they will think, if they will be mad that I've been making fun of them so much, or what.

[00:28:28] But honestly, again, it comes back to just being authentically who I am and kind of staying true to myself and doing what I really feel, like, compelled to do personally because I don't know, for whatever reason, I really want to do what I'm doing here. And it's about following sort of my own goals and dreams in that sense. And I hope that the way that I explain it to my kids, I'm really honest with them and stuff, that they will also respect that. So, upsides are super personally fulfilling, and downsides is maybe, in real-life, community perception of you. But you have to just sorta roll with that, take it on the chin.

[00:29:06] Dr. McBride: For anybody who's not following Caitlin yet, when you say, Caitlin, that you're making fun of your kids, it's so clear the deep love for your children that you have. Because as we both know, there are a lot of people on Instagram talking about early motherhood is the best time of their lives, and, "Look at my child with this perfect outfit."

[00:29:26] And anyone who's been a mother knows that those early years are particularly hard and, like, not pretty in so many ways. And so, you're giving people permission to acknowledge that. And it's obvious that you love your kids beyond words. It's obvious. So, you can then make fun of them and make... There's no mean-spiritedness about it. I'd love you to give some examples of what diddies have you done lately that gave you the most kicks. Because I'll tell you the ones that I like the most, but go ahead.

[00:29:55] Caitlin: I'm fairly known for just going right out there and calling toddlers a bunch of a**s because they are.

[00:30:01] Dr. McBride: It's perfect. It lands so well. How are toddlers a**s?

[00:30:04] Caitlin: They're so ego-centric, which is by no fault of their own, their little underdeveloped frontal lobes. And they only care about themselves, they don't care about you. They care about what they want when they want it and they make everybody miserable until they get it.

[00:30:19] Dr. McBride: And then tell me about, like, the most fun diddies you've done where... Like, one of my personal favorites is when you're...I mean, you dance a lot but when you're in the...I think it's one of your most popular...it's one of your most viewed where you're in your kitchen and you're dancing with a broomstick and your son kind of, like, pads up to you and, grabs something that you have.

[00:30:49] Caitlin: Dance ones are like... There's a whole portion of the audience that, like, loves the dancing. And then I think there's a whole portion of the audience who is just there for the jokes or the stories. I think, like, the stories are pretty popular because that's really where you get, I think more of the real me if you follow along. Because the grid, my grid is more, it's jokes or dancing or something. It's, like, the hook and then you stay for the real in the stories, I'd say.

[00:31:08] Dr. McBride: And so, what do people respond to the most? What do people write back, and what do people say to you?

[00:31:13] Caitlin: I mean, so many DMs about, like, just conversations that I have in my stories. I mean, I did kind of a botched silly makeup tutorial...not a tutorial, just so many people had just asked me like, "How do you put your makeup on?" And so...

[00:31:31] Dr. McBride: Oh, my god. You know you've hit the big time when people are asking you what your makeup routine is.

[00:31:36] Caitlin: I'm, like, also hardly ever wearing makeup on my Instagram page, so it just made me chuckle. But then, like, people have their suggestions about, like, what you should or shouldn't do with your face or whatever and I'm kind of like, "I'll [bleep] decide what I wanna do with my face." You know, like, I wasn't asking for advice. But I think people respond to the story. I think that's why people...like, where they feel the real connection to me is via my Instagram stories because that's really where I am a real person. Because the page, the profile grid is more theatrical and the joke being delivered or dance or something.

[00:32:15] Dr. McBride: Where are you going with this? What is your...? Do you have a plan or are you just sort of taking it one day at a time, or do you have sort of, like, big aspirations for Big Time Adulting?

[00:32:24] Caitlin: I do have big aspirations if I'm being totally honest.

[00:32:28] Dr. McBride: Be honest.

[00:32:28] Caitlin: I'm playing the long game with all of this. So, it was never, "I want to jump into this and become an influencer." That was never a goal for me. I want to be able to monetize what I'm doing, but in a more meaningful way, I guess, so via real content that I've created or partnerships, and those sorts of things. Because I have sort of waited and waited and waited, and not accepted some sort of opportunities that I didn't feel like were really true to me or authentic for me.

[00:32:59] I'm starting to see some doors opening right now that are really exciting opportunities that I'm hopefully going to be getting involved in. And it's been just kind of being patient and waiting to see what opportunities sort of naturally come into my life via this platform. I will probably, maybe soon, do some sponsorship, something with a brand that is truly a brand that I like and use. And I will always probably have, you know, a give back to pediatric cancer research and stuff, which I feel like is just...it's a motivational thing for me too. I'm like, "Yes, I can make money and I can also give back as I'm making money."

[00:33:43] Dr. McBride: I mean, during your son's treatment, I think you started a Cycle for Survival team.

[00:33:46] Caitlin: Yeah. We've been doing it since 2017 and we've raised, like, over $0.25 million through our team. We've become really invested in the organization because it gives specifically to rare cancers. And all pediatric cancers are rare. So, it's just phenomenal in terms of a research-driven program because 100% of every dollar raised goes to research.

[00:34:11] Dr. McBride: That's incredible. And it's another example of how you're using your content for good. I mean, you're reaching people as individuals in their kitchens and you're also reaching a wide audience. You're also helping childhood cancer with this work. That's amazing.

[00:34:28] Caitlin: Yeah. I feel, you know, it's gonna be something that will be part of my life forever now. So, I'm committed to always giving back.

[00:34:48] Dr. McBride: So, when I asked you the question, what does it mean to be healthy or what's your definition of health, you immediately said self-awareness. So, I would argue that it's that self-awareness for all of us and then it's a laddering up from awareness to acceptance of things we can't control, and then agency. So agency and feeling like you have meaning, purpose, and the ability to affect change in your life or in others' lives is part of being healthy.

[00:35:07] And that's what you're doing because you've taken a vulnerable moment in your life like being a parent of a child with cancer, where you have very little agency, to creating a platform where you are forced to be more self-aware than ever, accept things you can't control like what other people think of you, and then now you have these opportunities and you're making a change in the world for childhood cancers en masse.

[00:35:30] I mean, the world is your oyster. I don't mean to be hyperbolic. I tend to, pedal in hyperbole, my kids accuse me of that. I'm so excited to see where you go with this because you have all those ingredients. You have the self-awareness, you have the acceptance, and you have agency. Obviously, you're a work in progress like the rest of us, but it's gonna be fun to see what you do with this.

[00:35:50] Caitlin: That's so kind of you. I really appreciate that. I mean, I'm really flattered when I hear anyone say something like that. And it's been a really fun journey. And having an opportunity like this just to, like, chat with you and kind of think deeper into those topics of health and things that are really important. So, who wouldn't like to spend, you know, an hour and change of their day doing that?

[00:36:16] Dr. McBride: It's great. And social media has so many warts, but the upside of it is the connection that's real and authentic. And that's what's fun about it for me.

[00:36:25] Caitlin: Yeah. I never would've imagined that would be real. It would be like people that you speak to online, that sounds really creepy, you know? But it's so true. You really do feel like you've come to...I mean, and we've obviously had real conversations before, come to know someone via online.

[00:36:45] Dr. McBride: It's possible and it's a very cool feature. If you can abandon the BS that comes along with it and just lean into the fun part and the connection part, it's a really amazing place.

[00:36:56] Caitlin: It is. I'm grateful for it.

[00:36:58] Dr. McBride: Caitlin, thank you so much for joining me today and for sharing part of your life, and yourself, and for reminding us what it means to be human.

[00:37:06] Caitlin: Oh, my goodness. Thank you, again, so much for having me. Such a pleasure getting to know you and chatting.

[00:37:14] Dr. McBride: Thank you for listening to "Beyond the Prescription." Please don't forget to like, subscribe, share, download, and rate the show wherever you find your podcasts. And if you have a comment or question, please feel free to drop me a line at lucymcbride.substack.com.

[00:37:31] Our theme song is courtesy of my brother, the multi-talented, Walter Martin. Thanks, Walt. You can sign up for my free weekly newsletter about mental and physical health at lucymcbride.substack.com. The views expressed on the show are entirely my own and do not reflect the views of my employer and should not be a substitute for advice from your personal physician. "Beyond the Prescription" is produced at Podville Media in Washington, DC. Until next time, be well.

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In honor of Mental Health Awareness month, we welcome Dr. Samatha Boardman. Dr. Boardman is a New York based positive psychiatrist who is committed to fixing what’s wrong and building what’s strong. She writes the popular newsletter called and is the author of Everyday Vitality, a book about leaning into our strengths to bring about positive change.

Historically, psychiatry has focused on the diagnosis of disease and the treatment of individuals with mental illness. Positive Psychiatry takes a more expansive approach, focusing on the promotion of wellbeing and the creation of health.

Dr. Boardman is passionate about cultivating vitality, boosting resilience, and transforming full days into more fulfilling days. Today Dr. Boardman sits down with Dr. McBride to discuss finding wellness within illness, strength within stress, and how to live with anxiety rather than being defined by it. Dr. Boardman is here to help!

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, review — and enjoy — the show!

The full transcript of the show is here!

[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.

[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out whether they are okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter through my website at lucymcbride.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.

[00:01:01] Today's podcast guest is Dr. Samantha Boardman. Samantha is a positive psychiatrist, a clinical assistant professor at the Weill Cornell Medical College in New York, and the author of a book called Everyday Vitality. It's a book that combines her research as a clinical psychiatrist in New York to help readers find strength within their stress.

[00:01:24] I met Dr. Boardman through a mutual friend. I started reading her book and listening to her talk on Instagram, and it was clear that we had a common interest in helping people marry mental and physical health. Today on the podcast, we will talk about when is therapy not appropriate? We'll talk about medication, we'll talk about Zoom versus in-person therapy, and we'll talk about leaning into our strengths as opposed to focusing on the negatives. Welcome to the podcast, Samantha. I'm so happy to have you.

[00:01:53] Dr. Boardman: Thank you so much. Thank you for having me. I'm a huge fan.

[00:01:57] Dr. McBride: So today, Samantha, I'd love to talk to you about many things. One is your definition of health. What does it mean to be healthy? So let's just start there.

[00:02:07] Dr. Boardman: Great place to start. And so I think my definition of health has really changed over the past 20 years. Like you, I went to medical school and then I did a psychiatry residency. The definition of health for me then was the absence of illness. And what I thought of myself as doing my role was to make people less miserable as a psychiatrist.

[00:02:30] And I've gotta tell you, I got pretty good at misery along the way. But one day I was actually fired by a patient who said, when I come to see you, we just focus on what's wrong with me. We don’t really focus on what's going on, what's wrong with what's going on in my life?

[00:02:47] And she was right. I was so fixated on symptoms and dialing down the issues, dealing with conflicts in her life and that type of thing, and less focused on what makes life meaningful for her, what she enjoys doing and where she finds purpose. It sort of woke me up and I ended up going back to study applied positive psychology, which was sort of the opposite of everything I had learned in medical school, in psychiatry residency.

[00:03:14] I studied optimism. I studied resilience. I studied post-traumatic growth. All these data-driven experiences that were really absent in my education and so much that had been focused on pathogenesis, which is the study and understanding of illness in switching over more to salutogenesis, which is the creation of health.

[00:03:36] So this is a really long-winded way of saying, I think of health as so much more than the absence of illness, and I'm deeply interested in how we can help people create wellness within their illness and strength within their stress, and add vitality even into their very busy lives. And as you know, when we ask patients, what's most meaningful to you?

[00:03:57] What do you care most about with your mental health? Or your health in general? People say, I want to have a good day. I want to feel energetic. I want to feel strong. I want to be able to give back. I want to spend time with friends and family and those types of things, that's what salutogenesis is—creating experiences of health and joy and meaning and vitality and energy for them in their everyday lives.

[00:04:24] Dr. McBride: It's so important because just like you discovered along the path of your training and clinical work, I too realized that my job isn't just about helping people not die. It's about helping people live. And it's not enough to tell people at their annual physical, “Hey, your labs look fine. Get a little more exercise, eat a little healthier, and I'll see you next year.” Not dying is good. But what about living? What about having agency over our everyday lives the 364 days a year that you're not in the doctor's office? And what has always struck me since I was a pup of a medical student is that self-awareness is like ground zero for our health.

[00:05:14] When we are able to pull the curtain back on who we are as people to understand not just our genetics, but really our stories and how our stories inform how we feel—literally our body parts—and then how we organize our everyday behaviors and thoughts around the narrative that we tell ourselves, and that's really why I became in interested in mental health and why I find your work so compelling is because I think we're having a moment in our culture where mental health is more acceptable to talk about; where people are more empathetic about mental illness.

[00:05:55] I still think we don't have a great understanding of what mental health is. And to begin with that we all have it. And I wonder what you think about this concept of everyone having mental health and it's just on a continuum versus mental health versus mental illness. And then secondly, to what extent do you think just mere self-awareness is an important ingredient in having mental health?

[00:06:25] Dr. Boardman: Both [of those are] awesome questions and I think that kind of you have it or you don't is this binary, and really limits us about either you're mentally healthy or you're not. And I think that's sort of the way I was trained. Not to be critical of my training, but that was either: you need to be hospitalized or you don't, you're ready for discharge… and not kind of looking at all of those other factors that you look so closely at.

[00:06:51] They kind of give you and provide for you even this scaffolding around you to help you make better choices, to have more better actual days in your week. And this idea that how do you find wellness within illness? And it's something Dr. Ellen Sachs was the one who first I heard speak about this and she was a graduate student.

[00:07:13] I think she was at Yale where she had her first psychotic break and she was diagnosed while she was a student there as having schizophrenia and having a psychotic illness, and her parents were told at the time that they should remove all the stress from her life, that she should withdraw from school, that it was too much for her to bear and that, you know, that maybe she could get some very simple job somewhere.

[00:07:38] Maybe she could pump gas. She could do something that was not going to strain her or stress her in any way, and that most likely she should be hospitalized over again and again, and she might end up rocking back and forth in some institution watching television on lots of medication and drooling.

[00:07:54] And she said her parents understood this diagnosis, but they refused to accept this prognosis. And she had support, she had resources. She went back to school. She had psychiatrists, she had therapists. She, I mean, she was, she was supported by so many buoys around her and scaffolding.

[00:08:15] She returns to school, she finishes at Yale. She then goes on to Oxford where she gets a degree as a champion of mental health law. She goes on to win a MacArthur Genius Grant. She's an extraordinary woman and defies how people like me are trained into sort of expect that runway of what schizophrenia can do to a human being.

[00:08:36] And you know, and she says that actually having this meaningful work in her life has really been, is what saved her. When her voices get loud, she uses her legal training to say, what evidence do you have for that? And how having a really strong sort of sense of purpose in her life has really saved her.

[00:08:55] So when psychiatrists like me say, take all the stress out of your life. Remove anything difficult. How do we find that balance for people of helping them lead that kind of meaningful life in finding wellness within their illness, and even for those who don't have a diagnosable condition… [finding] some strength within their stress so they can live with it.

[00:09:18] It's not being able to… I think we've all learned about Winston Churchill, who had that black dog of depression, but learning to live with it rather than trying to sweep it under the rug or be in denial about it. Or completely defined by this. And we know even with the language we use when you call somebody a schizophrenic versus somebody who has schizophrenia, not only does it change the way that the person thinks about themselves, but it also changes the way that the people who work with them think about them.

[00:09:47] If that is part of their identity, that's who they are versus that something they live with. And it comes and it goes. And there's interesting, Jess Day has done some really interesting research on schizophrenia looking at how a significant number find happiness, find meaning, and it's those who have some of these more lifestyle factors available to them that do make them more resilient.

[00:10:09] Dr. McBride: It's a really good point. You wouldn't be surprised to hear, I had a patient who exhibited all the symptoms of depression. Fatigue, sort of that psychomotor fatigue, that sort of hopelessness joylessness, and then was gaining weight. And we didn't have another diagnosis because we had done all the tests, we'd done the scans and everything was normal.

[00:10:28] And I said, “do you think it's possible that you're depressed?” And she looked at me and said, “what do I have to be depressed about?” And I thought, gosh, this is such an interesting thing. This is someone who unfortunately is a victim of this concept that you're either mentally healthy or you're mentally not.

[00:10:46] When we all have moods, it's a continuum, and my question to patients isn't, do you have an ICD 10 code of F 32.9? My question is, where are you on the continuum of mood and what tools do you have to manage them? What symptoms are you having and what tools do you have? Because it's not about are you mentally healthy? Are you mentally well? And it's not about, are you happy all the time and joyful and gleeful and skipping through the streets, or lying in bed or standing on the edge of a cliff about to jump. It's where are you located on the continuum of these universal conditions of having moods, having fears, having anxieties.

[00:11:26] And so I said to her, it's really not about a thing, it's about what's happening to your body and mind right now. And I don't need to name it. I don't even need a code or a label for it. I just want to understand if this is an organic depressive phenomenon, what agency we can carve out to help you feel better in your everyday life.

[00:11:47] Dr. Boardman: That interesting point that you're making too, that she's feeling guilty about, what do I have that… that question your patient asks, what do I have to be depressed about? And that's something I hear a lot in people who think, “I'm so lucky. How on earth, how dare I be in this state of mind? It’s shameful.” And I think this sort of goes hand in hand with some of this toxic positivity we hear all the time as well. You have to be happy all the time. You have to not have stress, you have to sort of have that sort of fan wind blown hair and that everything has to be perfect or there's something really wrong with you.

[00:12:24] And what you're pointing out too is this notion of over the course of a day, over the course of a week, over the course of a minute, how our emotions can shift and it's calling into question, this idea of your personality type, you're just a grump and all those different things.

[00:12:42] Maybe I'm a grump right now because I just got a parking ticket. But if I actually filled out some of those forms testing my personality an hour or two later, I would probably be in a better mood. All of these, we have so much emodiversity in our days and how things come and go and actually there's evidence to show that people who honor and are able to acknowledge their emodiversity…we have this like binary idea that either people are good or you're bad. You had a good day, or you had a bad day, you're happy or you're sad. Anything that really kind of limits the way we think about our own mental health. It's even the way we think about our loved one's mental health, trying to tease apart the nuance and appreciate the emodiversity that we're handing, like enjoying the laughter through tears.

[00:13:28] How we can hold emotions side by side. It's not that either or situation. And the other side of this is this kind of wellbeing industrial complex that is: feeding off of toxic positivity too, this idea that we need to really make these radical changes and transform every single thing we do.Like: we should move neighborhoods. We need to go on vacation for six months. We need to buy this candle or this bubble bath, or this new exercise bike, or all of these wildly expensive and time consuming endeavors that we are kind of constantly told are the only way that the clouds will part and that we will be able to be happier.

[00:14:15] And I think that it really frustrates me and it's sort of like a pet peeve as you can tell. I'm getting sort of animated and annoyed by it. But this, this idea that you have to buy it and consume it and carve out all this time for it and that we're kind of missing a lot of these everyday actions that we can take that boost our everyday wellbeing.

[00:14:34] Dr. McBride: So let's talk about that. I'm assuming that in your practice you see patients who are experiencing relationship stress, who are experiencing anxiety symptoms, who are having insomnia, who are dealing with substance abuse issues, who are depressed. Obviously you can't speak to every person you see, but what are some common themes that you see in patients where they have more agency than they think they do?

[00:15:04] They may think if they just had a different job, everything would be okay, or if they could just take a six month vacation, they'd be okay. Or if they didn't have the mother that they had, they would be okay. And I think what I'm hearing you say is that sometimes radical changes are necessary. Certainly if you're in an abusive relationship or if you're addicted to alcohol, change is appropriate, external change. But sometimes it's a mindset and it's an internal change. And so what are the sort of simple tools that you commonly dispense to your patients?

[00:15:37] Dr. Boardman: Well like you're describing, I think these people sort of living in this as soon as space in their head, like as soon as I get this project done, I'm going to start working out. Or like as soon as I deal with this thing with my kid, then I'm going to… And that as soon as can kind of create this, we end up inhabiting this kind of liminal space where this penumbra of just kind of flailing and not really embodying and I, you and I, I think, share this belief in embodied health, kind of actually doing as you say, and acting as you do… wanting to kind of have your intentions align with your actions and I've been really interested in that research of how do you kind of close that intention-action gap. Like we, how do you get from where you are to where you would like to be? And that's such a, I think a common experience for all of us. I just consumed a huge bag of Cadbury mini eggs, like I didn't want to, but there they were.

[00:16:38] And there's a limited edition. So that's just the way that it is. But those intentions that we have don't always translate. And so identifying what is the barrier between you and actually the action that you wanna take. And Gabriele Oettingen, who's at NYU, she's been doing a lot of research on mental contrasting, this idea of figuring out what your reality is versus what your hopes are. And as much as maybe it's an American thing, that whole idea of like dream big, think positive, you know, you can manifest your dreams. You wanna manifest that you have lost 20 pounds, or that you're going to the gym all the time.

[00:17:21] All of this actually really doesn't help us. And it might feel good at the moment when we're sort of thinking positive, but it really doesn't translate into action usually, and typically, it makes us feel worse when our reality, when we bump up against our reality in some way. And so how do you close that?

[00:17:42] And so her research shows with mental contrasting—she calls it using this acronym of WOOP, W-O-O-P. And this is an exercise I think all of your listeners can do, and it, it, it really works. And they've seen it with weight loss, with saving money, with exercise, in relationships, all these different domains where WOOP translates into actionable change because as we know, it's quite hard to sustain change.

[00:18:07] We can get somebody to stop smoking for a day, but. A week later, they'll probably go back to it. So here's what whoop is. The W stands for like what is your wish? It has to be something that's intrinsic to you. It's not that something your partner wants you to do, something you care about deeply that aligns with your values. Make it as specific as you can. Like my wish is I would use my phone less when I'm with my kids or whatever that thing is. And then the O stands for, okay, what would be the outcome of that? Like really think about what that outcome would be. I'd feel more connected. I'd feel less pulled in a thousand directions. I'd feel more present. What would that outcome be? And kind of feel it. Literally feel it. And then the next O is, okay, what is the obstacle? You've got to identify the obstacle. Okay. Well, it's always in my hand. Whenever I pick them up from school or whenever I'm sitting at home, it's always next to me. If I'm cooking or at the table, it's always there.

[00:19:04] Okay, so you've got your wish, you've got your outcome, you've got your obstacle. The fourth part is what is your plan? How are you gonna deal with this? Okay, I'm going to turn it off when I'm at home, when we're all together, I'm not going to have my phone at the dinner table. Knowing that wish, but also understanding what is getting in the way of that thing, that obstacle and then having a plan around it is much more likely to produce actionable change. And she's shown this in over 35 papers and, and just really shown the positive outcome of doing that. So just thinking positive, it's not gonna get you anywhere. But actually kind of having, contrasting that, thinking positive with that plan and that identification of the obstacle will.

[00:19:47] Dr. McBride: I think that's so important. I think what people don't like doing, myself included, is turning the mirror on themselves and looking at hard truths about themselves that they maybe go on their phone because it sort of quiets the noisy brain, or it's sort of a distraction from all the messiness in our internal world, and we haven't thought through what the consequences are, and we think we'll do better in the next day.

[00:20:15] And so we do much better liking an Instagram meme that says, think positive than we do at actually looking at our interior and making changes. So like you, I'm particularly interested in that gap between our best intentions and the execution of them, because that's really the most interesting part of my job and the hardest part of my job is helping people start an exercise program, put down the cigarettes, lose the weight they need to lose for their diabetes. And a question I have for you is, because to me a lot of the gap is about self-awareness and sometimes mental health, but not mental illness necessarily. Mental health being defined as really an awareness of our moods, our anxieties, and how are they calibrated to the actual facts in our reality.

[00:21:11] And my question is then, how often do you find people not being aware of their own sort of internal barriers? How common is denial and an absence of self-awareness and an absence of wanting to look at people's stories the problem as you try to affect change?

[00:21:34] Dr. Boardman: I mean, I think we're all in denial.

[00:21:36] Dr. McBride: Yeah, I think we are. I think it's convenient.

[00:21:38] Dr. Boardman: Yeah and it serves us really well in the short term. And we're not even meaning, I mean, denial is sort of an unfair way to put it. I think we're trying to live in a different reality than what we're in, or we tell ourselves stories as you know, like, well tomorrow I'll do it, or, today it's somebody's birthday or whatever. There's so many justifications in the moment, but it is at the same time, I think that gap between our intentions and our actions is an annoying feeling. It's what kind of keeps us up at night. Why didn't I? It's a lot of regret and beating oneself up.

[00:22:12] Even though maybe we're going through the day putting out lots of fires, I do think there's that lingering sense of, especially in the evening, or especially if you can't sleep at night, of why didn't I, why did I do this? And that sense of when we're not aligning our values with our actions, and it's something that I actually ask patients to do when I first meet them, as in, it's part of that kind of self-awareness tool I think you're describing is to write down or just to think about what are three to five things that you value most.

[00:22:47] What matters? What do you care about deeply, what is most meaningful to you? And oftentimes, we're all such busy people, [so we] don't take the time to figure out what those things actually are. And it might be being a good grandparent. It might be taking care of my dog. It might be my health, it might be learning something, whatever that is.

[00:23:09] And then I ask them to think about when you last, on Saturday or when you had some free time, how did you spend it? And really trying to kind of break down how they spend their time and how that aligns with what they value most. And ideally trying to create as much overlap as possible between the two.

[00:23:32] Because I think when there is this disconnect, even when things don't go the way we hope, that at least I think when you feel like you're embodying those values and they're manifesting in your life, even when things aren't going your way, it kind of creates a bit of an armor around you because you actually feel that you're embodying what you care about most, even if it didn't work out for you.

[00:23:53] The other thing is just to remind people, I think we often feel like a failure. [In terms of] I made this commitment, I was going to go to the gym every day this week, and Wednesday just got so busy or whatever. I'm a failure. I'm not gonna start till next week. This idea that every day is an opportunity for a fresh start, even this idea that, oh, I have to wait until this landmark in time… I'm gonna wait till New Year's to stop smoking…

[00:24:18] Tomorrow's a new day, and I think you can kind of just try to harness that fresh start effect at any point. We know typically that people who went, who do, and this is Katy Milkman’s research, if you do it on a Monday or you do it on your birthday, or you do it the first day of the month, you might have more momentum behind you, which is great, but you know, I also think that every day is a new opportunity, rather than thinking, oh, I just gotta throw this all out. You know what? I'm just gonna have a crazy binge eating weekend and just let it all go, versus, you know what? Tomorrow's a new day. And we're really good at beating ourselves up over the stuff that we didn't do well.

[00:24:52] Dr. McBride: Yeah, I mean, I think so many patients that I see who are having a hard time losing weight, exercising more, eating healthy, whatever it is, they lead with a heavy sense of shame and fear in their lives and I'm interested always in pulling back the curtain to figure out what is driving those feelings. Sometimes it's just not doing what they know they should be doing. Sometimes it's pretty simple. It's like, well, I wanna lose weight, but I ate a plate of cookies, so I feel bad about myself. But I think you might agree that there's something deeper going on, and maybe there isn't. I'm not trying to say that everyone's experienced childhood trauma and that pops up at the minute they look at the cookies and they feel bad about that experience and then they binge eat.

[00:25:33] I just think that there's, there's something about our stories and our childhoods and our past that holds us back from being honest about ourselves and overlapping, as you said, the intention with the execution and living that sort of authentic life that we wanna lead.

[00:25:56] And I wish we had an injection for pulling the walls down of shame. If we could take shame and fear away, we would be… we don't want to take away too much fear, otherwise we'd be walking into traffic and we'd jump off of high dives without water in the pool. We need a little bit of fear and we probably need a little shame too, otherwise we'd be sociopaths. But so many people that I see who are trying to make changes in their lives and live authentically, adhere to the rubric of whatever the meme on Instagram said. They can't execute on their best intentions because they are so ashamed of who they are and the stories they tell themselves.

[00:26:36] And that's when I send them to you. That's when I send them to a psychiatrist. Not because they're crazy, but because they're human. And I say, look, I literally say those words and I don't think you're mentally ill. I just want to help mine that space. I could just tell you to do better tomorrow, and I could tell you that you're okay. But I, I think there's something there that I think… I just wish we all had more of a permission to explore those parts of ourselves.

[00:27:01] Dr. Boardman: As a psychiatrist, maybe this is weird to say, but sometimes I think we don't need to always be looking under the hood. Maybe just to push back a little bit on this, that there isn't always an explanation… like my mother did this, or whatever that thing is, or this is my comfort food and that's why I do this now, and it is wonderful. I think when you have those light bulb moments, you know that you have this idea of, oh, this is why I do that. But here's the thing. I mean, research shows that it doesn't necessarily translate into behavior change. You might be like, oh, this is why I do that but you're not, you're still not going to make any meaningful, or take any meaningful steps to stop that thing.

[00:27:47] It's kind of a cool thing, but it's not necessarily transformative. And so one thing that I'm deeply interested in is this mode of therapy called behavior activation that is really asking people rather than to focus on their emotions or always kind of trying to excavate the past in some way is to just focus on the change, the actual behavior, and then see how that changes the way they feel.

[00:28:18] Because I think so much of psychiatry is the whole idea of if you can change how you think and you can change your emotions and your relationship to them, then that's going to change your behavior. And behavior activation kind of flips that on its head and says, oh, if you change what you do, you're going to change the way you feel. And we know that to be the case. If you ask people to, for 30 minutes a day, four days a week walk on a treadmill slowly, it immediately changes their mood. We know that going outdoors, you get this transformation. Even if you're sitting and you're kind of hunched over and then you stand up and you put your shoulders back, you actually feel differently

[00:29:00] That idea again of embodied health, what you do changes how you feel, as much as how you feel changes what you do. And I think in psychiatry and therapy, we've been so focused on one side of it and not looking at that kind of more embodied health of the behaviors that are going to impact what you do because we often get wrong a lot of stuff. We think the thing that's gonna make us feel better is not. Like, oh, I had a long day. I'm going to binge watch tv. I'm going to open up my favorite bucket of ice cream and that kind of short term emotional junk food or actual junk food that we indulge in.

[00:29:37] But we all know that we had to, the first bite's good, the next one, not so much, you end up feeling worse about these types of things. And they are de-vitalizing, I think of them as like a vampire, as a vitality. And the stuff that makes us feel better is actually when we're learning something, we're actually not just engaging in efforts, sparing activities, we're actually doing something that stretches our minds or stretches our bodies in some way. That's, that's kind of engaging us in some meaningful way. And so, I guess I'm a big fan of doing, not dreaming in some way and engaging and acting and seeing how that makes you feel. And this is research out of Stanford that looks at behaviors and what creates behaviors, it's either motivation. That is something we focus on probably way too much. And it's either a trigger, like you see somebody light up a cigarette and you're like, oh, I want one too. Or it's accessibility, how easy is that behavior? And I think an underrated part of this kind of equation is accessibility and making it easier for people to do the behavior that they want.

[00:30:48] Because when we're so focused on motivation, self-control and self-control as we know it comes and it goes. You have it in the morning, you have the best intentions by the afternoon. Somebody puts a plate of cookies in the conference room. You can't help yourself. But if you make it a little bit harder to do that behavior that you don't want to do, like you get rid of those M & M’s or you you make it a little easier because you put your sneakers out in front of your bed the night before and you make, so the behavior you want to do easier and the behaviors you don't want to do harder.

[00:31:21] And this comes from even a community system standpoint, you create accessible parks, you have lighting, so it's easier for people to walk outdoors. You create attractive staircases for people to be able to use in buildings, all those types of things to make it a little bit more fun and easier and more playful to engage in better behaviors. So I think about, how do I make the behavior that I want to do easier, [and] how do I make the behavior that I don't want to do harder?

[00:31:49] Dr. McBride: I love it and I love the pushback. I mean, I love anybody who has an opinion. And I also love anybody who is challenging the popular narrative out there because I think the popular narrative is, and I do subscribe to it in many ways, that excavating our interior is a way to begin that laddering up of health and wellbeing, that understanding our stories can help us make the behavioral change we want to make. But I think you're right, and I see this in patients. Therapy is not a good idea for everybody. It's not necessary and it's not sometimes helpful. It sometimes does harm. And what I mean by that is that, first of all, there are some pretty terrible therapists out there. There's some pretty terrible doctors out there too, and I'm sure I'm terrible on some days of the week.

[00:32:40] But also I think that the talking, the thinking, the intellectualizing can, as you're maybe suggesting, distract us from executing on some of the changes that can then feedback and change our thoughts. And I think there's also the potential risk of attributing some of our behaviors to things that aren't actually true in therapy.

[00:33:01] So what my observation is is that we have two major schools of therapy as far as I can tell. We have the psychodynamic type of therapy, the sort of psychoanalysis where people are lying on a couch and talking sort of in an open-ended way. And that can be every day and can be week after week after week.

[00:33:22] And then you cognitive behavioral therapy where people are trying to change the thoughts and the behavioral patterns that stem from thoughts. And so my question to you is, is this like a third way of thinking about mental health, like not in therapy and just doing the behaviors and sort of societal changes to make behavioral change more easy? Or is it outside of therapy altogether?

[00:33:48] Dr. Boardman: I mean my dream is that one day we will all be put out of business. People won't need us and won't need therapists. And I wish this was part of curriculums and students were taught how to activate change and that this started in, in kindergarten and…

[00:34:06] There's a third type of therapy. You talked about kind of more the psychodynamic talk therapy and then CBT, which is kind of identifying specific negative thinking patterns such as catastrophizing or engaging in black and white thinking. And then what I'm very interested in, and I think of myself as a positive psychiatrist, is kind of a third really complimentary, not an either or, but it's a both, both and kind of situation is focusing on people's strengths.

[00:34:34] What are your strengths, as actually research comparing CBT with strengths-based therapies is what are your top five strengths and there are tests you can do at viacharacter.org, you can take this free test that turns out your top five character strengths. And we know that people who then use their top five strengths in new ways even in a week feel less depressed and less stressed.

[00:34:57] We’re so good at shining the light on our weaknesses and what we've done badly, but looking at our strengths and how we can harness our strengths. Even to look at, there was a study looking at people who had diabetes. How could they use their strengths to be more, to adhere more to their medication regimens? What were ways to kind of align, not their deficits, but what they're good at? We know even that, I think again, kind of part of psychiatry and therapy has become so interiorized, so fixated on the individual and the inner workings of what's going on in your head. And I think maybe at the expense of looking at the community that they exist within, the fabric of their relationships and a little bit too much of this whole idea that happiness only comes from within.

[00:35:43] I'd always argue that it also comes from with. And when we are in a group, a community that is reminding us to take our medication that is there with us, that's helping us use our strengths, it is helping us kind of even where we feel like we are adding value in helping others. I think having a sense of mattering and meaning, it's not just feeling valued, it's also adding value in some way beyond the self. So I do think kind of having a more strengths-based approach to physical illness and mental illness is also really worth our time and our time in the medical profession.

[00:36:20] Dr. McBride: Yeah, it resonates with me what you're saying. For example, I was trying to get a patient last week to think about exercising. It's sort of cliche, the doctors tell people to exercise. We all know it's good for everything from diabetes to dementia prevention. And she was beating herself up because she hadn't been exercising and she had put off the appointment to come see me for two weeks because she didn't want to get weighed.

[00:36:43] And I reminded her, this is not an appointment you can win or lose. This is just a data point and there's just no shame in the number on the scale on my end. But the way I think we're gonna execute on her in getting some exercise is that we looked back at her childhood. What did she like to do before she had a busy job and three kids and a mortgage and it was dance. And so we looked online and found this dance class in her community that’s at the Y and it looks it's not a class that requires designer leggings and an expensive membership. And I was like, just go to one class, just go in the back, wear shorts and just see how it feels.

[00:37:24] And she's like, yeah, I remember being just sort of, entranced by the music and just the movement and the sort of the organic, it didn't feel like exercise. It felt like fun. And I'm like, that's it. That's it. Let's lean into the things that are already in your arsenal of tools. And you know, we gravitate to things as children that we like. That's what we do. We don't have this complicated sorting system in our mind. So I said, just try it. And so I think I hear exactly what you're saying, which is that we have so many strengths, but we tend to focus on the negative.

[00:37:55] We've also lost a sense of community and kind of collective goodwill, I would say, in the last three years during the pandemic and certainly before that, with all sorts of political unrest and social unrest. And I think there's an intrinsic sort of sense of dis-ease among people. At least I see it in my office. And I think what I hear you saying is that you're just building back a sense of community and a sense of purpose outside of our own selves is important.

[00:38:27] Dr. Boardman: Yeah I'm thinking of that study with that looked at asking people to make a New Year's resolution. We know it's very hard to stick to. But those who made kind of individually based ones that were like, I'm going to stop smoking, I'm going to lose weight, versus those that had much more socially oriented resolutions. It was like pro-social, I'm going to walk with my friend once a week. I'm going to meet up with a friend and go to the movies or do a book club. Not only were they going, they were much more likely to stick to it. They were more satisfied over the course of the year. And it was just fun. And I think we have this terrible idea about health is that it has to be punishing and we've got to somehow always be miserable and depriving ourselves. It's full of deprivation and removing that element of joy and others and whatever made you laugh as a child, that you can find things that are fun and that lift you outside of yourself rather than, I think that kind of self immersion that sometimes I think the wellbeing, industrial complex kind of green lights, that's not necessarily healthy. And if anything it can kind of remove us from a lot of those experiences that boost our mental health.

[00:39:42] Dr. McBride: I think it's so true. Okay. I have two more questions. One, what do you think the biggest differences are between in-person therapy versus virtual therapy?

[00:39:52] Dr. Boardman: Call me old… I definitely, just as a practicing psychiatrist, prefer seeing people in person. I think one has a much better sense of who they are in their presence, in their physicality, and I really enjoy it. I mean, I'm grateful for Zoom. I became, you know, it took me a while to kind of get fluent in Zoom in March 2020, but it happened. And certainly I think with online therapy, accessibility is a good thing. The more people who can access therapy really matters, and people are always trying to look at what's the best type of therapy. The best type of therapy is a therapy where you have a good relationship with the therapist, where you trust them, where you feel safe, where you feel connected.

[00:40:34] That's the winning type of therapy. You want to have one argument, I would say, it's just always for quality therapy, not necessarily quantity therapy. I think the idea of being able to constantly text your therapist and actually not speaking to them in real time, I'm not sure about the outcome. I think maybe for younger people, that has been perfectly helpful. There is something though, just to keep in mind. Metabolizing, like when you are having a hard time or something's happened, kind of sitting with those feelings of distress, anger, sadness, frustration, disappointment, and you metabolizing it and knowing that on Tuesday at six o'clock, you're going to maybe address it because it's going to feel really different in the moment versus how it's going to feel, maybe 48 hours or three days later, and sometimes that digested way… and trust yourself, we are human beings. Human beings are supposed to bump into stress, sadness, all these negative emotions. They're information. This is stuff for us to take in and learn from and we don't necessarily need to constantly pick up the phone or text somebody and say, wait, help me. Because I think that really removes agency ultimately and basically suggests that we are ill-equipped to handle these very human experiences.

[00:41:52] Dr. McBride: Yeah. As if you can discharge that emotion by texting and putting it on someone else's plate.

[00:41:58] Dr. Boardman: Yes. Yes, exactly.

[00:42:00] Dr. McBride: So my next question is about medication. There's no kind of short answer to it, but I think we overmedicate people. I think we under-medicate people. It depends on the person. I am a big, big fan of the SSRI medications when appropriate in the right context. What is your general sense of the psycho-pharmacology state of the US right now. I mean, do you see people commonly coming to you who have been on medications that may have been inappropriately prescribed? Do you see people who are just looking for a pill to fix their kind of broken marriage? Do you see it being an asset, a crutch? What's your take?

[00:42:39] Dr. Boardman: I mean, I would say all the above. I think our culture is, Hey, I've got a problem. What's the pill for that? I can't sleep. I'm overweight. Whatever that thing is, I need a pill for that. I'm feeling down. And people feel… even like my kid has an earache, I want an antibiotic prescription. I mean whatever those, there's a culture of satisfaction when you walk out of a doctor's office. You feel like it was a job well done when you have that prescription in your hand. And so people are always blaming the doctors for this. I also think it's kind of cultural, this is the way we've told patients, people to be, they see advertisements all the time for this medication. They go into their doctor requesting that this is going to make me happy. I think of those Paxil ads from the early 2000s of that sad looking blob and then it starts taking Paxil and really happy and like socializing at a party.

[00:43:35] And so I worry about the overmedicating even in ADD. But then you also see in certain populations, it's the exact opposite as you're pointing out people who aren't getting the medications that they need for these issues. So it's not a blanket statement at all. So I'm a big believer in always re-looking at that. Especially when somebody has a tackle box of pills that they take for sleep or anxiety or depression. Wait, how long have you been on these pills? Are they doing what we want them to be doing? And what's the dose? Is this just something that you just kind of keep accumulating over time and you just feel sort of safe doing this?

[00:44:15] And we also know that it’s really hard to get off of antidepressants. It takes time and there's so much research about dosages when you're dialing them up, but not how you dial it down. And people who really feel bad and sometimes they can misinterpret some of their symptoms can feel like depression or anxiety returning when it's actually withdrawal from the medication itself.

[00:44:35] there was a big controversial paper that came out a few months ago, maybe you discussed it on the show, looking at these medications and maybe they're not as helpful as we thought they were. We also do know that there are lifestyle changes that when people. You know, exercise a couple of times a week that they can get the, the benefits of being of like an antidepressant essentially in that movement. It also protects young people against depression, which is so important as well. So I think it's one of those things we have to look at individually, and it's kind of a default answer, but it's kind of a case by case basis. And I know people who've been tremendously helped by these medications as well. So I take it very seriously and I really think of the individual involved.

[00:45:17] Dr. McBride: Same with me. And I think the downside of the article that came out, I think the one you're talking about is the one that said kind of definitively what we've known for a long time, which is that depression and anxiety are not “chemical imbalances.”

[00:45:30] Dr. Boardman: The serotonin hypothesis is debunked.

[00:45:33] Dr. McBride: Exactly. It's not the, it's not a serotonin deficit, which is not to say that increasing serotonin with selective serotonin reuptake inhibitors cannot help. So I think some people took that study and said, oh, then why the hell am I on this Prozac? And stopped taking it. And then other people sort of used it as ammunition to say, you know, modern psycho-pharmacology broken. As with everything, there's nuance, it's somewhere in the middle and it depends on the individual and it requires listening and curiosity about the human in front of us. So Samantha, I am gonna let you go. You've been so full of information and tools and amazing thoughts, and I'm really excited to kick off Mental Health Month with you on social media and to kind of blitz our shared audiences with practical information to be healthier from the inside out.

[00:46:25] Dr. Boardman: Oh, I cannot wait. We're gonna have a great month.

[00:46:27] Dr. McBride: It's gonna be fun. Thank you so much for listening, everybody, and sign up for Samantha's newsletter on Substack, it's called The Dose and I love it. I love the graphics, I really love your logo and I love what you're saying in it, and I read it religiously. I'll see you next time!

[00:46:46] Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us at info@lucymcbride.com.

[00:47:08] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.

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Did you know things like sugar-free gum, Advil, or simply eating too fast can cause gas and bloating? Everything we put into our ecosystem affects our gut health.

Our gut often reflects our emotional health, too.

In today’s solo podcast, Dr. McBride explains the practical framework she created to help patients conceptualize their health, integrating medical evidence, the patient’s story, and real life.

She calls it the FOUR “I”s:

• Information & data = the elements of our health that we can measure and see.

• Inputs = everything that we put into our health ecosystem.

• Infrastructure = the vehicle (i.e., the skeleton) that drives us through life.

• Insight = the process of laddering up from self-awareness to acceptance to agency over our health and well-being.

It turns out that this framework can help explain and trouble-shoot common gastrointestinal woes.

Health is about more than the absence of disease. Health is about having awareness of data and the stories we tell ourselves, acceptance over the things we can't control, and agency over our life.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, review — and enjoy — the show!

The full transcript of the show is here!

Intro: Hello and welcome to my home office. I'm Dr. Lucy McBride, and this is Beyond the Prescription. Today it's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as a process of self-awareness, acceptance, and agency.

[00:00:28] In clinical practice for over 20 years, I have found that patients generally want the same things: a framework to evaluate their risks; access to the truth and data; and tools and actionable information to be healthy mentally and physically. We all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today. Let's go.

[00:00:56] Today is a deep dive into gastrointestinal health. There is no possible way I could cover every crevice of the vast amount of knowledge we have on the gut, but I will focus on common things I see and common causes for gastrointestinal distress that often are missed. You may remember from a couple of months ago that I explained in detail the visual representation of how I think about patients.

[00:01:26] I call it the four I’s. It's a two by two grid. Imagine a box with four squares in it. And today what I want to do is talk about the gut and how the different I’s inform gastrointestinal health using some patient examples, things that I see commonly in my office. You can listen to that 15 minute podcast about the four I's for more of a dance remix version of the concept. But briefly, the four i's, are this: the top left square is information. Information and data. Things we can measure, things we can see like lab tests and colonoscopy reports. The top right corner is inputs; things we put in our body from kale and quinoa to alcohol and recreational drugs.

[00:02:15] The bottom left box is infrastructure. Our skeleton, literally the skeleton, literally the vehicle we drive through life, the container of all of our parts. And then finally, the bottom right box is insight. Awareness of the stories that we tell ourselves. Awareness of how our stories manifest in our bodies, and our understanding of our mental health, our anxiety, our moods, our relationships with food, alcohol, each other, and so on.

[00:02:45] So let's talk about a common complaint I see. I don’t think a day goes by in my clinic where I don't see someone who has gastrointestinal complaints like bloating, irregular stools, gas or abdominal discomfort. Now the list of possible diagnoses for these complaints is vast, from diverticulitis to colon cancer to I ate a hot chili pepper.

[00:03:11] But common things are common. That's a very favorite expression that doctors use all the time. And so I wanted to go through how I might conceptualize thinking about the diagnosis or how to help a patient troubleshoot these symptoms when it's sort of bread and butter. Take a middle-aged guy who comes in complaining of bloating, gas, and irregular bowel movements.

[00:03:32] When I think about the top left square, that information, I want to know, what do his lab tests look like? If he's over the age of 45, has he had a colonoscopy? Because 45 is the age where we start screening colonoscopies. By the way, if you have a family history, you should start earlier. So I want to know what's going on internally.

[00:03:52] What's his information? For example, if his lab tests show that he has hyperthyroidism or liver enzyme abnormalities, or a pancreas problem or celiac disease, that may directly inform how I'm going to recommend treatment. In other words, the data and the things we can measure are very important. So let's say he had a normal colonoscopy.

[00:04:14] Let's say his liver tests are normal, his pancreas is normal, his gallbladder is normal, and his blood counts show no evidence of infection or inflammation, and he's negative for celiac disease. So those are just some broad brush stroke tests I might order. I also might not order tests because sometimes it's a simple solution, but let's say that his information is normal.

[00:04:35] Then we'd move over to the inputs. That's the one I'm most interested in. When people have these kinds of complaints, I want to know, how much alcohol do they drink? What is the cadence of their eating? Are they eating a lot of processed, greasy food? Are they consuming a lot of sugar? What's the level of acidity in their diet and how fast do they eat? People who eat fast often swallow a lot of air and can get gas in the colon. Do they drink a lot of soda? Do they chew gym? Sugar-free gum is notorious for causing gas and bloating. So I would do a thorough history of what the patient's inputs are. What are they putting in their ecosystem?

[00:05:15] Sometimes people can get gas and bloating from taking too much fiber. I think most people know that fiber is healthy and fiber can help with digestion. But if people escalate the dose of their fiber intake too quickly, that can backfire and they can get bloating and gas. This is a common phenomena. The other thing I would ask in the input department is, are they taking any supplements or vitamins? Because even though supplements and vitamins are considered natural, sometimes they contain fillers or the supplement itself can accidentally cause bloating and gas. Magnesium, for example, which people often take to help them sleep, can cause diarrhea.

[00:05:50] It’s important to think about all the different things you put in your ecosystem and how they might affect your digestive health. One of the most helpful interventions I find for patients with this kind of complaint is to keep a food journal. It sounds really boring and it sounds kind of onerous, but writing down every single thing you eat is kind of an interesting exercise.

[00:06:12] People often connect the dots between their digestive health, their mood, their energy, and their bloating and gas when they look at the things they're eating. It's really interesting how mindlessly we consume foods, supplements, vitamins, and how little attention we pay to the things we pop into our mouth all day long. So I would suggest writing things down if you haven't done it already and you have this complaint.

[00:06:35] The next quadrant I would look at is infrastructure, our skeleton. So it's not uncommon for people who have a bum hip, a bum knee, an aching back to pop an Advil, to take Tylenol, to take supplements that are over the counter that they think will help with their achy joints and skeletal health. One of the more common triggers of gastrointestinal stress is NSAID's, non-steroidal anti-inflammatory medications. Advil is one of them. Aleve. Naproxen. So we want to think about are we taking any medicines to treat our skeletal woes? And then we can also think about pain and how pain itself can cause distress. Distress can show up in the gut.

[00:07:17] The other thing we need our skeleton for is just basic, everyday mobility. If we have some sort of limitation in our mobility, or we're just living a sedentary lifestyle, like we sit behind a desk most days, then that can affect our gut function, too. Often, one of the solutions for a chronic constipation is just regular walking, regular exercise, hydration, and movement to get our motor running. Our infrastructure really does matter. Sometimes just moving our bodies, hydrating and avoiding Advil is the way to keep our gut healthy.

[00:07:49] Moving over to the insight quadrant, it never ceases to amaze me how patients will report to me these terrible gastrointestinal woes. We will think it may be an appendicitis, a diverticulitis. They will have a colonoscopy, they'll have extensive lab work and maybe even a CAT scan. And some of the times we find a diagnosis, someone has diverticulitis and I put them on ciprofloxacin and Metron dissolve for 10 days and they get better. Other people have a diagnosis that we can name through blood work like celiac disease or inflammatory bowel disease like Crohn's or ulcerative colitis.

[00:08:24] When a patient has gastrointestinal distress and we have no obvious cause, tis is when I get my mojo on because I love talking about how our gut is often the home for our emotional health. It sounds kooky to many people, but I see it every day. Stress and anxiety in particular can manifest itself in our gastrointestinal tract. So when I have a patient who has a normal set of labs, normal imaging, a normal colonoscopy, and they're still suffering, we default to calling this irritable bowel syndrome. Now, patients often don't like having that diagnosis because they consider it a throwaway diagnosis. And I totally understand that because being diagnosed with IBS or Irritable Bowel Syndrome feels like the medical establishment is dismissing the patient.

[00:09:13] It’s like, we can't figure it out. We're gonna slap a diagnosis of IBS on it, and say, “see you next time, good luck.” But irritable bowel syndrome is a real phenomenon. It is literally the spasm and irritability of our colon, and it's from something. Just because it's IBS doesn't mean it's not real. IBS, however, is not a life-threatening diagnosis. It is not a result of inflammation. It is simply a functional issue that is often driven by emotional distress. One of my favorite exercises with patients is to take inventory of where they are on the continuum of anxiety. Where are they on the continuum of mood? Where are they on the continuum of their relationship with work, parenting, caregiving and just being alive in the modern world.?

[00:10:03] In other words, we all have fears. We all have moods, we all have relationships to food, alcohol, our work, and to each other. When those things are on the fritz, when our anxiety is out of proportion to the actual threat; when our moods are not stable, despite our best effort to get sleep and to get exercise; and when our mental health is not in balance; those are often the triggers for gastrointestinal distress. So sometimes, dare I say, often the solution for gastrointestinal woes, if we can't find an obvious cause again, to identify thoughts, feelings, and behaviors that are causing us to feel distressed. In the short term, I will recommend to a patient that they try this, I don't wanna call it a diet because diet to me implies weight loss, but there's a diet, or actually call it a framework called the low FODMAP Diet.

[00:10:55] You may have heard of the FODMAP Diet from a friend or on the internet or on Instagram. And when people say the FODMAP diet, they often mean a diet that is low in FODMAPs, F-O-D-M-A-P-S. And the diet is really designed to help people with irritable bowel syndrome, and one of the problems I think people run into is I give them the list of foods and they accidentally hear me say, cut all these foods out of your diet and good luck.

[00:11:20] That's not my plan. All I want people to do is use that list of foods that are potentially irritating to the gut, that potentially accelerate that gastrointestinal spasticity and see if they can connect the dots between what they're eating by that journal we talked about and how they feel in their gut. FODMAP stands for Fermentable, oligosaccharides, disaccharides, monosaccharides, and Polyols.

[00:11:45] What that basically means is that these are some foods that the small intestine absorbs very poorly, and people can experience cramping, diarrhea, constipation, bloating, and gas. So one of the occupational hazards of recommending the low FODMAP diet to patients is that people often go and restrict and then feel worse.

[00:12:03] Maybe their diarrhea and cramping is better, but they're hungry. So the other potential occupational hazard of recommending the low FODMAP diet is people using the diet as a panacea and not then addressing the other triggers of their irritable bowel in the first place. From work stress to the Advil they took for the headache to the alcohol they overdid and kind of forgot they did because they didn't count it because it was the weekend.

[00:12:29] In other words, there's really no one size fits all prescription for IBS/irritable bowel syndrome. But in my experience, it's usually a little bit of a lot of things and it's usually one little piece of something from the information quadrant. Maybe you have a predisposition to constipation or diarrhea given your family history.

[00:12:51] It's one little piece from the inputs, like maybe you had too much alcohol and you didn't really register it, or maybe you're eating too much tomato or Brussels sprouts. Maybe it's in the infrastructure space where your body isn't moving enough. You need to give your body and your colon a little more time and space for activity.

[00:13:09] And then sometimes it's in the insight. We need to recognize that our stories live in our bodies, and that self-awareness is often the key to health and wellbeing. So that is my little spiel about gastrointestinal health. It's pretty basic, but I find often that when we have these symptoms, we tend to overdo and over-test and over-worry when actually some of the solutions that I find the most helpful are really, really simple.

[00:13:35] It's paying attention to thoughts, feeling. Taking stock of what we're putting in our body and our everyday habits, and then thinking from the ground up about how to be more self-aware and how to problem solve using a very basic set of tools we already have inside us. I hope that's helpful. If you enjoyed this podcast, I would be so happy if you liked it, if you subscribed, and if you recommended it to a friend. Thank you so much for joining me, and I'll see you next time.

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On this episode, Melissa Urban talks candidly with Dr. McBride about her struggle with drugs and disordered eating and how her recovery stemmed from creating healthy boundaries around food, substances, and interpersonal relationships.

Her latest book, The Book of Boundaries, is about the importance of setting limits on relationships and choices, and putting ourselves back in the driver’s seat of our health and wellbeing.

Melissa is living proof that health is about laddering up from self-awareness to acceptance to agency of our body and mind.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast or at https://lucymcbride.Substack.com/listen.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

The full transcript of the show is here!

Dr. McBride: [00:00:00] Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is "Beyond the Prescription," the show where I talk with my guests, like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at lucymcbride.com/newsletter and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.

Today's guest has been on the New York Times' bestselling list six times. She is the creator of the Whole30, which is not just a diet plan. It's a way to rethink our relationship with food. Melissa Urban joins me today to talk about overcoming addiction and the lessons learned in recovery that inform how she thinks about food, nutrition, body image, and the boundaries we set in our everyday lives. Melissa's newest book is called "The Book of Boundaries," published in October 2022. In it, she describes how we can say yes to things we need and want and no to things we don't to put ourselves back on the driver's seat of our health. Boundaries, in my world and in hers, provide the groundwork for improved health and well-being. Melissa Urban, thank you so much for joining me today.

Melissa: [00:01:48] Thanks for having me. I'm excited to chat with you.

Dr. McBride: Here's why I wanted to have you on the show. The way you talk about boundaries and the importance of setting limits on our relationships, our choices, is so important to how we show up in the world, how we relate to food, how we relate to alcohol and other substances, how we relate to other people, and how we feel about our own bodies that it's really at the core of what, in my opinion, health is.

[00:02:17] Health, as I introduce in this podcast, is about self-awareness, and it's about acceptance, and it's about having agency. And having agency, in my opinion, includes knowing what we need and knowing what we don't need, which is driven, ultimately, by knowing our value and our meaning and our purpose. So that is a wide lens with which to open the conversation and for me to ask you, Melissa. How do you, as an expert in nutrition and eating and health, define health yourself?

Melissa: Well, that's a big question to open with. You're just going right for it.

Dr. McBride: We're going to go right from the top, and then we're going to get granular.

Melissa: [00:02:57] I had to do a piece recently for Oprah Daily where we talked about the concept of wholeness and what does wholeness mean to me, and I think that that can relate very nicely to this idea of what health means to me. So I think, very often, we look at health through a very narrow lens, and often, when it comes to diet culture, it's through the lens of body size. I mean, they are just absolutely equated that the smaller your body, the healthier you are. If you take a step back from that, maybe you're looking at health from the perspective of, "What does my diet look like? Do I have a movement practice? What does my sleep look like?"

[00:03:31] But even more than that, there are so many different factors that make up this concept of health or wholeness. I'm looking at it from a physiological perspective. So, do I have the energy to do the things that I want to do in my life to keep up with my kid, to do the recreational activities that make me happy? Do I feel satisfied from a personal development standpoint? Do I feel like I'm working on myself and I have the time and capacity to do some self-awareness or do therapy? Do I feel like I have a spiritual practice, whatever that looks like? Whether I'm connected to God or the universe or just my own highest self, am I cultivating that spiritual practice? Do I have social health? Do I feel like I have good connections with other people in my community? Do I feel like I have support? Do I feel like I'm not isolated?

[00:04:16] I think there are a lot of different aspects of health. You have to look at them from a position of wholeness. You can't just look at any one aspect, because one aspect can be going very, very well, but if all of the others are falling behind or you're not paying attention to them, to me, that doesn't feel particularly healthy or feel like thriving.

Dr. McBride: You couldn't have said it better, and it dovetails exactly with the way I think about health. It's not about the absence of disease. It's about the integrated sum of different components. It's about nutrition, body mechanics, self-awareness, which includes awareness of our medical vulnerabilities, which are often genetic and environmental, and it also includes, as I said earlier, that sense of agency. When I think of agency, I think of the ability to execute on goals that are yours and only yours. That's a luxury for a lot of people to have the opportunity to grow and to personally grow health-wise, grow professionally, grow relationships. But I think agency can also be on a really small level, feeling more in control of our everyday habits and even our everyday thoughts.

Melissa: [00:05:21] I agree. You know, when you say agency, I immediately think about self-efficacy, this idea that, like, I feel as though I am able to accomplish the things that I want, and sometimes that involves, if I think back to my recovery and the serenity prayer, giving me the patience to accept the things I can't control and, leave them out, but recognize that, for the most part, I do have control over how I choose to respond to those situations in that I usually or almost always can have agency. And again, there's an element of unacknowledged privilege in that statement alone, but we'll just say that agency, to me, does involve this aspect of self-efficacy and recognizing the things that I can't do while making strides on the things that I can.

Dr. McBride: [00:06:02] At the risk of repeating myself on this podcast, and my listeners may be, like, "Oh my God, there she goes again, talking about the serenity prayer," the serenity prayer, like, it's kind of the final common pathway of so many different conversations I have with patients, whether it's about parenting, like, letting of the fact that your teen doesn't want to talk to you right now and accepting that's normal for their age, and leaning into the opportunities, you have to talk to them when you're driving a car and it's quiet and there's no eye contact, to managing your addiction to alcohol, accepting you don't have control and leaning into the parts of your life that you do have control, finding joy and pleasure in other places and asking for help.

[00:06:40] I’d love to, therefore, pivot to the conversation about your addiction and your health, because you grappled with addiction to heroin, cocaine add other substances. And so I'm aware that you, like so many of us had enormous struggle as a younger person, and I'm imagining also that informed a lot of how you are today and show up today. Can you talk a bit about that process, not that that can ever be encapsulated in a quick podcast?

Melissa: [00:07:15] Yeah. I mean, you know, my drug addiction started when I was about 18, and it came as the result of some sexual abuse I experienced at 16 by somebody I was very close to. And I had just...you know, after that experience, I didn't tell anyone for a year. I didn't know how to handle it. When I did tell my family, they didn't respond super well. It was a really challenging situation that I was definitely not equipped to handle. And so I was looking for ways to essentially escape my own life. And I tried drinking, and that didn't work. And I tried restricting my eating, and that didn't work. And I tried dating guys who were terrible for me, and that didn't work. And it wasn't until I tried drugs that I was like, "Oh, this is it. Here we are. Here's the thing that can pull me so far away from myself." And I was addicted for...

Dr. McBride: Can I interrupt you for a quick second?

Melissa: Yeah.

Dr. McBride: [00:08:00] I'm going to guess you weren't aware at the time you were dating the wrong guys and restricting calories, that you weren't aware that you were self-medicating. You were just doing it. Or were you that aware of your own pain?

Melissa: I was pretty aware.

Dr. McBride: You knew what you were escaping, like, "Oh, I'm going to go, like, looking on a menu of things to self-soothe. And here they are."

Melissa: [00:08:17] I don't think I could go that far, but what I knew was that I did not want to be in my own life, and I was very actively looking for things that would take me away. I don't think I could have explained it any more eloquently than that at the time because I didn't have the language and I didn't have the tools. But I knew that I was hurt so much, and I didn't want to be there, and I was looking for something to take me out a bit. That was about my experience.

Dr. McBride: It's interesting because, as you know, sexual abuse, sexual trauma, is so common and so commonly ignored by all parties. Like, because it's so stigmatized and so shameful to talk about in people's minds, people often don't know they're self-medicating. They don't know until they're in a real bind that their alcohol use is related to that trauma. And it's not a lack of intelligence, it's just a lack of insight. So it's impressive to me that, at an early age, you knew your feelings and you just didn't have an outlet.

Melissa: [00:09:09] My sexual abuse was, like, a record scratch in my life. Up until that point, I was the good kid. I didn't get in trouble. I got good grades. I read a lot. I was quiet. Everybody liked me. But, like, I wasn't super popular. I mean, it was a very middle-of-the-road. Like, I was about as even-keeled as they came. And then, after that incident, everything went sideways, my behavior in school, I started acting out, my behavior with my family and with my parents, I started dressing differently. So, to me, it was very obvious that all of these things were related to this incident of sexual abuse, but I hadn't told anybody. So, to everyone else, it looked like it was coming way out of left field, but I knew what was happening.

Dr. McBride: You didn't want help in the beginning, right? You wanted to hold that boundary so tight that you weren't going to let people in. But, like, what happened? When did you get kind of caught or busted, or when did you get enough insight to know this is a real problem and affecting your everyday health?

Melissa: [00:10:00] Pretty dang early on, you know. I dove in as hard and as fast as you could. I didn't have a drug of choice, which I now know is quite unusual. I only dated drug dealers for five years. And very quickly, I realized that this thing that I was using to escape from my problem had now become a problem unto itself, and now I had a problem layered on top of problems.

And I was like, "Well, I'm this far in. I don't really know what else to do." And so this is the cycle that addicts get stuck in, whether you're talking about food addiction or drug addiction or alcohol. I overconsumed, and I hated myself for it. And I had guilt, and I had shame, and it led to isolation. And that led to stress, and that led me to overconsume the very thing that I hated myself for doing. And I was stuck in that cycle for a very long time because I didn't know how to get out of it.

[00:10:45] And it wasn't until I had this moment of, like, literal divine intervention with a boyfriend who was miraculously stable and wasn't a drug addict who gave me, essentially, an ultimatum and said, like, "You need to go to rehab. I can now see how problematic your behavior is and how much you're killing yourself. And, like, I really want to see you go. Would you consider going? And if you can't go, I'm going to have to leave. I can't watch you do this to yourself." And in that moment, I somehow found the strength to be, like, "Okay, I'll go."

Dr. McBride: That person set a really good boundary, and they knew what they needed from a relationship, and they were trying to use their own healthy boundaries to help you. It's just an important moment in your life.

Melissa: [00:11:21] He's my favorite ex-boyfriend, for a reason. I talked to him not that long ago. We texted, you know, just a couple of months ago, and I was like, "Hey, in my book, I'm still calling you my favorite ex-boyfriend." And he's like, "I will always cherish that," you know. But, yeah, he literally saved my life, and he did set boundaries with me. He set boundaries while I was using. He would say, "We can't have this conversation if you are this high. So when you come down, let's talk because we need to talk," or "It's okay that you stay out late, but you need to call me to let me know where you are. Otherwise, I worry." He tried to set boundaries for me for his own protection because I was destroying him and the relationship, and ultimately, that was what got me to rehab the first time.

Dr. McBride: [00:11:59] One of the things I find so interesting and this is getting really granular, is, like, what was it about him that allowed you to trust and receive that message? In other words, I'm guessing there are other people in your life who were, like, "Melissa, get a grip. Melissa, you're sick. Melissa, you need help." What's interesting to me is, like, the messenger in that moment and who has access to someone who needs help and who needs to make important changes in their lives. And I wonder what it was about him that gave you the kind of confidence and openness to receive that message, given that I'm guessing other people had said similar things.

Melissa: [00:12:33] It was the moment. I remember very clearly sitting on the couch. I had just been paid. My money had been... Because I was very functional as an addict. I still had a job. And I had just been paid, and all the money was in my bank account. And I remember him saying, like, "I need you to go to rehab, or I'm going to have to leave." And I remember calculating how much heroin I could buy with the money that was in my bank account and knowing, if I did that, that I would die, and not really caring that much, and having just a split second moment of "You could have something different." And in that split-second moment, I was like, "Okay, I'll go." And faster than I could even take it back, he was on the phone. He found me a bed. Like, I say it was divine intervention because it really feels like that.

Dr. McBride: It also sounds like he wasn't judging you or shaming you.

Melissa: No. He was sad for me. He knew who I was earlier in my addiction. I was always using when I was with him, but I was nowhere near as bad off as I was at the end. He really hated to see me do this not only to our relationship and to him but, like, mostly to myself.

Dr. McBride: [00:13:28] In order to access other people and their willingness and ability to make changes, whether it's around food or other habits, to me, the messenger has to be free of judgment and someone they trust and then lead with empathy and curiosity. I find that if I'm counseling someone who's an addict on not just the benefits of quitting alcohol for them, because people often know the health benefits, but the other possibilities of how their life could be going and what other root causes that underlie this self-destructive behavior, coming at those conversations with blame, shame, and declarative statements does not go well.

[00:14:12] In fact, I don't recall ever having a conversation with anybody, including my kids and my spouse, about changes, from doing the dishes or whatever, that landed well when you lead with shame, blame, and declarative statements. But, hey, I wonder if you could connect the dots between the way you relate to alcohol to that childhood trauma you told me about, similarly, I might say to my kid. I wonder if you thought about doing the dishes as part of the family unit. In other words, questions instead of declarative statements.

Melissa: [00:14:42] There was nothing at that point that anybody could have said to me in terms of trying to shame me or blame me or disparage me that I wasn't already saying to myself 10-fold. Nobody could ever say anything to me that would be worse than what I had said to myself. And at that point, I was really struggling with, like, do I even have any worth or value left if I do enter into recovery? I'm going to have so much harm to repair. I'm going to have so much life to rebuild. It really did feel hopeless in that moment. But, you know, I had so much privilege, again, going into my recovery.

[00:15:17] I had a family who had not abandoned me. I called my mom from rehab, and she was, like, shocked and upset. And she was, like, "Okay, let us know when we can come visit." I had a boyfriend who was there and ready to protect me. I had a decent job with health insurance so I could go through rehab and spend time in counseling and have that covered by insurance and a job who said they'd hold my job for me. Like, in terms of my recovery, I had everything going for me, and all I needed to do was show up and do the work, which is so much more advantage than so many other people have.

Dr. McBride: [00:15:45] One hundred percent. And I'm sure you would agree that if everybody had access, unfettered access to mental health services, addiction, and rehab services and had a doctor, a nutritionist, priest, rabbi, who could talk about addiction in a matter-of-fact way, lead with curiosity and empathy, and know that the person they're talking to is already filled with shame, and then we could talk about mental health issues like we do any other physical health issue, we would be in a world of a better place.

Melissa: It would be a very different environment. You know, I've been in recovery for almost 23 years now, so this was a very long time ago. We are much more free now in talking about mental health, in talking about recovery, in talking about addiction. There's a lot of destigmatizing that has gone on, at least in certain circles, right? If you're on those sides of TikTok and Instagram, people are very free, and you're even seeing it at the highest level of media, you know, when you have champion tennis players talking about taking a break or gymnasts talking about taking a break for their mental health. It is now something that we are effectively working to destigmatize. Twenty-three years ago, it was even harder. So I want to continue to see the progress that we have made, and I want to see that progress continue to increase.

Dr. McBride: I totally agree. And I think, as I say to patients all the time, when we talk about mood or anxiety and they're kind of wondering why I'm asking, I remind them, we all have mental health. It's a feature, not a bug. It's something that you either address or you don't address.

[00:17:15] And to you, Melissa, I'd love to ask you next, how did your mental health and recovery process inform the decision to start the Whole30? And how did the lessons you learned about yourself in recovery inform how you talk about food?

Melissa: There's so much recovery language built into the Whole30 that I did not even recognize when I wrote it, but other people who were also in recovery would show up at a seminar and they'd be like, "Are you a friend of Bill W.?" And I hadn't talked about my recovery for the first year or two that I was running Whole30. And I was like, "How did you know?" And it was like, "Oh, it's, like, these six terms and phrases that you've used in these seminars." When I got out of rehab the second time, because I had a year of recovery and then I relapsed, which is very common, and then the second time I, [00:18:00] you know, entered into recovery, I realized I had to change everything about my life if I was going to maintain my recovery.

[00:18:05] I needed to become a healthy person with healthy habits immediately. I had to adopt that identity, create that growth mindset, set in whole boundaries with other people and myself, and that was when I started going to the gym and eating healthier. I made a new group of like-minded girlfriends who ran instead of drank, and we would go for morning runs instead of go out for drinks at night. And I changed everything about my life. And that led me to, in 2009, this 2-person self-experiment that was to become the Whole30. And, you know, for 30 days, we eliminated foods that are commonly problematic to varying degrees according to the literature to see if they were problematic for us.

[00:18:44] And while I experienced incredible physical benefits from that Whole30 energy, sleep, mood, performance in the gym, recovery, the most important thing that my first Whole30 did for me was identify the ways that I was using food like I used to use drugs, as punishment, as reward, to self-soothe, to cope, to relieve anxiety, to show myself love. I didn't have any other coping mechanisms. And it wasn't until I took those foods away for 30 days that I was like, "Oh, crap, I have to figure out how to sit with discomfort and not automatically look to food or drink to, like, numb or run away from that." And my behaviors with food were relatively healthy. I wouldn't call them incredibly dysfunctional, but I came away from that first Whole30 with so many more tools in my toolbox. It radically transformed, permanently transformed, my relationship with food. And that was such a powerful experience that I was like, "Okay, I wanna tell other people about it and share about it."

Dr. McBride: It's incredible what you've done. I mean, I was just in the grocery store earlier this week, and I'm looking at a label on something, and it had a Whole30 label. I'm like, "Oh my gosh, that's my podcast guest."

Melissa: I know her.

Dr. McBride: [00:19:49] Yeah, that's cool. I mean, it's extraordinary what you've done, particularly, the nuanced way you talk about food. Like, I notice, even just when answering my question now, you don't talk about eating healthy. You talk about eating healthier, meaning, it's all relative. It's not a black or white, on/off, kind of binary system you're talking about. The way this shows up in my office as a primary care doctor, as you imagine, I have people who ask me about, "How do I lose weight?" all the time. And some of them need to because they have metabolic syndrome, diabetes, you know, heart disease, high cholesterol, the various consequences of extra weight or poor health habits. I also have patients asking me all the time, "How do I lose weight?" And they don't need to lose weight. It's more of a body image, you know, often informed by kind of the subtle cruelty of diet culture that infiltrates the minds of women more than men, but women, in particular.

[00:20:42]So I guess my question to you is, given that the Whole30 does involve elimination and sort of draconian measures in the first 30 days of no sugar, no alcohol, no caffeine, no gluten, no dairy, how do you talk to audiences about the harms of restriction, balanced with the benefits of understanding exactly what you're putting in your body and the emotional, physical, and medical effects of them?

Melissa: I mean, this is an incredibly nuanced discussion, because diet culture and anti-diet culture are just two ends of, like, a very long spectrum.

Dr. McBride: You said it.

Melissa: [00:21:22] The Whole30, as we've alluded to, is not a weight loss program. We are not a prescriptive approach in that Whole30 doesn't say, "You should eat like this forever." We also don't categorize foods as good or bad. There are no good or bad foods, and you are not good or bad when you eat food. We remove all morality from the equation. What Whole30 is is a self-experiment, because any medical doctor or registered dietitian will tell you, there is no one-size-fits-all when it comes to diet. You have to figure out what works for you. And your patients say, "Yes, that makes so much sense, of course. How do I figure out what works for me?" And so Whole30 is the answer to how.

[00:22:02] It's a 30-day elimination diet, and elimination diets have been around since the 1920s. Many medical doctors still consider them the gold standard for identifying food sensitivities. What the Whole30 does is it eliminates foods for 30 days that are commonly problematic to varying degrees across a broad range of people. We pull these foods out for 30 days and see how the elimination of these foods impacts your energy, your sleep, your mood, digestion, cravings, joint pain and swelling, acne, allergies, asthma, anxiety. All of these conditions can be impacted by the food that you eat. At the end of those 30 days, you'll reintroduce those food groups one at a time very carefully and systematically, like a scientific experiment, and compare your experience.

[00:22:48] Based on what you learn through the Whole30, you will then have a blueprint for how foods work for you and your unique context, and you'll be able to take that to create the ideal sustainable diet for you according to your definition of health. We don't prescribe that for people. As you've mentioned, there is an element of restriction to Whole30, which is why we don't suggest the program for people who have a history of disordered eating or eating disorders. Any program with restriction can be triggering, so we are very open about that and very encouraging of those folks to work with a qualified healthcare provider to see whether or not Whole30 or some modified version of Whole30 might be right for them and make sure that they're completing the program with supervision, if at all.

However, when you look at most weight loss diets that involve restriction, you're talking about restriction maybe of entire food groups but also specifically of calories. And when you restrict calories and either macronutrients, micronutrients, or both, that obviously sets the body biologically for that rebound effect that almost always happens at the end of a weight loss diet, because you are underfeeding yourself, undernourishing yourself. The Whole30 does not have that aspect. We don't count calories. We don't restrict calories. We don't restrict portions. We're eating three, four meals a day to satiety, real whole nutrient-dense food.

So, from that perspective, you don't have the same physiological rebound effect to the restriction of calories on the Whole30 that you might have with other plans, which can help people feel more satiated, more satisfied, and not deprived for those 30 days if they choose to take on this self-experiment.

Dr. McBride: You explained that so well. In practice, as you might imagine, I see lots of patients who undertake diets for the wrong reasons, or they're well intended, meaning, like, they actually need to lose weight because they have type 2 diabetes and they need to lose 50 to 100 pounds, but they haven't set themselves up for success because they haven't fully understood what a program can and cannot do for them. For example, there are certain diets, which will not be named, that basically give you fake food, and indeed, you will lose 10 pounds to fit into the mother-of-the-bride dress in 2 weeks. But you will inevitably feel ashamed when you can no longer keep that up, because who can eat fake food unless you're a robot, and then you gain all the weight back.

I have patients all the time who are valiantly trying to lose weight without connecting the dots between the real parameters of their everyday life and setting themselves up for failure by saying, "I'm gonna chop vegetables. I'm going to prepare a protein-rich meal and quit alcohol in perpetuity." And then, if they have a full-time job, and they've got kids, and they travel for work, the wheels fall off the bus. In other words, what I see being successful in practice is when a patient's expectations are managed for what a behavioral change can and cannot do for them when it comes to food or anything else, when they have a healthy respect for behavioral patterns that are paved like concrete highways in their brains that are hard to break up, and they're willing to alter habits, and they have the time, energy, resources, space to make changes, and they're not looking just at the number on the scale. They're looking at the metrics of how do I feel, how's my sleep, how's my energy, how's my poop, how's my sex drive, how's my ability to concentrate at work. And when people can take away that obsession with the number on the scale and even their A1C diabetes test, which we need to see, but isn't the end all, be all. When they look at how they feel and how they are in their bodies, then people are setting themselves up for success in a sustainable way.

So what I like about Whole30 in the way you described it is that, yes, there are gonna be people who use it for the wrong reasons, people who don't need to lose weight and are starving themselves not just for 30 days but for 60, 90, 100 days. But when a patient is given the framework within which to think about this change, and they are looking at the right metrics, it can be successful. It can be a knowledge exercise. It could be an exercise in understanding what works for their bodies.

Melissa: It's a huge exercise in self-efficacy as well, because it's not easy, right? And here's the thing, we know that people come to the Whole30 and say, "I know you're not a weight loss diet, but I'm still trying to lose weight." And it's like, "Okay, I respect that. You have the right to do with your body as you choose. That's not my business." But if they stay connected to Whole30 through any medium, whether they're reading a book, they're on our social media feed, they're watching my YouTube live, they're getting our email newsletters, you are getting every single moment of every single day focused on no-scale victories, "Here's your Whole30 mindset and how it differs from your old diet mindset. Here's how you can restore that connection with your body and learn to trust the signals that your body is sending you, because your body knows better than any calculator on an internet how much you should be eating." Those are the messages that you're getting.

We invite people to take a well-deserved 30-day break from hyper-fixating on that number on the scale as your only success metric and look at all of the other benefits that changing the food you put on your plate can bring into your life and what that does for literally every area of your life. The Whole30 is about food, but it's about so much more than just food. And when people do the program and they feel that sense of self-confidence and self-efficacy, the only benefit you had from the Whole30 was that you ate really good whole food for 30 days, like, you know, nutrient-dense, vitamin-dense, micronutrient-dense food for 30 days, and you kept a promise to yourself. I would call that a home run.

Dr. McBride: One of the harms, in my opinion, of diet culture, mixed with hustle culture, mixed with social media, mixed with just the modern world, is that so many people have lost touch with hunger and satiety cues. In other words, patients commonly will say to me, "I've cut out alcohol. I've cut out gluten. I'm not eating as much overall, and I can't lose weight." If they actually need to lose weight, I will talk to them about what the cadence of your eating is like during the day. Because sometimes people aren't losing weight as they want to and need to because they aren't eating enough. They aren't in touch with their hunger and satiety cues. And I think when we're busy, when we're eating on the run, when we count coffee as breakfast, a KIND Bar as lunch, and then we don't eat all day because we're so busy, and the floodgates open at 7:00 at night, we lose track of what does it feel like to be hungry and what does it feel like to be sated.

I don't know if this resonates with you, but I talk with patients commonly about hunger being, [00:29:30] like, a wave. You're gonna notice it rising. I'm not a surfer. But you notice it rising, and you notice it about to crest, and that's when you wanna eat. If you're tangled with your proverbial surfboard in that crashing wave, you're going to overeat, you're going to overeat the wrong stuff, and then you're going to feel bad about the next day. But if you can understand your cues, which often get lost in our everyday lives, that can do so much good.

Melissa: I mean, it's not just that they're getting lost. It's that, if you have been weight loss dieting, you have conditioned yourself to not pay attention to those cues.

Dr. McBride: That's right.

Melissa: Your body says you're hungry, and you're like, "No, you're not, because I don't have any points left today," "No, you're not, because you can't eat lunch until 1 p.m.," "No, you're not, because you just ate your 100-calorie snack bar, and that's the only snack that you're allowed to get." So there are a lot of experiences, especially for women, that disconnect us from our body. Maybe it's religious influences. Maybe it's diet culture. Maybe it's trauma. But we lose that connection, and then we're told over and over again that we can't trust our own bodies.

Dr. McBride: [00:30:30] One hundred percent.

Melissa: So one of the biggest benefits of Whole30 is, like, restoring that connection and saying, like, "Yes, you can trust the signals that your body is sending you and to start to tune back into that."

Dr. McBride: Yeah. I mean, so many of my patients who are in recovery for disordered eating, we talk a lot about just trusting the neck down again. This is not, like, the CEO and then your body is the, like, chief operating officer, right? It's not supposed to take marching orders from your brain in its rigid form. It is integrated. Your body can actually give you all the information you need, and your body is your friend. If I had one message to give patients who are struggling with weight or relationship with food, it's, first, try to get back in touch with your hunger and satiety cues and give yourself permission to notice hunger and to feed yourself and to be sated. Satiety is one of the best things for calming anxiety, for focus, for concentration. It's normal. And pleasure is not something we should be avoiding. Even if it's by eating a chocolate bar, that's okay.

Melissa: [00:31:29] Absolutely. You know, I talked earlier about how I used to cope all the time with food with self-soothing and relieving anxiety. And I still do that sometimes in a very conscientious way, and it still feels good. And I feel good about it, but that is no longer my only coping mechanism. And I think that's the difference. I now have a therapist, and I talk about my feelings with my husband and my friends, and I journal, and I walk, and I hike, and I meditate, and I reparent, and all of these other coping skills that now are just this, you know, nice, holistic picture of ways that I relieve anxiety and discomfort and self-soothe. Food is still one of them, but it's not the only one. And I no longer have the shame or guilt or negative self-talk associated with it. And I think that's the difference.

Dr. McBride: You are really on the other side of that recovery, and I love what you just said, which is that recovery includes pattern repetition, repetition compulsion. As long as you know that that's happening and you forgive yourself for having dessert or you open a pint of ice cream because you're sad and you eat it, like, that's okay. That doesn't mean you're "relapsing" or morally flawed or gonna gain 100 pounds. It just means you're human.

Melissa: Yeah. I mean, the other day, I was having a really hard mental health day, and I said to my husband, "Today is the day that I'm gonna skip the gym, I'm gonna sit on the couch, and I am just gonna eat whatever comes up for me." For me, on a normal day, those might be seen as not healthy behaviors. Skipping the gym is, like, not typically what I do, because I love going to the gym. But on this day, that felt like the thing that I could do that would nourish myself the best, and I was still conscientious and deliberate in how I chose to do it. I loved every second of sitting on my couch, watching Netflix, eating Smartfood Popcorn, and then, when it was done, I was like, "Okay, all right, that felt good. But that's not sustainable, and I don't wanna do that again tomorrow. What am I gonna do tomorrow? Because I still don't feel great, and although that was nice, I need another tool from my toolbox." And that's what I did.

Dr. McBride: You're so wise. One of my favorite expressions is this, and I actually just used it with my daughter who is feeling guilty about saying no to something that, in my opinion, and I think in hers too, would actually help, she's, like, a classic perfectionist, an achiever, I mean, she's the best thing since sliced bread, but I said to her what I say to my patients, which is, "Saying no to something means saying yes to something else." Saying no to going to the gym that day because you didn't feel like it is saying yes to the permission to be a blob. And that's healthy.

[00:34:00] I mean, if you say no all the time, like, "No, I can't turn in that term paper," "No, I can't participate in that sporting event," "No, I can't show up at school," that's a problem. But this comes down to what you talk about in your new book about boundaries, knowing what your needs are and having a diverse portfolio of things you can turn to to manage the inevitable stress and distress that life brings.

Melissa: You know, we were, just a moment ago, talking about this idea that it's in our best interest to check in with ourselves and ask ourselves, "What do we need? How are we feeling? Are we hungry? Are we full?" and that we can trust the signals that our bodies are sending us. That applies equally to this idea of setting and holding boundaries. So often, in our lives, we look to everyone else to tell us how to show up, how to behave, what to do, when to be there, how much to give based on their expectations, and again, very rarely are we encouraged to and we're basically never taught to pause and say, "Hold on just a second. What do I need? What would I be comfortable with? How do I feel about this?" And then respawn from that place of self. And that is really at the foundation of my boundary practice. You don't know where you need to set a limit to keep yourself safe and healthy and protect your energy and mental health and time unless you are able to check in with yourself and assess what your own needs are.

Dr. McBride: This is exactly why I think you and I both love our mutual friend Elise Loehnen. She's, like, a Buddha on this stuff. I love the way she talks about and you talk about knowing your north star, knowing what you need from relationships, from food, from the world to be healthy, and then giving yourself permission to ask for it, and then not apologizing for having needs. I think, in the world we live in, men too, but women, in particular, often suffer from this, like, sort of self-sacrifice as a badge of honor, as subjugating our needs, as being altruistic, when, from my own experience and from working with patients for 22 years that always blows a gasket somewhere. I mean, there's anger, there's resentment, and then we'd end up meeting our needs in other ways that aren't maybe so healthy.

Melissa: [00:36:07] Yes. We have been conditioned. Women, and especially moms, have been conditioned by the patriarchy and stereotypically rigid gender roles and religious influences and diet culture to be small, to be compliant, to put everyone else's needs and feelings above our own. We are praised the most when we are not even on our own list, and then when we do ] have a need, we either hint around it because we've been told we can't ask for what we need directly, because that's rude, or if we do ask directly, we are called the B-word, or we're told that we're cold, or selfish, or we have too many rules.

There is this conditioning in society around how a woman and how a mom is supposed to show up, and there's a lot of unlearning we have to before we can start advocating for ourselves and setting boundaries without feeling guilty. Because when I set a healthy limit that is designed to improve our relationship, I am not doing anything wrong, and there's nothing to feel guilty about. But I've got to unlearn all of that other stuff that tells me that I should feel guilty for simply existing and having needs.

Dr. McBride: Amen. Hallelujah. As you might have guessed, I am an oldest child, I am a woman, I'm a perfectionist, I'm a pleaser, and I had to unlearn a lot of lessons that weren't even taught to me by my own family but just by society and living in the world I live in. And what's been "fun," [00:37:30] although, let's be honest, painful as well, is setting boundaries as a grownup and feeling how it's working and not working, and then seeing the net benefit of setting boundaries, whether it's with another person or with habits or behaviors, and then feeling the discomfort of setting that boundary, like, maybe disappointing someone or saying no to something everybody thought you'd go to or declining something else, and then seeing how you're actually really paying it forward for your own health and well-being and actually nurturing relationships by saying no. Because, then, that person knows what your limits are, what your boundaries are. And then, if that person's meant to be in your life, they have a better understanding of your needs.

Melissa: Yeah. You know, boundaries are such a gift in relationships. They create such a sense of safety in relationships, because the other person knows that I am going to take responsibility for my own feelings and needs. So if I say to them, "Hey, I'm really going through something right now. Can we talk?" and they say, "Oh, I can't talk right now. I'm in a meeting,"

[00:38:30] I'm not just gonna wait around for them to be free and dump my problems onto them. I'm gonna say, "Okay, thanks for letting me know, because I respect your boundaries." I really need to talk to someone right now, so I'm gonna go call my therapist. I'm gonna call my mom. I'm gonna call my sister.

If you say to me, "Hey, Melissa, do you wanna do this podcast with me?" and I say, "Sure, I'll do that with you, but I don't really have the time or capacity," and I'm saying so resentfully, and then I'm showing up for this interview, and I'm distracted, and I'm not prepared, and I'm kind of all over the place and scattered, and then you're wondering, "Well, she said yes. Why is she showing up like this? Maybe I did something wrong." No. If I say yes to you, you know I say yes authentically, and I'm going to show up as my best self and my most prepared, and I'm not going to be resentful, and I'm not gonna show up begrudgingly. And if I say no, that's a gift, because you know that I can't give you what you need right now, and you'll go find another podcast guest that's gonna be better than I can right now.

So boundaries are really this clear, kind communication that improves your relationships, and when you can shift and start to see them like that, they no longer feel selfish. They no longer feel like something you should feel guilty for.

Dr. McBride: [00:39:30] It's such a good message. It's so important. It's exactly what I try to teach my kids. Because when you don't set a boundary, you end up paddling in gossip. Your love language can be resentment and, "Wow, look at her. Look at how she's so important." If you don't set a boundary, you end up doing things that go against the grain of your own integrity, and that is intrinsically uncomfortable. And if you're not honoring that discomfort, it's going to show up in another way.

The other thing, on the flip side of that, is there are some times you had to do things you don't wanna do, right? Like, you know, sometimes you just have to turn in the term paper even though you don't want to. You sometimes have to say yes and participate on that sports team because that's the way the world works to be able to make the team. I think the question is, knowing your place in the universe and knowing how to advocate for yourself in a healthy way, you know, that's something you have to learn the hard way, I think, in this world.

Melissa: You know, what I find is that when people live in boundaryless relationships, [00:40:30] they are walking around resentful, they're walking around anxious, they are dreading interactions, they're keeping people at a distance, which hurts the relationship. If my mother-in-law keeps dropping over without calling, and I don't say anything to her because I'm trying to be nice, so I open the door and I'm like, "Hey, Carol. Yep, come on in." And then she comes in, and I'm cold, and I'm short. And I don't wanna visit because it's not a good time, but I don't wanna say so because I'm trying to be nice. And she's like, "What did I do? Like, what is wrong?"

Boundaries [00:41:00] can be uncomfortable. It can be uncomfortable to say, "Hey, Carol. Would you please call before you come over and give us about an hour's notice?" That can be uncomfortable. But what you're doing now is already uncomfortable. You're walking around anxious and resentful and dreading certain interactions, and your relationship isn't going well. And eventually, if you keep holding that in, you are going to explode. And, like, that path doesn't get you anywhere. That's just a circle of doom and unhappiness. And the discomfort of setting a boundary can be momentary but lead to this huge [00:41:30] improvement and expansion of your relationship. And that's the discomfort that I'm willing to go through.

Dr. McBride: I mean, mic drop. Passive aggressiveness is also a byproduct of absent boundaries or wobbly boundaries. We all know when we're being passive-aggressive, and we all know when we're the victim of passive-aggression. And to me, that's a signal that, you know what, it's time to be honest about what's happening here without blame or shame, but just name and own your part of the boundary that was broken. Say, like, "Look, I realize I showed up at a time that was not convenient for you. I hope that next time you just let me know if it's not a good time," or "Hey, I think I might have asked you a question that made you uncomfortable. My bad. So sorry." And then let them talk, right? Just being honest and authentic. And that's a tall order in the world we live in.

Melissa: It is, especially, again, because women, especially, are taught to talk around everything. We're not taught to be direct. We're taught to hint and to hope that people read our minds, and then we get disappointed when they don't do the thing that they didn't know they were supposed to do. And then it just goes back and forth and back and forth, right, and then you end up in these fights where, like, your husband is like, "Hey, can I go out with the guys for a drink tonight?" And you don't want him to because you have a million things to do, but you go, "Sure." And he thinks you don't mean it, but he doesn't really wanna hear it, so he just leaves. And then he comes home three hours later, and you're in full-on rage mode. And you're like, "How could you go out? I really needed you home." And he's like, "You said it was okay for me to go." And I can't tell you how many times in my past lives those cycles had [00:43:00] repeated until, finally, I was like, "Oh, clear communication is kind." And if everyone just said what they meant, relationships would instantly get 78% better.

Dr. McBride: Like, that little story resonates with me 100 times over, by the way. Anyway, it's all so healthy, and these are sort of, like, the infrastructure that we all should be thinking about putting into place in our regular lives, because it's like the skeleton we need to be healthy and happy and to be honest with ourselves. What are you working on? I mean, you've obviously reckoned with addiction. You've reckoned with boundaries. You've reckoned with a conversation around food and bodies in a public-facing way and in your own life. What's on the frontier for you now?

Melissa: You know, I tend to take on self-improvement efforts or self-experiments as they come up for me. I'm not a new year's resolution person, so I don't think ahead of time, "Oh, I'm going to work on this this year." Right now, I'm heavily invested in my own mental health, so I typically have, because of my post-concussion syndrome, combined with winter, I typically get really serious seasonal depression. And this year, I don't have any, and so I'm like, "Okay, what am I doing? How can I keep it up? What are the practices I've put in place that are really helpful?"

So I'm kind of really diving into that and making sure that I'm caretaking for my mental health. And then I feel like I'm in a season of work right now where I'm thinking about how can I rebalance my work and my life. I've had a period of hustle where I just put this book out, and that was a year and a half of really intense writing and touring and media. And, like, maybe it's time to rest a little bit more, and how can I incorporate some more rest into my life? So those are two things I'm focused on right now that I think are going hand-in-hand.

Dr. McBride: You're just trying to be intuitive, it sounds like, and not plan for the inevitable ups and downs. And then it also sounds like you're trying to breathe in and consciously note the conditions that allow you to feel good.

Melissa: I build in moments many times a day every single day to check in with myself, "How am I doing? What do I need?" I do these meditations where I talk to parallel timeline Melissa, "How are you? You're doing amazing out there. What have you done to get yourself there? Like, talk to me about it." I talk to 16-year-old Melissa. I represent myself in these meditations where we talk about what she was feeling and what she was going through and, like, where we are now and how good we're doing new. I have all of these built-in sort of touch bases that I learned in therapy and through my own practices, and I'm constantly checking in with myself to be, like, "What do you need? How do you feel? Where would you be comfortable?" I act on those.

Dr. McBride: [00:45:28] I love it. And then I think, as we focus on self and self-actualization, self-discover, and health, and well-being, we then bring that improved self to our parenting, to our work, and to the world, because we can often confuse effort to know oneself and check in with ourselves as indulgent. When I look at it as the opposite, it is a way of nurturing self to then present to other people, because, to me, and I think to you, being other's focus is a way of maintaining meaning and purpose and satisfaction.

Melissa: I am not a people pleaser. No one would ever describe me as a people pleaser. I am a firm believer in paying myself first. When my cup is full, when I am nourished, when I am fed, when I am well rested, when I am happy, when I am taking care of me, I have so much more to give to everybody else in my life. And that giving feels more authentic, it feels more organic, it feels more joyful. I do this for me. But by extension, that allows me to do things for others.

Dr. McBride: [00:46:30] You're awesome, Melissa. And I'm not saying that just so you like me. What I think is so unique about you, Melissa, is that you're not only writing and speaking and talking to people about health, you're modeling behavior and vulnerability and authenticity and the ability to be forgiving of ourselves when we make mistakes. You're walking the walk, not just talking the talk. So I think you're helping people just by being yourself and by sharing your story, which ultimately is, I think, an important way of affecting behavioral change in others. So thank you for joining me. I'm thrilled that you came today.

Melissa: It is my pleasure. Thank you so much for the conversation.

Dr. McBride: Thank you all for listening to "Beyond the Prescription." Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com.

The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician. "Beyond the Prescription" is produced at Podville Media in Washington, D.C.

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How often do you think about your skeletal health? Too often, we take mobility, absence of pain, and physicality for granted—that is, until we are sidelined.

Whether we’re nursing a torn ACL, an arthritic hip, or an osteoporosis-related fracture, even temporary immobility can alter our physical and mental health. It can threaten our sense of self.

Health is about more than the absence of pain or disease; about more than just treating the physical symptoms of a condition. Health is about taking a holistic approach to wellness and recognizing that we are the integrated sum of complex parts. Health is about having awareness of data and the stories we tell ourselves, acceptance over the things we can't control, and agency over our life.

In today’s solo podcast, Dr. McBride discusses the importance of caring for our skeleton like we do our cars—taking it to the shop when it breaks down, and providing regular maintenance.

She gives three examples—including herself!—of people whose physical injuries force them to reckon with their health

How do you care for your skeleton? What can an injury teach you about your health? What is the relationship, for you, between mobility and mental health?

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast or at https://lucymcbride.Substack.com/listen.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

The full transcript of the show is here!

Dr. Lucy McBride: [Intro] Hello and welcome to my home office. I'm Dr. Lucy McBride, and this is Beyond the Prescription. Today. It's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as a process of self-awareness, acceptance, and agency.

[00:00:28] In clinical practice for over 20 years, I have found that patients generally want the same things—a framework to evaluate their risks, access to the truth and data and tools and actionable information to be healthy mentally and physically. We all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today. Let's go.

[00:00:56] [Episode] Hello, everyone and welcome to my solo podcast. Today we're going to be talking about skeletal health and what happens to our bodies and minds when we are out of commission. Today is the final game of March Madness, and I don't know about you, but I am pretty obsessed with March Madness. I love how it signals the beginning of spring.

[00:01:14] I love the friendly competition of all the brackets, and my family's pretty obsessed with the games. I am no basketball aficionado, but I really enjoy looking at the athleticism, the strength, and the grit on the courts. I also can't help but wonder what these guys are gonna look like when they're patients in their fifties, sixties, and seventies, for example, when they've had a lot of overuse injuries and they show up in the doctor's office, perhaps like mine.

[00:01:40] I think it's important we acknowledge we each have only one skeleton that drives us through life, and we cannot trade in our skeleton like we can our Honda or our Prius. We can only take care of it the best way we possibly can. We can only do maintenance. And I think it's interesting. Many of us take our cars to the shop to rotate the tires, change the oil, align the axles—more than we take care of our skeletons or take them into the shop.

[00:02:06] And by the shop, I mean to a physical therapist or other body. Okay, so why does this matter? Why do we need to think about skeletal health? Why do we need to think about injury prevention and why do we need to treat our skeletons at least as well as we do our cars? The short story is this: our skeletal health is foundational.

[00:02:26] A couple of months ago, I unveiled the visual representation of the way I think about patients’ health. I call it the four I’s. It's a two by two grid, and the way I think about health is that we are the integrated sum of these different components, these four I’s that intersect and that really talk to each other all day long.

[00:02:48] One I is information and data. The second I is inputs—all the things we put in our ecosystem. Another I is infrastructure—our skeletal health, the container that drives us through life. And this is what we'll focus on today. And the fourth I is insight. Our self-awareness and our understanding of how our story lives in our body.

[00:03:08] In this ecosystem, I have assigned an entire quadrant just to skeletal health. That is because our skeletons are essential and foundational to our whole health and the way we move our physicality directly affects our medical information. It also affects our insight and self-awareness, so it's essential that we care for the bones, the muscles, and the connective tissue that carry us through life.

[00:03:33] When these systems are going well, we tend not to notice. When we're walking, jogging, swimming, lifting our grandchildren, putting luggage in the overhead compartments and playing bridge, knitting, gardening, and living our lives without any discomfort or limitation, we tend not to notice. We tend not to pay attention to our skeleton.

[00:03:56] We end up taking it for granted and thinking it is going to be there for us whenever we need it. But guess what? Every now and then we blow a gasket. Every now and then the muffler starts rattling before we even blow the proverbial gasket. And what I see in my office is people who are experiencing pain, discomfort, limitations in their range of motion, limitations in their quality of life and their ability to do the things they want to do.

[00:04:22] And in the case of people who have exercise routines who are managing their cholesterol or their heart health, or their mental health with exercise, being sidelined has major, major consequences. It affects our physical health, our mental health. It can affect our sleep, it can affect our whole sense of self.

[00:04:39] Let me give you three examples. I have a number of patients who are student-athletes. Either they play high school sports or college sports. And you know, these young athletes are very accustomed to being strong, fast, nimble, and not limited in their ability to perform. And so when an injury happens, It can be devastating. Not only can they experience pain and disability, they can also experience a crisis of identity. Particularly as kids tend to specialize in sports earlier and earlier these days, their identity can very much easily get wrapped up in their sport and their performance. I have a patient who's a young woman who plays collegiate soccer at a very high level, and when she tore her ACL—which is an important ligament in the knee—in her season, she was devastated.

[00:05:26] She was experiencing quite a lot of pain after her surgery and was having a difficult time rehabilitating her knee. Unfortunately, the orthopedist was giving her more pain medicine—more Percocet—and that was making her feel more blue, more disconnected, and she came into my office wondering what to do.

[00:05:43] I'll give you a second example. An 80 year old patient of mine broke his femur. The femur is the thighbone, and he broke it because he fell and he has osteoporosis. Now this man was an incredibly proud man. He'd had an extraordinary career doing diplomatic work overseas and he had taken great pride and joy in caring for his beloved wife who had died three years prior from Alzheimer's. Mobility to him was not just about getting exercise, which he was good about doing to manage his heart health. It was also about socializing with his friends. It was about playing cards with the guys once a week. It was about taking his dog for a walk every evening and looking at the bench and the tree where he and his wife would sit every evening.

[00:06:26] In other words, mobility is not just about exercise. It is about our daily activities, our daily life, our daily ability to function. When he came into my office to talk about the upcoming surgery for his femur, he was noticeably distraught. He wasn't in pain physically, he was in despair over his loss of independence and sense of identity.

[00:06:48] I'll give you a third example, and it's me. When I was in college, I developed depression. I didn't know that's what it was at the time, nor did the myriad doctors I saw for the various physical symptoms I brought into them. In fact, they thought that I had things like giardia or an autoimmune disease instead of just asking me, are you okay, and basic screening questions about mood and anxiety and stress. One of the solutions that was suggested to me for this mysterious disease that no one could name, and for which I had no vocabulary to discuss, was running. And so I began running in college and running made me feel better. Running made me feel really good.

[00:07:25] In fact, running in retrospect was providing me with dopamine. It gave me pleasure and joy and some sense of relief from this uncomfortable feeling I was experiencing. But the problem was, guess what? When you only run and you don't do stretching and you don't do any other activities, you get injured. And I did. I developed tendonitis in my knees and I couldn't run, and guess what? I got depressed.

[00:07:46] The point of these three anecdotes is that our skeletons matter not for the reasons we often think. Most people understand that exercise is good for us, that it can help prevent everything from dementia, depression, and diabetes. And indeed I spend a lot of time in my office trying to help people exercise in ways that are sustainable and realistic for their lives. But the reason I so commonly emphasize movement, structural stability, structural integrity of our skeleton, is not just because exercise is cool, exercise is good for us. It's because we literally need our skeletons for our identity, for our mood, and for our ability to function. So when I'm talking to a patient about their skeletal health, I'm not simply saying exercise is good for you. Go do it.

[00:08:33] I want to know the why, the how, and the what. I want to understand what kind of movement gives them joy, what gives them pleasure, and what limitations in mobility they have that they might not even have identified? What are the things in their life that they live to do that requires skeletal mobility and flexibility and strength? Let's think about exercise, not just as a way to fit in your jeans or to run the next marathon. Let's think about it as a way to move through your everyday life.

[00:09:01] My other question is this—What hurts? What is your body telling you about what needs to change? I need to know if you're experiencing pain in your low back, because that may be a signal that we need to work on tightening up your core muscles or your pelvic floor. In other words, we need to listen to those mufflers when they rattle because they are telling us something. They are giving us clues to a part of our body that needs attending. And if I had one lesson for you today, it's to listen to your body. Listen to your skeleton. It matters. So to my patient who's torn her ACL and is recovering postoperatively, I want her to think about exercise in a new way.

[00:09:39] I want her to use this injury as an opportunity to reflect on her identity. I want her to think about—who am I beyond a college athlete? So as much as she didn't want to, she embarked on a project of increased self-awareness. She started doing daily meditation. She started cultivating friendships with people who are not athletes and realizing that, wow, there's a lot more to school and to her social life than playing soccer. Her injury had actually given her permission to explore the ways in which her physicality was central to her identity, but also not sufficient to define her.

[00:10:13] So was there any silver lining for my patient who broke his femur? Well, not right away. After a surgery like that, you're in rehabilitation for many months. You're doing physical therapy twice a week and really building back your strength gradually. As you may or may not know, when you break your femur, it causes atrophy of the surrounding muscles, the glutes, the hamstrings, the quadriceps, and it's a lot of work to rehabilitate those muscles, particularly when you're older.

[00:10:41] So I wouldn't say that there was a real silver lining for this gentleman, but I would say that it forced him to reflect on his mortality in a way he hadn't done. Having to plumb the depths of his grief without the benefit of exercise and socialization as he had been accustomed to since his wife died. It forced him to reckon with a lot of uncomfortable feelings that he had not dug up. And while I wouldn't wish that on anybody, he did tell me towards the end of his recovery from his hip surgery that he had learned more about himself having been sidelined than he would've other. So after his recovery, I reminded him that he was really, really one of the healthiest 81 year olds I'd had in a long time.

[00:11:20] And finally, what about me? So when I was injured and I could no longer run in college, I connected the dots between my physical self and my mental health, and that was a valuable lesson. It was painful because I had no other tools in the toolkit to manage depression. I had nothing. Moreover, I didn't have any vocabulary with which to talk about feelings, and I didn't have healthcare providers to know how to guide me or even to make an appropriate diagnosis. But it did force me to really dig deep into my internal arsenal of tools and to cultivate other coping strategies because I had to, I had no other choice. So what is my point in telling you about these three anecdotes? It is to say that movement, physicality, mobility, range of motion, absence of pain, those things we take for granted until we're sidelined.

[00:12:14] I ask you to do this. Think about your skeleton for just a minute. Take a survey, going from your neck all the way down. What is hurting? What is tight? What is strong? What is weak? What hurts? Taking stock of our muscles, our bones, our joints, and our structural integrity, and taking that moment of mindfulness about our own bodies is step one.

[00:12:41] Step two is the context. What about your skeleton is allowing you to do the things in your life you want to do and what is holding you back? Maybe you have no problems with your skeletal health because you're young, because you happen to be an athlete and because you just haven't been injured. Or maybe you can do the things you want to do because you've worked really hard on pelvic floor muscle tone since you've had three children, and that is the reason your herniated disc is no longer bothering you and that is important to you because when your back goes out, you're unable to live your life. And maybe you're someone who has knee pain and is slowly and gradually limiting your mobility. You're taking the elevator, you're avoiding long walks with your friends, you're taking more Advil and you haven't yet registered that discomfort.

[00:13:26] I encourage you to register what your body is telling you, and then, what is the context? What is that limitation in mobility or in comfort? How is that limitation in your mobility and comfort affecting your everyday life?

[00:13:38] Step three: What is the relationship between your physicality and your mental health? Is exercise good for your mood? Does it help you feel less anxious and more focused? Or do you feel like you are a victim of your own exercise routine such that you're anxious and stressed and dreading getting up in the morning because you know you have to get up so early to go to that class because you said you would. And then ask yourself, how do you feel when you've exercised or you've been in a good routine, and how do you feel when you've been out of a routine or you've been sidelined? What does that do to your sense of wellbeing, your sense of self, your sense of identity?

[00:14:14] And step four: How does regular exercise or just being mobile and living without limitations or pain affect your relationship with food and the content of what you eat? Those inputs in that one quadrant? For so many people, the absence of pain and the ability to move and exercise is directly tied to their ability to eat intuitively and to eat nourishing, healthy foods.

[00:14:38] And step number five: how does movement, mobility, and exercise affect your physical health? Your lab tests, how much better is your blood pressure, your heart rate, your blood sugar, and your weight, if that's what you're working on in the doctor's office. And how good do you feel when your doctor gives you that “hooray! Your blood pressure is so much better and you can attribute it to your exercise routine.” As it turns out, our skeletons provide a map for multiple parts of our lives. They offer us clues about who we are, why we get up in the morning, why we get moving every single day. So let's pay attention to them.

[00:15:15] Let's not wait until we blow a gasket or get sidelined from the court. And even if you're sitting on the couch right now with a big bowl of popcorn about to pop on that NCAA finals game, let's try to treat our skeletons like the foundation to our health that they are. We have one vehicle to drive us through life. Let's care for it like we do our cars and keep moving. Thank you so much for listening. I would be thrilled if you shared, liked and commented on this episode. Your feedback means everything to me. Thank you so much for listening.

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If you are a parent searching for answers — or a teenager yearning for tools to understand yourself better — look no further!

Dr. Lisa Damour is a New York Times bestselling author, podcast host, clinical psychologist, mother, and all-around brilliant human. Her new book, The Emotional Lives of Teenagers: Raising Connected, Capable, and Compassionate Adolescents, is an essential guide for parents and teens looking to make sense of their emotional distress, complicated feelings, and current climate of fear and anxiety.

Lisa sits down with Dr. McBride to discuss the recent CDC data on teen mental health and common misconceptions about anxiety, distress tolerance, and how parents can help their teens cope with the ups and downs of adolescence.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast or at https://lucymcbride.Substack.com/listen.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

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Our stories live in our bodies.

No one knows this better than Dr. Suzanne Koven, a master storyteller and primary care doctor at Harvard Medical School. In caring for patients for 30 years, Dr. Koven learned that patients are more than a set of organs.

“There is nothing that I can think of, there is no kind of testing, there is no sort of physiology or pharmacology that is more essential to clinical skill than the ability to elicit, interpret and communicate someone else’s story.”

It turns out that Dr. Koven has a story, too. Despite her accomplishments and accolades, as a young woman Dr. Koven felt like an imposter—a surprisingly common sentiment for career-oriented females. Her memoir, Letter to a Young Female Physician, is a series of personal essays that reveals the importance of identifying negative self-talk. The book is must-read for women physicians and for anyone experiencing self-doubt. It’s also part of the reason she became the inaugural writer-in-residence at Massachusetts General Hospital in Boston, helping other physicians explore the art of listening, writing, and authoring our own narratives.

On this episode of Beyond the Prescription, Dr. Koven discusses with Dr. McBride how her own process of self-discovery improved her own health. Her humility and humor are just what the doctor ordered.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast. https://lucymcbride.Substack.com/listen

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

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Three years after the World Health Organization declared the COVID-19 pandemic, we have widespread population immunity against the virus. But no one is immune to accumulated fear and uncertainty.

On this episode, Dr. McBride talks about where we are now and what to expect with COVID. She discusses various topics including

• the transition from pandemic to endemic

• rapid antigen versus PCR testing

• treatments, including Paxlovid

• the recent Cochrane review on masks and mask mandates

• vaccines and immunity

• what to expect in fall 2023

• addressing our pandemic story

Finally, Dr. McBride argues that recovering from the distress of last three years requires understanding our unique risks and risk tolerance—and appropriately reckoning with vulnerability.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

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Family dynamics are complicated—but what happens when you learn that you have dozens (and possibly hundreds) of siblings?

When writer Chrysta Bilton’s mom decided to build a family as a gay woman in the early 80s, she employed a sperm donor. This man also played a role in Chrysta and her sister’s life as “dad.” But he continued to donate to other women—in secret—for almost 10 years. Chrysta learned this shocking truth from an article in the New York Times. On this episode, Chrysta joins Dr. McBride to discuss family secrets, shame, her unconventional coming-of-age story, and how all of this affected her mental and physical health.

Chrysta’s critically acclaimed memoir “Normal Family: On Truth, Love, and How I Met My 35 Siblings,” is available now.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

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Screens have become a necessity of modern life. Whether we like it or not, they inform how we work, play, parent, and relate to other people.

Technology is a wonderful thing. But too much screen time can negatively affect our health. From sleeplessness and agitation to addiction and social isolation, our relationship with tech directly affects our body and mind.

On this episode, Dr. McBride expands on her concept of the Four “I”s. She discusses how to think about screens like we do other “inputs.” Whether it’s alcohol and sugar or Instagram and TikTok, the question isn’t just How much? It’s What is my relationship with the thing I’m consuming?

Maintaining digital hygiene takes work. Here, Dr. McBride argues that a healthy relationship with technology requires understanding the power of social media algorithms—and the same self-awareness that we should apply to everything we feed our eyeballs and brains.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

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Leading political and intellectual historian and certified fitness instructor, Natalia Petrzela, firmly believes that exercise matters not only for your physical health, but mental health as well. Yet while we as a nation are obsessed with exercise, too many Americans are sedentary. Many of us equate exercise with losing weight – but health is about more than the number we see on a scale.

Natalia joins Dr. McBride to discuss America’s complicated relationship with exercise; why it’s so important for our overall health to prioritize movement; and how we can become healthier from the inside out.

Natalia is also the author of Fit Nation – The Gains and Pains of America’s Exercise Obsession, which shows how fitness in America is about more physical health— it’s a means for equity, inclusivity and community-building.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

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Human suffering is impossible to fully measure. It includes our core values and beliefs. It encompasses our tolerance for pain. If medical decision-making is about avoiding risk, who gets to decide what’s even worth risking? If avoiding one risk means adding another, when are we doing “no harm”?

Doctors can measure blood pressure, blood sugar, liver enzymes, and white cells; we can even run genetic profiles to look for elevated risks for cancer (like the BRCA gene mutations). But there is no blood test for depression, no MRI for chronic pain, no line in the sand separating worry from debilitating fear.

In this episode, Dr. McBride discusses how modern medicine tends to discount things it cannot see — and how to better advocate for ourselves in the doctor’s office.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

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It turns out that caring for others carries occupational risk.

Anyone who has ever cared for aging parents, agitated teens, or sick friends has experienced symptoms of emotional and physical depletion. Caregiver burnout is not only common, it affects our health. Just as caregiving bleeds into everyday life, there’s no partition between our body and mind.

Dr. Emily Silverman, physician and host of The Nocturnists podcast, shares her remarkable journey from burned-out physician to advocate for caregiver well-being.

Eager to go to med school from a young age, Dr. Silverman approached her medical training with enthusiasm and eagerness. Everything changed when her health started to suffer from burnout—a fact crystallized after working two back-to-back 28-hour shifts.

Coping with her own health issues as she cared for patients, Dr. Silverman realized that if she was to treat others, she first needed to show herself the same level of care and respect. She also began identifying more with her sick patients than her medical colleagues. The “work hard” culture of her residency program seemed to favor showing up at all costs and efficiency over the emotional and physical needs of residents. It was only when she acknowledged her suffering and asked for help that she knew she could authentically care for others.

Dr. Silverman went on to create a successful live show and podcast, The Nocturnists, for the medical community to speak openly about the struggles and triumphs of being a caregiver. There she has given space for others to tell their stories, learn from one another, and model compassion for others and for self.

It turns out that burnout applies not only to doctors but to anyone in a caregiving role.

At some point in our lives, that’s all of us.

Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast.

Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome

Please be sure to like, rate, review — and enjoy — the show!

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Twice a month, Dr. McBride is trying something different. She will talk directly to you — sharing advice and top-line thoughts about the most important health issues she sees.

On this 13-minute episode, Dr. McBride explains the practical framework she created to help patients conceptualize their health, integrating medical evidence, the patient’s story, and real life.

Dr. McBride calls it the FOUR “I”s

• Information & data = the elements of our health that we can measure and see.

• Inputs = everything that we put into our health ecosystem.

• Infrastructure = the vehicle (i.e., the skeleton) that drives us through life.

• Insight = the process of laddering up from self-awareness to acceptance to agency over our health and well-being.

Helping people connect the dots between their own four “I”s lays the groundwork for improved physical and mental health.

For now, this twice-monthly feature will be free for everyone. Paid Substack subscribers get early access each week.

Join Dr. McBride every Wednesday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.

Please be sure to like, rate, review — and enjoy — the show!

Disclaimer: The views expressed here belong entirely to Dr. McBride. They do not reflect those of her employer, nor are they a substitute for advice from your personal physician.

This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit lucymcbride.substack.com/subscribe

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Tashira Halyard is as fashionable as she is fearless. As an attorney, racial equity consultant, breast cancer survivor, and founder of the wildly popular blog and Instagram handle, Politics & Fashion, Tashira brings her audience inside her closet — and her world — nearly every day of the week.

Tashira brings her passion for equity and her fierce personal style everywhere she goes, but her path to success wasn’t paved in diamonds. In this episode, Tashira reveals how childhood trauma, her diagnosis of breast cancer, and a toxic relationship with work changed her, physically and emotionally, and how these painful experiences helped clarify her commitment to living boldly and unapologetically.

She is the author of Fight for Our Girls, a TV series that explores the intersection of race, gender, and trauma in the lives of Black girls. She also created the “The 21-Day Happiness Project,” a toolkit to foster self-awareness and self-care, and, most recently, a podcast called JustUs where she riffs with her BFF Margo about everything from racial justice to fashion runways.

Her goal? Empowering other women to leverage their self-worth for social progress.

Join Dr. Lucy McBride every Wednesday for a new episode of Beyond the Prescription.

You can subscribe on Apple Podcasts, Spotify, or on Substack at https://lucymcbride.substack.com/podcast. Sign up for Dr. McBride’s free weekly newsletter at lucymcbride.substack.com/welcome.

Please be to like, rate, review — and enjoy — the show!

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I’m excited to share my roster of amazing guests — and our conversations about health, wellness, and how to be a little more okay tomorrow than we are today.

A fun new feature! This season, every other week will be a sit-down with just you and me — where I go into more detail about the nuances of common medical issues. From the new weight loss drugs and hormone replacement therapy to the complexities of treating depression and anxiety, I can’t wait to share some practical advice and top-line thoughts about issues that affect our everyday lives.

Be sure to subscribe to the podcast on Apple podcasts, Spotify, or wherever you get your podcasts.

My weekly Are You Okay? newsletter is delivered free in your inbox every Monday. For lots of fun extras including early access to the podcast, consider a paid subscription!

Are You Okay? is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

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Click the red arrow above to listen!

I’m excited to share my roster of amazing guests — and our conversations about health, wellness, and how to be a little more okay tomorrow than we are today.

A fun new feature! This season, every other week will be a sit-down with just you and me — where I go into more detail about the nuances of common medical issues. From the new weight loss drugs and hormone replacement therapy to the complexities of treating depression and anxiety, I can’t wait to share some practical advice and top-line thoughts about issues that affect our everyday lives.

Be sure to subscribe to the podcast on Apple podcasts, Spotify, or wherever you get your podcasts.

My weekly Are You Okay? newsletter is delivered free in your inbox every Monday. For lots of fun extras including early access to the podcast, consider a paid subscription!

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Journalist and best-selling author Daniela Pierre-Bravo took an 18-hour overnight bus to New York City for her first interview in journalism. As the oldest daughter of a large family of Chilean immigrants — and having worked multiple odd jobs to put herself through college — this interview was her ticket to a new life. Yet as a DACA recipient, she struggled to feel like she truly belonged in the US.

Working tirelessly to be included in American life took a toll on Daniela’s mental health. She realized that she had tied her self-worth to productivity, sacrifice, and “fitting in” — instead of celebrating her individuality and unique talents.

Her new memoir, “The Other: How to Own Your Power at Work as a Woman of Color” chronicles her journey from self-sacrifice to self-empowerment. It is an honest account of the hopes, dreams, and barriers in the way of hard-working immigrants. It’s also a practical guide for women of color navigating the workplace.

On this episode of Beyond the Prescription, Daniela joins Dr. McBride to talk about the difference between inclusion and belonging, the emotional toll of not feeling seen, and the importance of showing up as our true selves for our mental and physical health.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. You can find all of her podcast episodes — plus her weekly Are You Okay? newsletter — on Substack.

And to read about what Dr. McBride has been up to for the last three years, click here!

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Principal dancer for the New York City Ballet, Tiler Peck, woke up one morning in 2019 in excruciating pain and unable to move. She was diagnosed with a herniated disc in her neck on an MRI, and multiple doctors recommended surgery. They also suggested she might never dance again. When Tiler asked if she could instead pursue physical therapy before — or instead of — surgery, one doctor asked if Tiler’s physical therapist wanted to be responsible if she ended up paralyzed.

Tiler went from abject despair to dogged determination to heal on her own terms.

And that’s what she did. Tiler listened to her body and sought a more nuanced approach to her neck. In the process, she learned more about herself than she ever imagined. From the physical manifestations of emotional distress to the power of saying “no,” Tiler’s seven months of immobility turned into a process of self-discovery.

As a result, she came back to ballet stronger and smarter.

In this episode of Beyond the Prescription, the dancer shares her insights about doctors, self-advocacy, and the power of knowing our own body and mind. She and Dr. McBride discuss treating the patient — and not just their test results — and the critical importance of more holistic approaches to health and well-being.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts.

You can subscribe here to her weekly newsletter Are You Okay? where she writes about what it means to be healthy — physically, mentally and Beyond the Prescription.

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Dr. Glynis Albright, fondly known as the Waffle Queen, has built an empire off of her pies, cookies and pound cakes. As CEO of the world renowned Glynis’ Kitchen, her treats have been tasted and loved by the likes of Bill Clinton and John Legend.

But cooking isn’t just Dr. Albright’s passion, it’s been her lifeline. When she was diagnosed with leukemia in her 30s, and with a PhD in nutrition, she used her superb culinary skills to whip up treats that tasted good and provided her with the nutrients she needed to heal. She then used those recipes to help others in her community struggling with their health.

On this episode of Beyond the Prescription Dr. Albright and Dr. McBride discuss our often complex relationship with food, how to abandon the shame inherent in diet culture, and to appropriately nourish our bodies and minds. They talk about the baker’s journey of self-discovery as she moved away from skipping meals toward preparing delicious ones for herself and others. As the inventor of the “Just Sweet Enough” line of treats for people undergoing cancer treatment, Dr. Albright herself is food for the soul.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

Get full access to Are You Okay? at lucymcbride.substack.com/subscribe

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Dr. Glynis Albright, fondly known as the Waffle Queen, has built an empire off of her pies, cookies and pound cakes. As CEO of the world renowned Glynis’ Kitchen, her treats have been tasted and loved by the likes of Bill Clinton and John Legend.

But cooking isn’t just Dr. Albright’s passion, it’s been her lifeline. When she was diagnosed with leukemia in her 30s, and with a PhD in nutrition, she used her superb culinary skills to whip up treats that tasted good and provided her with the nutrients she needed to heal. She then used those recipes to help others in her community struggling with their health.

On this episode of Beyond the Prescription Dr. Albright and Dr. McBride discuss our often complex relationship with food, how to abandon the shame inherent in diet culture, and to appropriately nourish our bodies and minds. They talk about the baker’s journey of self-discovery as she moved away from skipping meals toward preparing delicious ones for herself and others. As the inventor of the “Just Sweet Enough” line of treats for people undergoing cancer treatment, Dr. Albright herself is food for the soul.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Award-winning NPR education reporter Anya Kamenetz saw firsthand the devastating effects of school closures during COVID on children’s learning, mental health and social-emotional well-being.

Her 2022 book “The Stolen Year: How Covid Changed Children’s Lives, And Where We Go Now” brings the stories of these children and their families to the forefront while providing historical context on the broken state of the U.S. education system.

Anya joins Dr. McBride to describe how the shift to remote learning exacerbated an already tenuous American public education system and discusses the lessons learned from a massive disruption of the U.S.’ last true social safety net. Anya offers advice to parents as they navigate the new “normal” while recognizing the diversity of pandemic experiences — even within the same household — and offers hope for the future of American families and children.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Laurie Cameron watched her father die in her arms when she was just a teenager. Out of this loss grew Laurie’s passion for psychology and for understanding the human condition. As the CEO of PurposeBlue she helps busy professionals and people around the globe incorporate mindfulness into their daily lives. Her 2018 critically-acclaimed book The Mindful Day is a practical guide to build a more meaningful life.

The author shares with Dr. McBride some of her easy-to-replicate methods for finding tranquility amidst chaos and calm within the hubbub of everyday life. Laurie discusses how she inserts moments of quiet “presentness” and gratitude into her own schedule. The mental health practitioners agree that agency is born out of radical acceptance and about the intrinsic connection between a calm mind and a healthy body.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Mike Bassett is living proof that good people sometimes do bad things. In his case, that bad thing was signing a box of fraudulent checks that nearly caused him to lose his law degree, his reputation, and his family. His 2021 book, "The Man in the Ditch,” details his path to reconstructing his reputation and learning how to forgive himself.

On this episode of Beyond the Prescription, he describes his incredible redemption story with Dr. McBride. They discuss the dangers of "black or white thinking” in health, in life, and on the path toward self-compassion. Mike offers hope to anyone down in the ditch — whether they landed there after a traumatic event or they dug the ditch themselves.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Elise Loehnen is helping redefine wellness. As the former chief content officer of goop and Gwyneth Paltrow’s right-hand woman, Elise understands health as the complex intersection of mental, physical and spiritual health. She has created a cult following through her own writing, Instagram monologues, and her hit podcast Pulling the Thread. Each week, she brings her fans on a journey of self-discovery, pondering life’s biggest questions alongside cultural luminaries like Gabor Mate, Susan Cain, and Nedra Tawwad, sprinkled with her signature warmth and curiosity.

On this episode of Beyond the Prescription, Dr. McBride and Elise discuss reconceptualizing what it means to be healthy. Elise talks about her own encounters with Western medicine, her complicated wellness journey, and how she envisions leading a healthy and fulfilling life. Elise opens up about the physical manifestations of emotional stress, the power of introspection, and her multi-factorial intuitive understanding of healing.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Jeffrey Blount is an Emmy-award-winning story-teller. During his 34 years at NBC News, Jeffrey directed a decade of Meet The Press, The Today show, and NBC Nightly News. As the first African American Director of the Today show, he credits his parents for insisting on quality education for him and his brothers. Keenly aware of the toll of racial injustice on one’s mental and physical health, Jeffrey left his television career to directly reach people of all ages and races with his poignant and emotionally robust novels. Through his writing, Jeffrey is helping Black youth feel seen, heard, and empowered to realize their full intellectual capabilities. His latest best-selling book, The Emancipation of Evan Walls, mirrors his own upbringing in segregated rural Virginia in the 1960s and shines a light on the importance of education — and a sense of belonging — for our health and well-being.

On this episode of Beyond the Prescription, Dr. McBride and Jeffrey discuss his work, life, and mission to empower young people of color.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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This week, we go BEYOND THE PRESCRIPTION with award-winning journalist, producer, and documentarian Soledad O'Brien. She discusses her new film, The Rebellious Life of Mrs. Rosa Parks, the first-ever full documentary of one of the most celebrated — and misrepresented — Americans of the 20th century. We discuss the importance of storytelling to accurately portray historical figures; to lift up marginalized populations; and to educate us all. Soledad talks openly about the personal and professional challenges she has faced as a woman of color and her “life hacks” for taking care of her physical and mental health.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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The Surgeon General of The United States, Dr. Vivek Murthy, is on a mission to amplify the importance of mental health. This week, Dr. Murthy shares his personal experience with loneliness and how he came to see healthy relationships as the foundation for emotional well-being. Drs. Murthy and McBride discuss the distinction between loneliness and isolation and the mental health toll of living through a pandemic. As the first White House official to sound the alarm on the youth mental health crisis, Dr. Murthy explains the harms of social media and our "culture of comparison” to young people today. He also shares his new framework on workplace well-being and why he remains optimistic about the future of our mental health.

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President Obama called his Head Speechwriter, Jon Favreau, his “mind reader.” On this week’s episode, Jon sheds light on his own mind — specifically his phone addiction — and what he learned about his emotional health during the pandemic. The political commentator, podcast host, and new dad was forced to reckon with his everyday habits and his relationship with technology. With heartfelt honesty, Jon shares with Dr. McBride his struggle and some of the lessons learned — including the importance of human connection for our health and well-being.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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This week, we go BEYOND THE DESCRIPTION with Shannon Watts, the founder of the largest gun violence prevention organizations in the US:  MOMS DEMAND ACTION. 

Dr. McBride and Shannon Watts talk about the 2012 Newtown Connecticut massacre that prompted the founding of her organization, what it's like to be targeted as the face of the movement, and how it has affected her emotional health. They discuss the impact of everyday gun violence in Black America. They address the harms of active shooter drills; the false dichotomies in the debate about gun violence in America, and the relationship between mental illness and violence.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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This week, Dr. McBride sits down with author Caralena Peterson to discuss her new book, "The Effortless Perfection Myth", about the mental and physical health toll of the pressure college-age women put on themselves to be pretty, thin, and accomplished. They break down how exhausting it is to be anything but yourself, that love is not something that you earn, and how getting a B+ is often better than getting an A.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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13-time World Champion Boxer Tori Nelson is a fighter in and out of the ring. 

Raised by a single mom and her older brothers, Tori spent her childhood stuffing down her emotions and desperately searching for ways to release her pent-up anger. It sometimes landed her in trouble. That was until she found boxing. The sport catapulted her into tip-top physical shape and provided an outlet for her anger.

In this episode, Tori discusses her rough-and-tumble childhood, dust-ups with the law, and triumphant moments that propelled her into the Boxing Hall of Fame.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify, or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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ABC veteran journalist Gloria Riviera has told a lot of compelling stories. 

The mother of three has spent two decades reporting on hard hitting topics like underaged sex trafficking. She’s also the host of the No One is Coming to Save Us podcast, where she examines the broken American child care system. 

Now Gloria is telling her own story. It begins in 2019 with an unforeseen brain cancer diagnosis, and it’s far from over. 

In this episode of Beyond the Prescription openly discusses how past trauma “prepared” her to cope with cancer, the lessons learned during her treatment, and why she doesn’t fear death.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast

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Journalist Meghan Daum has never been one to mince her words. In her books and on her podcast, The Unspeakable, she tackles some of life’s thorniest issues — from gender politics and wokeism to death and dying — with bold honesty and humor.

Megan is the queen of nuance, a crusader against absolutism, a fearless explorer of taboos. 

In this episode, Meghan gives Dr. McBride an unreserved look into some of her most vulnerable moments, including losing her mother and being placed into a medically-induced coma. Meghan’s fresh take on life, death, and health are just what the doctor ordered. 

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Dr. Sunita Puri  was raised in a spiritual family who taught her the significance of not only life, but of death. Now as a director of Hospice  and Palliative Medicine Fellowship, she has spent an innumerable amount of hours helping terminally-ill patients and their family members make end-of-life decisions. 

Dr. Puri outlines this intersection of her family’s spirituality and her medical career in her 2019 memoir  “That Good Night: Life and Medicine in the Eleventh Hour”. 

In episode 19 of Beyond the Prescription Dr. Puri and Dr. McBride blend their collective experiences as medical professionals into an insightful and honest discussion about the role of medicine in the quality and quantity of life. 

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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As a seasoned school counselor and mother of three, Phyllis Fagell knows exactly how fraught — and potentially how fabulous — adolescence can be. Her latest book, Middle School Matters, equips parents with tools and guidance to navigate the tween years.

Fagell joins Dr. McBride on this episode of Beyond the Prescription with practical advice and personal anecdotes on tolerating distress and approaching the school year with optimism. 

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Dr. Susan Landers is living proof that caring for others starts with caring for ourselves.
After 20 years as a neonatologist (pediatric intensive care doctor), she began to feel unmotivated and exhausted. She was burned out. Raising children and caring for sick babies became unmanageable. So she rethought it all. Her memoir, “So Many Babies: My Life Balancing a Busy Medical Career & Motherhood” reminds us that behind the scenes of many professional women lies self-doubt and struggle—and that vulnerability is the birthplace of health.
In this episode, Dr. McBride and Dr. Landers discuss their shared experiences of juggling motherhood with their medical careers and their insights on preventing burnout.
Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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In college, Larissa, “Larz,” May was dangerously addicted to social media. She’s now trying to change the world. As a trailblazing mental health advocate and entrepreneur, the 28-year-old founded #HalfTheStory in order to help young people navigate our brave new world of potentially harmful social media inputs. Through her advocacy work and educational initiatives, she is living proof that a healthy mind requires a healthy relationship with technology.

On this episode of Beyond the Prescription, Dr. McBride and Larz discuss how to better regulate our social media “diet” and the importance of digital detoxification.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Hamilton, “Ham” Leithauser is an American singer, songwriter, and multi-talented instrumentalist. He is also Dr. McBride’s first cousin.
Ham’s career took off as the lead singer of the now-retired Indie band, The Walkmen (founded by Dr. McBride’s brother Walter Martin). He has since gone solo, producing a number of critically acclaimed albums. Most recently he wrote the original score for his friend Ethan Hawke’s HBO Max series, The Last Hollywood Stars.
In this episode of Beyond the Prescription, the first cousins reminisce about growing up across the street from each other, their strong family bonds, and their grief over losing Ham’s mom (Dr. McBrides’ aunt). Ham opens up about the pressures of performing, the ever-changing music
industry, and being human on stage.
Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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As a child, Keri Blakinger competed on the regional and national levels, with the hopes of one day becoming an Olympian. But behind the scenes, the star figure skater was struggling with an eating disorder, suicidality, and, ultimately, a life-threatening heroin addiction.
In her last year at Cornell, she was sent to prison for heroin possession. It was at what was perhaps her lowest point that Keri found a new mission in life: Writing and advocating for the human rights of the incarcerated. What began as journal entries to get through her 2-year prison term turned into her book, Corrections in Ink, published in June of 2022.
As an author and investigative journalist for the Marshall Project, Keri is focused on her recovery and helping reform the fractured American prison system.
On Episode 14 of Beyond the Prescription, Keri and Dr. Lucy McBride have a candid conversation about overcoming addiction, life in prison, and addressing mental illness through rehabilitation over punishment.
Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Most of us would do anything to avoid the intensive care unit (ICU). Dr. Kyeremanteng wants to help. Caring for the sickest patients during the coronavirus pandemic opened this ICU doctor’s eyes. He quickly recognized that many of the underlying conditions that caused severe COVID outcomes were treatable—if not reversible.
In addition, patients who leave the ICU not only have to recover from whatever illness brought them there, they have to cope with associated PTSD, anxiety, depression, and significant suffering for their caregivers and their families.
So during the pandemic, Dr. K poured his energy into helping people prevent the chances of them landing in the ICU in the first place.
In this episode, Dr. K and Dr. McBride discuss their shared passion for “prevention over prescription”; patient education and empowerment; and their advocacy work together on kids’ mental health during COVID.
In short, they talk about ways to help individuals avoid the enormous medical, social and emotional costs of chronic illness—while redefining what it means to be healthy.
Dr. K wants to “Change the Boogey”—to start a “contagion” of healthy living. It starts here.
Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Trigger Warning: Sexual Trauma

Actor Katherine Kendall was only 23 years old when Harvey Weinstein lured her into his apartment, and then cornered and sexually traumatized her. For years she felt silenced and powerless, fearing backlash if she reported the then influential producer.

Years later in 2017, Katherine bravely spoke out. She was one of the first women to publicly speak out against Weinstein in a New York Times article, sending a ripple effect that would ignite the #MeToo movement. In this episode of Beyond the Prescription, the actress details her journey of overcoming the shame of being sexually traumatized; grappling with the physical manifestations of emotional pain; and finding the courage to advocate for other survivors.

Join Dr. Lucy McBride every Tuesday for a new episode of Beyond the Prescription on Apple Podcasts, Spotify or wherever you catch your podcasts. Find her at lucymcbride.com/podcast.

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Is it safe for pregnant women to drink a glass of wine? Should your child get a booster shot if they’ve already had COVID? What is the cost-benefit ratio of visiting grandparents during a pandemic?

On this episode of Beyond the Prescription, Dr. McBride talks with renowned economist, Brown University professor, and bestselling author, Dr. Emily Oster, to not only answer these questions (spoiler alert: it depends), but also to explore the framing around these often complex questions.

As one of the leading voices in health economics—and recently named one of Time Magazine’s 100 Most Influential People of 2022—Emily takes a data-driven approach to answer the difficult questions on everyone’s mind—especially for parents—in her wildly popular newsletter called ParentData. Her nuanced approach to data-driven decision making has provided a lifeline for the worried and uncertain, especially during the COVID pandemic.

No stranger to uncertainty herself, Emily was forced to overhaul her life plan after unexpectedly being denied tenure. She unpacks this challenging moment with Dr. McBride, and together they explore the ways that data can help anchor our emotions, more appropriately manage risk, and face the unknown with more confidence. 

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast).

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Legal scholar. Lawyer. Professor. Writer. Time Magazine’s Most Influential Person. Tiger Mom.

There’s not much that Amy Chua hasn’t done—or can’t do. She clerked for the U.S. Court of Appeals, worked on Wall Street, and authored an international bestseller. 

It wasn’t until she published her wildly popular memoir, Battle Hymn of the Tiger Mother, that Amy Chua became a household name. People around the world read about her unique, and often controversial, approach to parenting, i.e. “tiger mothering.”

Described as an “ox” by her father, Amy credits her own parents’ strict—and sometimes merciless—“tough love” style of parenting for her success. A daughter of immigrants, Amy learned from an early age to persevere against all odds, to eschew victimhood, and to take pride in her identity as an armor against discrimination.

But despite her fierce public persona, Amy is a lot like the rest of us: replete with self-doubt and struggle. In this episode of Beyond the Prescription, Amy shares her failures and successes as a parent, a hospitalized patient, and a self-described “work in progress.” 

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio).

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After Abby Greensfelder was told to prematurely end her maternity leave and return to a grueling work schedule as a new mom, she knew she had a choice to make – stay and compromise, or take a chance on herself. The next day, she took the first step toward co-founding her own media production company. And it paid off

Today, Abby is the founder and CEO of Everywoman Studios, a media company led by female creators committed to telling women-centric stories with social impact—including the story about the U.S. Women National Soccer Team’s historic fight for equal pay. Whether she’s in a meeting or at the Tribeca Film Festival, Abby’s work to close the gender gap continues. Abby is also the genius behind some of the most popular shows on TV today, such as TLC’s Say Yes to the Dress and Bravo’s The Real Housewives of DC. 

In this episode of Beyond the Prescription, Dr. McBride talks with Abby about risk-taking, trusting our intuition, and believing in ourselves.  .  

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio).

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For years, Kathleen Buhle—formerly Biden—has been a tireless advocate for women. Whether by helping provide legal support for domestic abuse victims or fostering community among women in DC, her advocacy and nonprofit work has given many women critical support for sharing their stories and voices.

Now she’s giving voice to the most difficult story she’s faced yet: her own.

In her memoir, If We Break: A Memoir of Marriage, Addiction and Healing, Kathleen opens up about her marriage and very public divorce from Hunter Biden; addiction’s devastating impact on relationships; and how she found resilience and healing through it all.

In this episode of Beyond the Prescription, Dr. McBride and Kathleen talk about parenting through trauma; the power of forgiveness; and the myriad health benefits of facing adversity head on. As Kathleen’s doctor, Dr. McBride has watched her struggle and grow—emotionally and physically. Now as Kathleen tells her own story, the power of personal story-telling and self-compassion is abundantly clear.

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio).

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For far too long, women have been left out of the conversations about their own health. They have been dismissed, misguided, or downright ignored when asking questions about their bodies. Millions of women lack access to the care they need, especially those in their post-reproductive years. 

Enter Dr. Sharon Malone — a leading obstetrician, gynecologist, menopause practitioner, and champion for women's health. With three decades of experience in treating patients, she’s made it her mission to shine a light on the myriad health issues facing women, especially those that are often overlooked or dismissed.

In this episode of Beyond the Prescription, Dr. Malone talks about the challenges facing women’s health today, and her own journey as the youngest of eight children to the becoming one of the nation’s leading experts in women’s health. Together, Dr. McBride and Dr. Malone discuss what is needed to achieve true equality in women’s healthcare and how to empower women with the information and resources they need to make informed decisions about their health.

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio).

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Resilience. Recovery. Hope. 

Few people embody these words like Greg Galeazzi—a U.S. Army veteran, doctor, and dedicated husband and father. 

While deployed in Afghanistan in 2011, Greg’s platoon was hit by an IED during a regular foot patrol—causing him to lose both of his legs and most of his right arm. After a grueling recovery process, Greg adjusted to a new life as an amputee, in which he met his wife, had two children, and began a new career in medicine. Last week, on the 11th anniversary of his injury, Greg graduated from Harvard Medical School and begins his career as a doctor serving people with physical disabilities and injuries like his own.

In this episode of Beyond the Prescription, Dr. McBride and Greg talk about how trauma affects our health, redefining what we think is possible, and finding success even in the most unimaginable moments.  

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio).

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There’s not much Will McCormack hasn’t done in Hollywood, but behind the scenes of his successful career, Will was abusing alcohol and drugs to cope with the pressure of performance. 

He’s acted, written screenplays, produced, directed, and won an Oscar for Best Animated Short Film. But Will is much more than a Hollywood star.

In this episode of Beyond the Prescription, Will opens up to Dr. McBride about the struggles of addiction, the joys of fatherhood, and finding gratitude and self-awareness on the path to sobriety. 

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio).

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When NASA's Director of the Jet Propulsion Laboratory (JPL) Management and Oversight, Andrea Razzaghi, began working at the agency, the sign on the restroom door said “woman,” not “women” — because she was the only woman working in a group of men.

In this episode, Dr. Lucy McBride talks with Andrea about the challenges of working as a woman of color in a male-dominated field, and her remarkable journey from engineering student to her current role. 

Together, they talk about the power of empathy in finding common ground with others and the importance of admitting that even the most successful people struggle with insecurities and stress. They also discuss ways to cope with stress, the connection between mental stress and physical health outcomes, and how to use mindfulness to navigate difficult situations. 

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio).

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It’s time for us to abandon the notion of the woman who “has it all together.” 

Mika Brzezinski has spent her life and career doing it all – from reporting live from the Twin Towers on 9/11 to delivering the news every morning as co-host of MSNBC’s popular show Morning Joe. As a journalist, author, talk show host, and advocate for women, Mika is one of the most formidable voices in our nation. 

Yet Mika has faced significant challenges on her path to success – including a long history battling shame, anger, a disordered relationship with food and the pressure to perform in a demanding industry while balancing her role as a mother. 

In this episode of Beyond the Prescription, Mika talks with Dr. McBride about the health struggles behind the scenes of her success, her path to self-acceptance without shame, and the unrealistic expectations women place on themselves. 

Together, Dr. McBride and Mika embrace vulnerability and the fact that we’re all works in progress – and that no matter how old you are, or what you’ve faced in your life, it’s possible to start again on your journey to find health and happiness. 

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio)

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To stress is human – but when does stress cross into distress? Dr. Lucy McBride talks with Scott Stossel, journalist, national editor of The Atlantic, and best-selling author about his lifelong battle with debilitating anxiety

In a fascinatingly raw conversation, they delve into how Scott manages the pressure of his high-powered and public-facing job alongside the emotional, behavioral and physical manifestations of anxiety.. Drawing from his best-selling book, My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind, Scott candidly discusses the stigma around mental health; the benefits of medications versus therapy versus both; and the complex roots of his mental illness. Scott’s insight and humor offer a refreshing look at an affliction faced by 40 million Americans—and helps us reconceptualize what it means to be truly “healthy.” 

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal (https://kglobal.com/podcast-studio)

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What do gymnastics, mental health, and success have in common? 

Jennifer Sey. 

Dr. Lucy McBride talks with former Levi Strauss & Company executive, elite gymnast, author and producer Jennifer Sey about the emotional and physical abuse she endured on her path to becoming the 1986 National Gymnastics Champion; her journey from post-traumatic stress toward post-traumatic growth; and why she walked away from a million dollars and the top job at Levi’s.

They unpack the anatomy of pain, disordered eating, shame, and the ability to own your narrative in order to be healthy, mentally and physically. 

A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/podcast) and produced by kglobal. (https://kglobal.com/podcast-studio)

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How do people at the top of their fields marry their physical and mental health to reach the height of success? Every week we bring guests into Dr. McBride’s office to break down how a comprehensive approach to their health has propelled them to greatness. Health isn’t just blood pressure and BMI. Our bodies are complex systems, and our symptoms are just the beginning. We dig deep into the lives of our guests to understand their often unpredictable rise to the top and how their health played a role in it all. A new episode launches every Tuesday. Beyond the Prescription is hosted by Dr. Lucy McBride (https://lucymcbride.com/beyond-the-prescription) and produced by kglobal (https://kglobal.com/podcast-studio)