January 16, 2025 • 51 mins
Today on ParentData, we're welcoming back Dr. Nathan Fox, Emily's co-author for The Unexpected- a book about when things go wrong, or at least get complicated, in a pregnancy. Nate is an OB-GYN and a maternal-fetal medicine specialist, and he is one of our favorite returning podcast guests, not just because he’s a great talker but also because it’s really nice to have a doctor who can both provide medical answers to questions that come up around pregnancy, and help you have the best possible experiences with your own doctor.
We’re discuss some big issues that arise during pregnancy and the many prenatal doctor’s visits; about the distinction between self-management and calling your doctor (when do you know if something is normal-bad or bad-bad?), and we’ll talk about just how subjective that line actually is. We also talk about risks and tradeoffs and about the kinds of postpartum issues that are worth addressing while still pregnant (we're looking at you, depression and anxiety).
The Unexpected, and this conversation, are meant to help people be much better prepared for what they may face in their pregnancies and to help better navigate conversations with doctors — both the expected conversations and the unexpected ones.
Subscribe to (the new and improved!) ParentData.org for free access to new articles every week on data-driven pregnancy and parenting.
Subscribe to (the new and improved!) PregnantData newsletter.
This episode is generously supported by:
• Hatch
• LMNT
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
This is parent Data. I'm Emily Oster. Today's a big
day at parent Data. Firstly, this week we are relaunching
the Pregnant Data newsletter, new and improved for twenty twenty five.
It's got answers to all your questions, and I know
you have a lot of them, so that's a big
(00:21):
thing and I hope you'll sign up. Secondly, I published
a book almost a year ago with my co author,
doctor Nathan Fox, called The Unexpected. It's all about when
things do go wrong, or at least get complicated, in
a pregnancy. And the two of these together, Pregnant Data
and The Unexpected, are meant to help people to help
(00:45):
you be much better prepared for what they might face
in their pregnancies, and to help better navigate conversations with doctors,
both the expected conversations and the unexpected ones. So of course,
to celebrate both of these things, I had to invite
Nate back on the parent at a podcast to chat.
Speaker 2 (01:07):
Nate is an OBGYN and an.
Speaker 1 (01:10):
MFM, and he is one of our favorite returning podcast guests,
not just because he's a great guy, but also because
it's really nice to have a doctor who cannot only
provide medical answers to questions that come up around pregnancy,
but also to help you have the best possible experiences
with your own doctor. I also just really like Nate.
(01:32):
That's why I wrote a book with him.
Speaker 3 (01:34):
He's great.
Speaker 1 (01:36):
We're going to talk about some big issues that come
up during pregnancy and the many prenatal doctor visits, about
the distinction between self management and calling your doctor, when
do you know if something is normal bad or bad bad?
And we'll talk about just how subjective that line actually is.
We talk about risks and trade offs, and about the
(01:57):
kinds of postpartum issues that are worth addressing while still pregnant.
I'm looking at you depression and anxiety. And you'll hear
about the one and only public place I ever vomited
while pregnant.
Speaker 2 (02:09):
Not to be missed.
Speaker 1 (02:13):
After the break, we welcome back doctor Nathan Fox. I
am delighted to welcome doctor Nathan Fox, my co author,
my friend, back to the Parent Data Podcast.
Speaker 2 (02:30):
Doctor Nathan Fox, Can you introduce yourself?
Speaker 3 (02:33):
We are friends, we are co authors, and that is
by far the most important thing in my professional life
right now. Secondary toll that I am a doctor. I
do see patients pretty much every day I'm an obgyn
and a maternal fetal medicine specialist, which some people call
a high risk ob colloquially. I practice in New York
(02:54):
City and that's what I do pretty much all the time.
On the side, I also have a podcast and I've
you know, other wonderful things in my life.
Speaker 1 (03:05):
How much of the time do you spend delivering babies
as opposed to doing prenate all stuff.
Speaker 3 (03:10):
It's varied over the years. You know, when our practice
was smaller, I was probably doing twenty percent of all
of our deliveries, twenty to twenty five percent. We do
about one thousand deliveries a year. And then as our
practice grew bigger, probably now on the labor floor once
a week, give or take somewhere there it's gone. As
(03:32):
one ages, he or she tends to do slightly fewer deliveries,
which is pretty typical. But I'm still actively there, like
I'm there a lot. I'm on call this weekend, for example.
Speaker 1 (03:43):
Christmas babies. We're recording this before Christmas. This will be
Christmas babies.
Speaker 3 (03:47):
This the New Year's babies. Those are the ones that
people are looking for.
Speaker 4 (03:50):
Oh yeah, yeah, those who want the glory of delivering
the first baby of the new year, and those who
want the tax break for delivering the last baby of
the old year.
Speaker 2 (04:03):
There are so many important reasons.
Speaker 1 (04:05):
For birthdays, all right, So let's talk first about hyperamesis
because this, for me, is an example of a place
where we hit a question that's actually quite common in pregnancy,
which is, like, is my.
Speaker 2 (04:19):
Experience outside the norm?
Speaker 3 (04:22):
So?
Speaker 1 (04:23):
You know what, Like everyone knows that vomiting, nausee and
vomiting is common in pregnancy, and some.
Speaker 2 (04:30):
People vomit more than others.
Speaker 1 (04:32):
And I guess the way I would I would say
this is people are worried about bothering their doctors, and
so they somehow want to know, like how do I
know if I should if I should call? How do
I know if things have gone off the rails or
if I should just sort of just suck it up.
Speaker 3 (04:47):
I'm surprised to learn that people are worried about bothering
their doctors, are you? None of them, like a major
none of them seem to be my patients. Not I
mean that in a negative way. I think I don't
you know, I think different people are different. Maybe it's
a New York City phenomenon that or New York. I mean,
I'm from the Midwest, so I was brought up politely,
(05:10):
I would say, and then I came to New York
and people are just a little more assertive, I guess
as a way to put it right practice and not again,
not in a bad way. I love New York. I
guess that's possibly true some of it, maybe that people
are just they don't want to bother their doctor. But sometimes, unfortunately,
maybe they're conditioned to believe that because of their experiences
(05:33):
with doctors, and maybe not the person the doctor, but
sometimes just the way someone's office is set up. It's
difficult to reach a doctor, you know, the visits are short,
you can't get them on the phone, it's hard to
get them through the portal, and so you're sort of
turning to Google. And that's a much more global issue.
(05:54):
I would say, medicine that we're not going to solve today.
But you know, I think that it is definitely a
challenge if you don't have access to your doctor or
your midwife wherever that is. But I would say that
you know, everyone has prenatal visits, that's for sure. And
(06:15):
if you have a question that you can't get answered,
over the phone or over a portal or whatever it
might be, see if you can make a visit, like
just show up, right, just say I'm not feeling well,
and usually I mean and usually if you call and
say I'm not feeling well, I'm pregnant, They'll want you
to come in and be seen, and so you're gonna
get FaceTime typically.
Speaker 1 (06:35):
Maybe, although I think what people are really struggling with
here on the sort of nausea pieces, like I know
this is there is some amount of this that's normal, right.
I was told it's like regular to be nauseous, and
so then you know, I've I've a nauseous in every
day I vomit and I vomit ten times a day?
Speaker 2 (06:53):
Was that too much?
Speaker 1 (06:54):
Is that like a too much amount of vomiting? Or
is like fifteen too much? Or is one too much?
Speaker 5 (07:00):
Like?
Speaker 1 (07:00):
How do I know that that I not just that
I could call the doctor, but that I should is maybe.
Speaker 3 (07:06):
Fair a way to say it? No, that's a it's
a good distinction. I would say. There's sort of two thresholds.
And this is true with vomiting, this is true with pain,
this is true with really anything. The more critical threshold
is Am I in danger? Right? Am I in danger?
As my baby in danger? Something like that. So that's
(07:28):
a critical threshold where you must call right, you have
to be seen because there's a possibility. And so that's
one threshold. And the second threshold is much more subjective,
which is, do I feel not well and I want
to get better? Right? And so what the average amount
of vomiting is or quote unquote normal amount of vomiting
(07:50):
and nausees is completely irrelevant for the second one. Right,
for some people there like, yeah, I'm nauseous and I'm vomiting.
What's today, And that's fine. I'm okay with this. I
don't need to be tree and I can walk around
like this and be fine. And other people are like,
this is debilitating. I hate being nauseous all day. I
hate vomiting once a day. I can't work, I can't
take your mayor their kid, whatever it might be. And
(08:10):
so for the second threshold, I would say it's subjective.
If you are nauseous or vomiting to the point that
it's distressing you, that it's affecting your life, that you
want to look into ways to make it better, then
that is reason enough to start doing that and whether
that's you know, calling the nurse, calling the doctor, whatever
it is. In terms of the threshold the must I
(08:32):
call so for vomiting and nausea, it's generally things like
can I keep nothing down? Am I dehydrated? And so
how would you know you're dehydrated? Well, if you're not
peeing anymore, or when you pee it's really dark, like
it's the color of iced tea versus the color of
lemonade or water. Am I losing weight? Can I knock
(08:54):
get out of bed? Right? Those are possibly dangerous signs
and those need to be address. So if you're having
one of those things again you're not peeing, or it's
very very dark, or you can't keep anything down and
you're losing weight, you should not be waiting. You should
call and say I'm very sick. I need to be seen,
or this needs to be addressed. If it's short of
(09:15):
that and you're just not feeling well, make a decision.
Is this something like I'd rather take nothing and just
have this and sort of you know, muscle through it
until the end of whatever. Fine, that's okay. Whereas if
you're like, no, this sucks, I really want to get better.
Then make an appointment and that's totally fine, and that's subjective.
Speaker 1 (09:31):
Yeah, I mean I think that's exactly right, and thank
you a piece of it that I think is exactly right.
The piece of it is that is hard, and I
always struggle with sort of how and I suspect you
struggle with how to express this to people also, is like,
how do you say that without it coming across like, well,
if you can't tough it out because you're like a
(09:54):
whiny loser, you know what I mean, how does it
not be like just try it until you're at the
edge of your like you know capacity fair.
Speaker 3 (10:03):
No, I mean, I definitely understand how it could come
out that way. What I'm trying to say is actually
the opposite. What I'm trying to say is we're here
for you, Like our goal is to make you. Obviously
top goal is you know, healthy mother, healthy baby. Fine,
but the next is we want you to feel well,
Like it is our goal for you to feel well.
And Okay, if someone calls me and says they're having
(10:24):
knowledge that they're having vomiting again, not severe to the
point that I'm worried about their health and well being,
They're just it bothers them. It's upset understandably, So what
am I gonna be able to offer them. I'm going
to offer them, you know, maybe some dietary changes, which
rarely do that much. And then we're talking about various medications,
and so people sort of know from the outset. Am
I the type of person who would like to take
(10:47):
a medication to feel better? Am I the type of
person who's like, I'm out, I don't want any meds
unless I'm like horribly ill, I don't want to take anything.
And so we're here for you. If someone is not
feeling well and they want to try something, I don't.
It doesn't matter to me how not feeling well they are.
If it's a little bit, I'll try something because they're safe.
It's not like we're talking about dangerous treatments or anything
(11:08):
like that, and so any amount is totally fine on
my end that I don't judge people. I hate being nauseous.
It sucks. It's like one of the worst feelings in
the world. And so even if you're not vomiting, I
don't like God, being nauseous is terrible. And so it's
not like we we advise people to tough it out
as much as you can, and then when you hit
a breaking point, call us.
Speaker 1 (11:29):
No.
Speaker 3 (11:29):
If you're disturbed in any way whatsoever, call us and
we'll try to sort it out. But if you know,
you're the kind of person who's going to say, no,
I don't want any medication for it, all right, I
can you know, we can talk and I can try
to be empathetic, but not much is going to change
in that sense.
Speaker 2 (11:44):
Yeah.
Speaker 1 (11:44):
Yeah, I like this or idea of kind of thinking
for yourself even exanty about you know what, what are
the things I'm going to be willing to do here
and therefore, like what could come out of this conversation?
Speaker 3 (11:54):
Yeah? Yeah, And different different people, different people feel differently
about this, and I don't. Again, some people are like, listen,
I'm just I'm just not a medication person. I'm not
into it. I don't, you know. Find that's perfect again,
unless we're in a danger situation where I have to
really like, listen, we gotta we gotta do this, or
bad things are going to happen. If someone says I'd
prefer to vomit once a day than take a medication
to not vomit, that's reasonable. I'm okay with that, And
(12:17):
as someone says, I'd prefer to take a medication rather
than vomit once today, I think that's reasonable. Reasonable too,
That's what I would choose personally, But that's me.
Speaker 1 (12:25):
Yeah, I vomited once in my pregnancy in like an
ikea bathroom. Is the only one time I ever and
I'm like, if it happened again, I was gonna do
something about it.
Speaker 3 (12:38):
My wife vomited on Lexa ninety sixth Street, which was
pretty gross. Uh, vomiting, people look at you. Vomiting is horrible.
It is. It's a horrible, horrible experience to everyone who
has it, and when you're pregnant you have it a lot.
It's it's pretty gruesome. So yeah, I'm I'm in favor
of helping people with it, but I don't twist people's
arms unless I think it's dangerous obviously, all right.
Speaker 1 (13:00):
Second thing I want to talk about is postpartum depression
and and on the one hand, it is quite different
from from vomiting. But on the other hand, I think
this same general idea about sort of how do I
know that this is something I should get help with?
And I think in that case it's it's in some
ways even harder because it can be hard to see
(13:22):
when you're It can be hard for you to see
when you're depressed.
Speaker 3 (13:25):
I don't know, you don't know you're vomiting exactly exactly.
Speaker 1 (13:29):
And so so let me ask to begin with, because
I think this is something people are just confused about.
Speaker 2 (13:34):
Do you see some depression start in pregnancy?
Speaker 3 (13:37):
Definitely? Definitely, and so is, Yeah, there's there's everyone is
hopefully everyone has heard of postpartum depression. Many people have
heard of postpartum anxiety, right, it's sort of it's a
parallel to postpartum depression, just different symptoms. But there's also
a concept called peri natal depression and peri natal anxiety,
(14:00):
which just means instead of its starting after you deliver,
it starts before you deliver at some point in pregnancy.
And then obviously there's people who come into pregnancy with
sort of pre existing depression, anxiety, or any other mental
health condition. Doesn't have to be those two obviously, So
definitely can happen during pregnancy. And in fact, nowadays, not
(14:20):
only do we screen routinely for postpartum depression and anxiety,
they're sort of these standardized their questionnaires is how they
play out, But it's a standardized screen that we do,
and pediatricians do it. You know, a lot of people
do it nowadays. Fortunately, we also do one during pregnancy,
standardized for the same reasons, and most people will be
(14:41):
able to tell you I'm not doing well, but not
everybody a feels comfortable with that, and also not everyone
realizes that they're not doing well, because, like you said,
all these times are very challenging. Being pregnant is a
stressful time period. Having a baby's a stressful time period,
and it's hard for some people to understand and differentiate
(15:03):
is what I'm feeling and how I'm responding to it,
sort of typical slash normal, slash whatever, versus like, am
I in a bad place? And I think there is
a parallel to what I was saying about the vomiting
in terms of thresholds, because it's some of it is
similar that there are thresholds where where someone is unwell
(15:26):
and they really really need to be treated, and signs
like I can't get out of bed, there's nothing in
my life that I enjoy. It's affecting my relationship with
my baby or with my loved ones, or it's affecting
my ability to eat or to care for myself, or
obviously i'm feelings of self harm or harming others like
(15:47):
those are danger signs and those need to be addressed immediately,
and they're treatable, thank god. But then it's the same thing,
you know, someone's mood. There is some subjectivity to it
if no one has those danger signs, right if someone says,
you know, my mood is down, I'm feeling a little depressed,
(16:07):
or you know whatever however they express it to me.
But no, I can go to work every day and
I can function. It's not affecting my relationships. It's not
affecting my ability to take care of myself and to
eat and to exercise, and you sort of do what
I need to do, and I just, you know, I
just don't feel so great. You know. Do they need
to be treated? Do they not need to be treated?
It's you know, there's some subjectivity there, and there's some
(16:31):
patient choice there. Obviously. The one difference I would say is,
as opposed to nausea vomiting, you don't always have to
go to medication to be treated, right, you can have
a for lack of a better term, let's call it
minor mood disorder, right, it's not really a good way
to put it. But whatever, your symptoms are less and
(16:51):
you're functioning, and you might benefit from things that are
non pharmacologic, like therapy, right with the professional therapist that
might be beneficial, or just other things like some anxiety
reducing or stress reducing, you know, cognitive behavioral therapy or
yoga or just taking a break whatever. It might be,
(17:12):
something ranging from very small to more aggressive, but again,
all non pharmacologic, So there's more options, I would say,
than for nausee of vomiting.
Speaker 1 (17:22):
Nick, can you just give us a little bit to
sort of frame this conversation about why we see prenatal
or postpartum depression, why that's something that happens more in
those time periods than maybe other parts of life.
Speaker 3 (17:37):
Yeah, I think that, I mean, the short answers. We
don't know exactly why, right, No one's mapped it out
to like the molecular level definitively, but I think that
there's a lot of reasons that it is more common
after people deliver or you know, in towards the end
of pregnancy that do make a lot of sense as well.
(17:59):
People talk a lot a lot about hormones, right, and
you know, and pregnancy they're high and then after you
deliver they drop. And so you know, how could it
be that increasing hormones and decreasing hormones both do the
same thing. And I think that people's brains are used
to certain environments. And remember, mood and mood disorders are
(18:21):
organic brain issues. They're not like, you know, someone's fortitude
is harmed, right, it comes. These are organic medical problems
that originate in the brain, and the brain is used
to a certain hormonal balance, and when things change in
either direction, it can affect people's moods in sometimes very
(18:43):
unpredictable ways. Right, Why does one person get depression and
one person gain anxiety? Why does one person get nothing? Why?
You know, there's different things that can happen, and so
we don't we don't have it mapped out exactly why
certain changes in certain people do certain things. But it
makes a lot of sense. The changes can do certain
things to people. So that's one reason the changes of
(19:04):
sort of hormonal estrogen, progesterone and whatnot. But the second
is also there's a lot of other things that go
into mental health related to circumstances, things like stressors, right,
So if you have more stressors, you're more likely to
have one of these things. It's not that stress causes
anxiety and depression, but it's one of the factors that's involved.
(19:27):
So pregnancy and postpartum are very stressful times for people
for obvious reasons. Also, things like nutrition, exercise, sleep, things
that definitely impact mental health, and again hard to map
out exactly what they do to any given person, but
I don't think it's a big leap to say that
(19:48):
if you don't sleep well you're more likely to have
mental health issues, or if you don't eat right, or
if you're not able to exercise or whatever it might
be that they can impact it. And so I think
that all of those sort of come together in the
same time period. Your hormones change, your body physiology changes,
and your circumstance change, increase, stressors, decrease sleep, change in nutrition,
(20:09):
change in activity, and they happen, they like blow up
for people at the end of pregnancy and after they deliver,
and that's why many people have again not even full
blown postpartum anxiety or depression, but certainly they have effects
on their mood. You know, that people used to call
the baby blues or whatever it might be, that they
just don't feel the same, and that's all normal and
(20:31):
expected and at a certain point it probably should be treated.
Speaker 2 (20:34):
This issue of.
Speaker 1 (20:35):
Sort of treatment, pharmacological treatment, I think is ann comes
up in both of these cases, but it comes up
here particularly in the particularly in the in the perinatal
but also in the in the postpartum phase, because again
people sort of end up hearing like you can take
an SSRI, but you know, we don't know if it's
(20:56):
like we're not one hundred percent sure it's safe, or
you can take it if you really need it.
Speaker 2 (20:59):
That is a phrasing that people.
Speaker 1 (21:02):
Come sort of come back to me, say, my doctor
told me I can take this antidepressant if I really
need it.
Speaker 3 (21:07):
Yeah, that's a bad that's a bad phrase.
Speaker 1 (21:08):
It's a bad phrase because I think and I think
it's it's meant in a positive way. It's meant in
this way of like, you know, if you feel like
you like the sort of the way you put it before,
it's like, well, if you feel like you need it,
of course we want to help.
Speaker 2 (21:18):
But it comes out.
Speaker 1 (21:19):
As like if you feel like you actually you really
need it as opposed to you know, if you feel
like you're willing to sacrifice your baby for this, I
guess you can do it.
Speaker 2 (21:28):
Yeah that's tricky.
Speaker 3 (21:30):
Yeah, well it's tricky. It's unfortunate for a lot of
reasons because it's it's not the correct messaging. And again
I'm not impugning the doctors. They they probably don't mean
it to come out that way.
Speaker 2 (21:39):
I don't think at all. I think it's help people
are hearing something different.
Speaker 3 (21:42):
Yeah, I mean maybe some of them do, but I
assume not. I think there's a lot of reason. Number one,
the safety of these medications is so studied, right, there is.
None of the studies are perfect, obviously, but people use
these medications, many men. People use them for many, many years. Right.
And when you have that, it's exceedingly unlikely that any
(22:07):
of these is dangerous because it would come out right
one way or another. And so you're talking about is
there a one percent risk or is there not a
one percent risk? Like that's sort of the type of
numbers we're talking about, and the predominance of risk in
that let's call it one percent range is really if
you take it in the first trimester, it's not if
(22:28):
you take it at the end of pregnancy here right
after you deliver. And so my messaging to people is
not take it if you want it, but if we
think you need something, let's decide what it is you need.
Are you someone who just needs to maybe have a
little bit of change in your lifestyle, maybe work fewer hours,
(22:48):
or get some help at home or something like that,
and that's all you need? Okay, that's sort of like
changing your circumstances, or maybe you need some meet with
a mental health professional, do some therapy that could be enough,
or do you need that plus maybe some medication. And
it's not sort of like what can you tolerate? It's
like what's going to work for you? And when people
(23:09):
ask me about risk, I say, there's basically almost no
risk to any of these things, and any possible, hypothetical,
theoretical small risk there is to the medication is greatly
outweighed by the risk of you not being treated and
not being well. And it's not just because you don't
feel good, but all right, you can't take care of
(23:29):
yourself properly, you can't take care of the baby properly.
Not sleeping is not good for you, not eating is
not good for you, Like having just anxiety depression walking
around with those things is not good for you. And
so I would say it's greatly outweighed. So I don't
That's sort of how we try to approach it. I
think the other issue that people here not so much
the I feel like I'm a failure type of thing.
(23:52):
But there's such a stigma that people have. They feel
like if they take a medication, they've somehow crossed the
threshold and they're now a different person. And I get it,
like that's I'm not poo pooing that feeling, but it's
just so crazy because we never have that feeling with right, Yeah, Oh,
(24:13):
I don't want to take antibiotic because I don't want to
be called a person who has an infection. Like who
the hell says that? Right? No one says that, right,
And it's it's or anything like I have a headache
and I'm gonna take a pain medicine for I'm gonna
take up a motrain or tile and all, like no
one says, oh, there's a stigma now person with headaches
and you know, no one thinks like that. But since
(24:33):
it's depression or anxiety. People feel that somehow they're going
to be like branded, you know, in town square, And
I don't think it's like that anymore. I think that's
a problem with people of our generation, much more so
than like my kids generation. They're all much more comfortable
with their mental health diagnoses, which is a good.
Speaker 2 (24:50):
Thing, Which is a good thing.
Speaker 1 (24:51):
But I do think there's a general issue with sort
of medication during pregnancy, which is sure, like people, you know,
some medications during pregnancy are are dangerous, but so much
of the messaging around medication and pregnancy is sort of like, well,
you want to be like more cautious than usual, or
maybe there's some risk, but there's you know, and that
really puts people in a often in a situation that's
(25:15):
more brought than it should be, you know, because actually
in many cases, like it's fine to take tile at all.
Speaker 3 (25:21):
Yeah, I think some listen, it's appropriate to have heightened
concern or awareness over medications when you're pregnant, because yeah,
you're you know, you're pregnant with the baby, and they
get what you get to some degree, and there's always
the possibility of risk, right, There are medications that are dangerous,
So it's it's not, you know, implausible that something could happen.
(25:41):
But I think the important thing, you know, sometimes people
think it's all or none, and this is also true
with doctors and the messaging. They say, well, the medication
has risks, and not taking the medication has risks, and
so someone's like, well, how the hell do I balance that? Right?
And so they think it's well, either I'm harming my
baby or I'm harming myself. Like that's sort of the
black and white that they hear. And so I would
(26:03):
say the important thing to ask your doctor, and hopefully
you know he or she can answer this for you,
is can you quantify that risk? Like, what are we
talking about here? And we talk about a risk of
you know, fifty percent risk my baby's going to be
harmed or one in one hundred, one in a thousand theoretical,
but unknown, like what we like, what are we talking
(26:24):
about so we can try to weigh a versus be right,
there's no way to walk through life with no risk.
I leave my house on that cross the street, there's
some risk that I'm going to get run over by
a bus. Right, It's very very small, so it doesn't
really come into my mind every day, and I mitigate
that by waiting till the light screen and looking both
ways and all that stuff. But it could happen. And
so it's the same thing when someone tells me I
(26:45):
don't want to take zoloft because I'm pregnant, I'll say, Okay, Well,
let's what is the risk we're worrying about. We try
to quantify that, and when it boils down to it,
it comes down to a risk somewhere between let's say
zero and one percent that it's going to cause something
in the baby. That's like, it could be zero and
the high end it's let's say maybe one. All right,
(27:07):
what are you going to be like if you don't
take it? Like I'm a wreck, I can't get out
of bed in the morning. I'm like, well, then it's
a no brainer. Then you should take it, because how
could you go the whole pregnancy without getting out of bed?
Versus if they're like, well, I don't really need it.
I started it when I was in college because I
had a bat semester and I'm on such a low
dose and I took it. I stopped it for two
years and I felt the same, and I'm back on it.
(27:29):
I'm all right, that's a person who if they don't
want to take any risk of pregnancy, maybe they should
try to come off it. But those are two very
different people because they have different risks on the not
taking it side.
Speaker 1 (27:44):
More parent data, including Nate's tips for how to have
the best possible conversations with your doctor and how to
push back if you're actually skeptical of their advice.
Speaker 2 (27:53):
Maybe after listening to this podcast after the break.
Speaker 1 (28:04):
Listening to you talk about this leads me into the
sort of second set of things which I want to
talk about, which is when you and I talk about
this stuff, like, I get the impression that if I
were your patient, like, we would have interesting, nuanced conversations
about risks and benefits, and that would be very helpful
and I would feel good about making different choices. A
(28:25):
lot of people struggle to have this kind of conversation
with their providers. How do you think that people can
make the conversations they have with their doctor better and
to not have them feel out of people's control. So
I think a very common way for people to leave
(28:47):
a provider's office is to feel like I didn't get
I didn't think about the questions that I didn't ask
them right and I wasn't able to get to the
answer that I wanted.
Speaker 2 (28:57):
So let's start like big picture there.
Speaker 3 (28:59):
Yes, So that's a big, big conversation obviously, but an
important one, clearly. I think that first it's important for
everyone to sort of think about deliberately what am I
trying to get here? Like what am I looking for?
Because so you, Emily, if you were my patient, you
(29:20):
would come in, you would have very detailed data driven questions,
you know, asking me how to you know, navigate this decision,
or you'd have no questions because you were to know
what you're doing. But whatever it is, it would be
very because you know you you're like, I want the data.
I want to look at it, I want to analyze it.
I want to make a decision that's right for me
and my family, And that's what you're looking for. Other
people are terrified of that, and other people don't want
(29:42):
to talk about these things because it just scares them.
And so some people want to just be told I
literally had this conversation with someone yesterday because it happens
all the time, because I was asked here, you know,
we have this conversation about something and she said to me,
you know what, these kinds of conversations just freak me out, right,
So is it okay if we just go about doing
(30:04):
things sort of regularly and you tell me if I
need to change something, right? And I was like, yeah,
that's fine with me. Like that works. I could do that,
like and the same thing, she was trying to decide
if she wanted a doulah in labor, right, and so
she's like, what are your thoughts on doula's. I'm like,
duelahs are great, you know. And we go through this
and this and this, and she said she spoke to
doula and the duela's giving her all this information and
(30:24):
it actually freaked her out. She goes, I don't want
a lot of information, Like I just want to show
up in labor and I want you to tell me
want to push, and I want you to tell me
if I need a C section. I want you to
tell me if there's a problem with the baby and
what I need to do. I'm like, I could do that, like,
no problem, right, So I'm fine. That's what she wanted
to get out of this, Whereas other people are very
very different obviously, So I think the first thing is
(30:46):
get us, like, do some introspecttion, like who am I?
What am I looking for? Am I looking to try
to make a lot of decisions on my own? Be
given choices, choose A versus B versus C, to know
the risk and benefits or all them? Or do I
just want to be told what to do right? And
I don't. I'm fine with all of these options, Like,
different people feel differently about their healthcare, and I think
(31:06):
that you also need to make sure your providers flexible
with that. Some providers really like one model versus the other,
and I think everyone needs to sort of try to
tailor it to what the patient wants and needs and not,
you know, to what someone expects or something like that.
So I think that'd be number one and number two.
(31:27):
If you have specific questions that you want answered, they
don't understand, write them down, write them down, write them
down on paper, put them on your phone, tattoo them
to your arm, Go with someone and give them the
list and say don't let me forget, like because time
with doctors are limited, and prioritize the questions you want.
(31:48):
So you may have six questions and you're like four,
five and six. I could probably google, but one, two,
and three I need to answer. I need to ask
this doctor it's very important to me, or I need
a precise answer. I need to know what he or
she thinks specifically. And when you start to visit, tell them.
I have six questions, right so, and I always tell
(32:09):
them first, like before we begin. I just want you
to know I've got five or six questions. Some are important,
some are minor. Do you think we can get to
them today? Because otherwise you're let's say, have a fifteen
minute WIZO of someone and we're doing this, and we're
bantering and blah blah bah, and the examine this, and
fourteen and a half minutes in she pulls out a
twelve page list of questions. Right, I'll say, like, listen,
(32:30):
we don't have time for that right now. I got
someone waiting to see me. Well, I mean, if I'm nice,
I'll do the best I can and try to schedule
something else. But if she told me on the front end,
I could cut out some of the banter. You know,
you can sort of maybe tailor it best. So have
an agenda when you come in. What do you And
you might want nothing? If you want nothing, fine, go in,
be seen, and go home. That's cool.
Speaker 1 (32:51):
Also, okay, I'm now going to give you this is
a great overview, and I've now had an idea which
I'm going to give you some harder questions about, like
to navigate a situations that people tell me like I
didn't know what to do in this part of the conversation.
Speaker 2 (33:07):
Okay, so are you are you ready?
Speaker 3 (33:10):
Hit me? This is like this like speed round and
like Jeopardy speed Round or something sort of.
Speaker 1 (33:14):
We're gonna all right, try first of all, in order
to ask you this question, I need to know what
is something in pregnancy where you think doctors often recommend
something but it's definitely not right, Like I was gonna say,
bed rest.
Speaker 2 (33:26):
Can we agree bed rest is not a good idea?
Speaker 3 (33:29):
I think yes, I think it's being recommended less and
less but fair. Yes.
Speaker 1 (33:32):
Okay, So let's say let's say your doctor, you come in,
you say I've been having some you know, more Braxton
Hicks contractions, and your doctor says, what I recommend for
you is that you go on bed rest. You're thirty
two weeks, Just lay down in your bed, don't go
to your job, just lay down because I Braxton Hicks
contractions have some have some bed rest, and you know,
because you have read something or you're aware that that
(33:54):
is not a good recommendation, what do you say to
your doctor?
Speaker 3 (33:59):
All right, yeah, all right, now we're getting really we're
getting We're getting in it. I'm rolling up my sleeves here.
So yeah, I think the short answer is it depends, right,
So it depends on your relationship with this person, It
depends on the nature of the practice you're seeing, and
(34:20):
it depends on are you the type of person who
is comfortable not listening to your doctor, Like just some
people like, yeah, yeah, whatever, I'm not doing that right,
you know? Are you that person You're like, no, my
doctor says it, and I will like not sleep at
night if I'm not listening to him or her. So, meaning,
if you have a very good relationship with the doctor
(34:40):
and this is someone who you know and you trust
and you've spoken to before, and you really have a sense,
you can push back a little and you could say
I hear you, thank you. Question, is this something you're
just advising because you think it's going to make my
life easier or do you think this is actually going
to prevent me from having a pre term birth. You
(35:01):
could say, because I've read a lot that people are
questioning the efficacy of bed rest, and you could say,
you could push all your covets. I'm not trying to,
you know, question you. I'm not saying that I know
more than you at whatever, but basically you know I'm
and you can say, can I push back a little
on that and ask and just politely very you know,
(35:22):
if you have a relationship with the person, and then
they might say to you, if they're good doctors, they
might say, yes, you're right, I don't think it's actually
going to cause you to stay pregnant longer. But in
my experience, a lot of people feel better, or they
feel like they're doing something, or it just seems to
have been helpful to many of my patients. And then
(35:44):
you can say, okay, I appreciate that. If I'm the
type of person who really doesn't want to be on
bed rest because it would drive me crazier because I
have a I have to do some sort of work,
or I have a kid to take care of. Do
you think it'd be dangerous if I did didn't go
on bed rest, or if I did if we found
somewhere in the middle, and if they were a good doctor,
they say, no, that sounds perfectly fine. Let's come up
(36:05):
with something and then boom, you've had a productive conversation
leading to a individualized plan of care for yourself. On
the other hand, if this is someone you don't know,
you don't trust, you never met before, you could either
try to have that conversation and you don't know how
it's going to play out, right they you could offend them,
(36:27):
you know, obviously unintentionally, or it could end up the
same way. Or maybe there's another doctor in that practice
who you trust, and you'll say, listen, I met and
you know he or she said this, and I'm I'm
not trying to question them, but it just seemed a
little bit aggressive for the situation. Can you give me
a second opinion and again, old on politely and if
(36:48):
you have a relationship with somebody that they'll probably help you.
If you're in a group where the doctors always just
say do this and this and this, and you know that,
or have a very strong sense that those recommendations are
maybe outdated or not evidence based, or they're not explaining
to you, well, maybe you need a new practice. Maybe
they're not the right people for you. And that's obviously
another big thing. How do you switch? When you switch? Right?
(37:09):
Is it worth it to switch? I mean, that's that's
a big thing. And I'm not advocating people switch. I
think for most doctors, at least that I know, and
most patients, if they had the conversation I was talking
about in a way that's you know, polite, not you know,
not combative, but just hey, can we talk about this.
Most doctors know enough to be able to have the conversation.
(37:33):
It's just hard to have that conversation with everybody on
day one, and so you make a recommendation of what
you think is best, and if the person pushes back
in a play way, you find a way that works
for them. And I think most doctors would be very
receptive to a conversation like that, and if they're not,
that's usually a red flag about how they, you know,
just address patients in general.
Speaker 1 (37:52):
I mean, I think they're for a certain kind of question,
a certain kind of patient. Eventually, I think you have
to realize it's it's your fault. I had a I
have a colleague who at some point, you know, was
having something about what like when were they going to
induce and so on, and he and he texted me
and he was like, I don't think these doctors are experts.
Speaker 2 (38:09):
In a basy and statistical updating. And I was like,
they're not. That's your job, but like they will be
delivering the baby, and.
Speaker 1 (38:17):
It seems like maybe I should just listen to them.
At this point, Yes, I would have just want to
listen to them. And I was like that sounds great.
Speaker 3 (38:25):
Right, I mean, there's there's definitely you know, that's actually
a really good point because sometimes people expect doctors to
get out of their comfort zone. So for example, like
there's certain things that are done routinely, they're done by everybody,
they're recommended by everybody, and then someone brings in, like
I want you to do it differently, and they bring
it forty five research papers because this is how they're
doing it in France and this or this or this,
and it's and then you sort of you've now elevated
(38:48):
the conversation to like an academic one, right, And for
most doctors, like they need to just take care of you,
like they need to do what they're comfortable with and
what they're used to. You're like you don't want to
try to push your doctor out of their box, right
out of their comfort zone, because nobody, nobody wins in
that situation. And so at a certain point you have
(39:10):
to just say, this is the these are the parameters
my doctor has for better or worse, and if we're
going outside those, it's probably just not going to work
anymore because they're just not going to be comfortable. And
you don't want a doctor who's uncomfortable in the situation
that's not good for your care.
Speaker 1 (39:26):
Okay, I have one more question for you, and then
I think Tamor has a question.
Speaker 2 (39:29):
Uh So mine is the following.
Speaker 1 (39:32):
I imagine I'm at the doctor and they say something
and I don't understand what it is or what it
means in the moment. The question is sort of when
do I how do I try to come back from that?
So let me give you a specific example. So sap
into a friend of mine recently. The doctor's measuring the
fundel height and they they're thirty person thirty four weeks
(39:54):
along and the doctor's measuring the funnel height and she says, I,
you're measuring thirty two, and then she moves on and
she just says her measurement is thirty two, and she
doesn't say what that number is, how it relates, whether
they're considered just to measuring you thirty two, everything's fine.
And then reflecting on this later, my friend was like,
does that like, I'm thirty four?
Speaker 2 (40:13):
Should it have been thirty four? What does this number
actually mean?
Speaker 1 (40:16):
And you know that particular example, you could you could
sort of look it up. But the question of if
somebody says something I don't understand, how do I pull
it back into something I do understand?
Speaker 2 (40:28):
How do I ask that?
Speaker 3 (40:29):
Yeah? I mean I think in that precise situation. You know,
if I were the patient and the doctor said that
to me, I would just say, pardon me? Is is
thirty two good? Is thirty two bad? Right? What thirty two? What? Right?
Thirty two? What? And is that a good or bad thing?
And the doctor say say, oh, I'm measuring your the
height of your uterus and it's thirty two centimeters and
(40:51):
usually it's around the same as you're just acial agent weeks.
But if it's within two or three, that's perfectly fine,
and that's normal and everything looks good. Right, So thirty
if you're thirty four and it's measuring thirty two, thirty three,
thirty four, thirty five, thirty six. We don't make much
of it. It's very imprecise. That's a perfect screen. That's it.
That's all it takes.
Speaker 2 (41:07):
And I think in partly there is just like I
think people.
Speaker 1 (41:10):
Are just the message of like not being reluctant to ask,
just like if somebody says something, you know, understand to
be like what, sorry, excuse me, what does that mean?
Speaker 2 (41:18):
And she has anything from it?
Speaker 3 (41:19):
Yeah? Again, doctors, you know, we're we're an interesting bunch doctors, right,
So we have a lot of things we got to do.
We got a lot of things on our mind. There's
a lot of things that we're trying to do. In
every visit. We're always you know, not always, we're almost
always you know, busy or in a rush or this
or that. But we also want to take good care
of people and we want people to understand what's going on.
(41:41):
And we don't like it's not our intention to confuse people.
We just confuse people because we're not perfect people, right,
and so sometimes we say things and for us it's
it's like common sense or nature. We've done it a
million times in the past week. And we forget that
it's not like that for the person on the other end.
And again, because we're we're fallible, we're humans, and so
(42:02):
we don't always communicate in the way we're trying to.
But the goal is so that the person understands what
the hell we're talking about. And so if I'm saying
something and someone just like you know, interrupts me or
raises their hand and says, can I ask you a question?
And they say, I really don't understand what you're talking about,
or can you explain that again? Or I have a
question about what you said or this, I'm like great, Like,
(42:23):
thank you for telling me that. Let me explain it
in a way you understand, because I don't want you
to walk out of here confused. Number one, like, that's
not good for anybody. Number two, I wouldn't feel good
about myself. And number three, it's definitely not going to
work in the long run because you're gonna come back
with questions or you're going to like it. Confusion is
not good for anyone, even the doctor. No one wins.
Speaker 1 (42:43):
Yeah, And I think one of the issues here is
just an issue of language that, like when you are
doing something all the time, you develop a shorthand, you
develop a jargon, you develop a set of words, and
you use them, and sometimes you forget that like, not
everyone is managed this too. I told my team the
other day that I thought something was orthogonal to something else,
and they were like, that's not a word that like regular,
(43:04):
that's not how the regular people talk.
Speaker 2 (43:06):
And it was like, what is that?
Speaker 1 (43:07):
And I was like, Oh, isn't that That's not how it's.
Speaker 3 (43:10):
I would say that if again, if someone knows that
they're the type of person again who likes to understand
what's going on and be sort of on top of everything,
one of the ways to combat this issue is again
to ask questions and feel comfortable to ask questions, which
is greatly encouraged. But I would say the other one
is do a little prep work on the front end,
(43:31):
meaning sort of have a general sense of what's going
to happen in the prenatal visits. And that could be
from a bajillion sources. Again, whether it's one of your
terrific books, whether it's from this podcast, my podcast, a website,
you like, a book, you like whatever, anything that sort
of is useful to you and speaks to you. Have
a sense, like what normally gets done in the first trimester,
(43:53):
what normally gets done in a prenatal visit, what typically
happens when you're in labor and delivery, just general general
general stuff. Some people take classes like birth classes, Like no,
they're very rarely anymore like lamas because people since ninety
plus percent of people get up at durals, people don't
need all the like pain training stuff. So birth classes
now are very much like birth one on one. It's
(44:15):
like just education comes out of yeah baby and so yeah,
so like those types of things. So if you so,
if someone walked in knowing that measuring the height of
the uterus is something doctors do and what it means
and what's normal it's not normal, they would have then said, oh,
thirty two on thirty four, that's good, and they wouldn't
even had a question. And so that's another way to
(44:37):
try to combat that is a little bit of prep
work might reduce some of those confusions.
Speaker 1 (44:43):
So tomorrow is about seven months pregnant, and tomorrow do
you have questions for me?
Speaker 2 (44:49):
Do I?
Speaker 3 (44:50):
Yes?
Speaker 5 (44:50):
I did?
Speaker 3 (44:51):
Do I?
Speaker 5 (44:54):
Well, this was actually this was this was a good segue. Well,
in talking a lot about kind the fear of the unknown,
you know, I mean, these are a lot of new mothers.
You know, these are mothers who haven't been pregnant before,
and so all of this feels very brand new. And
the more kids you have, I've actually discovered, and the
(45:16):
more pregnancies you go through. I'm on my third right now,
some things I'm much more relaxed about, and others it
feels like this is just like more bites of the
apple for what could go wrong, and that I don't
want to get too comfortable thinking that I know pregnancy
and thinking that I know my body. And I've been
(45:36):
actually really surprised this time around how anxious I've been that,
you know, I've had two healthy pregnancies, but it could
all go to hell with this third, and I'll be
completely unprepared because I thought I knew how I you know,
what it was going to be like. And so I wonder,
you know, what do you say to your pregnant women
(45:57):
knew who This isn't their first rodeo, but they've still
come to you with these kinds of anxieties. Is it
a different kind of conversation? Do you kind of still
have to have the conversation about low risk. It's not
really a lightning round kind of question, but I'm curious
kind of you know, how do you handle people who
(46:18):
are still anxious even though they kind of know the
nuts and bolts of what's going on.
Speaker 3 (46:23):
So I don't think that what you're describing or experiencing
is particularly uncommon. I think that one of the joys
of being youthful is you're ignorant of all the things
that could happen in this world. And as we age,
and as we have more kids, and as we have
(46:44):
more life experiences, you start to realize, oh, dear, like
there's you know, things can happen. And that's true from
our own experiences and from family and friends. And so
while your knowledge might be greater now than it was then,
your experience is much different now than it was then.
(47:08):
And this comes up for example, this happens a lot
actually with like genetic screening. Right, So someone in their
first pregnancy might say, you know, all my screening tests
were normal. The chance this baby has a genetic condition
is very, very low. I'm done. I'm not doing an
invasive test, a CBS or an amnio, perfectly reasonable choice.
Second pregnancy, all my tests are normal. My screening test
(47:30):
is normal. Everything looks good, my chance having a baby,
the genetic abnormality is very low. I'm not going to
do an invasive test. And in the third pregnancy screening
tests are normal, everything looks great. Chance of having a baby,
the genetic abnormality is exact same, very very low. And
they're like, you know what, I'm doing an invasive test
and why, Well, you know, I've lived a little I've
(47:51):
got two kids and the impact of my family would
be different, or a friend of mine had a baby
with this and that, and so now I just think
of the world different or whatever it is. And that's
totally normal. Your risk hasn't changed, your knowledge is anything
is higher, but your experiences lead you to make different
decisions because you have different things that were you right.
(48:14):
So you might not be as worried about let's say,
you know this complication, but you're more worried about this
complication and that's totally normal. So definitely, I wouldn't have
any like angst over the fact that you feel that way,
because that's very typical, or maybe not very typical, but
it's common. A lot of people have that, and so
addressing is really being very focused, like what is it
(48:37):
you're concerned about right this time around, and trying to
address it and say, Okay, is it a concern that
has always been there and you just never knew about it,
and or is it something that's actually new, or is
it something where we can do something to mitigate that
that we didn't do previously, Like maybe in your first
(48:57):
pregnancy you had visits once a month and in this
pregnancy you'd rather have them every two weeks, you know,
or vice versa. Right, anything could be in any direction.
You can sometimes tailor some of the aspects of your
prenatal care to address your specific concerns in this pregnancy,
And that's totally fine, because concern is not always that
the data has changed. It could just be that your
(49:20):
impression or your analysis of the data has changed, because
a lot of it is subjective.
Speaker 5 (49:25):
Yeah, when I was actually trying to get pregnant, I
had a conversation with Emily about it because I'm forty
one now and it took just a little longer than
it did when I was thirty five, and Emily gave
me creat she's really her outs right now. She gave
me great advice, which is that the data and risk
(49:48):
don't care about juju, like it didn't care about how
I kind of felt like there was some sort of
karmic fear that you know, your luck runs out at
a certain point, and I needed to hear that.
Speaker 2 (50:04):
And then you immediately got pregnant, like the next day.
Speaker 3 (50:06):
Yeah, I like, so.
Speaker 1 (50:10):
There you go, Nate, this is a delight. Oh we
had a little prenatal visit. We had a little data.
Thank you for being here.
Speaker 3 (50:22):
It's my pleasure tomorrow. Feel well, you look great.
Speaker 5 (50:24):
Thank you.
Speaker 3 (50:27):
What a love louis saying?
Speaker 5 (50:29):
How much lovely.
Speaker 3 (50:33):
Having my favor?
Speaker 5 (50:37):
What a love louis.
Speaker 3 (50:39):
Say, Let you think of.
Speaker 1 (50:44):
Parent Data is produced by tamorro Avishai with support from
the parent Data.
Speaker 2 (50:48):
Team and pr Rex.
Speaker 1 (50:50):
If you have thoughts on this episode, please join the
conversation on my Instagram at prof Emily Astar, and if
you want to support the show, become a subscriber to
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(51:11):
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(51:34):
you next time.
This is parent Data. I'm Emily Oster. Today's a big
day at parent Data. Firstly, this week we are relaunching
the Pregnant Data newsletter, new and improved for twenty twenty five.
It's got answers to all your questions, and I know
you have a lot of them, so that's a big
(00:21):
thing and I hope you'll sign up. Secondly, I published
a book almost a year ago with my co author,
doctor Nathan Fox, called The Unexpected. It's all about when
things do go wrong, or at least get complicated, in
a pregnancy. And the two of these together, Pregnant Data
and The Unexpected, are meant to help people to help
(00:45):
you be much better prepared for what they might face
in their pregnancies, and to help better navigate conversations with doctors,
both the expected conversations and the unexpected ones. So of course,
to celebrate both of these things, I had to invite
Nate back on the parent at a podcast to chat.
Speaker 2 (01:07):
Nate is an OBGYN and an.
Speaker 1 (01:10):
MFM, and he is one of our favorite returning podcast guests,
not just because he's a great guy, but also because
it's really nice to have a doctor who cannot only
provide medical answers to questions that come up around pregnancy,
but also to help you have the best possible experiences
with your own doctor. I also just really like Nate.
(01:32):
That's why I wrote a book with him.
Speaker 3 (01:34):
He's great.
Speaker 1 (01:36):
We're going to talk about some big issues that come
up during pregnancy and the many prenatal doctor visits, about
the distinction between self management and calling your doctor, when
do you know if something is normal bad or bad bad?
And we'll talk about just how subjective that line actually is.
We talk about risks and trade offs, and about the
(01:57):
kinds of postpartum issues that are worth addressing while still pregnant.
I'm looking at you depression and anxiety. And you'll hear
about the one and only public place I ever vomited
while pregnant.
Speaker 2 (02:09):
Not to be missed.
Speaker 1 (02:13):
After the break, we welcome back doctor Nathan Fox. I
am delighted to welcome doctor Nathan Fox, my co author,
my friend, back to the Parent Data Podcast.
Speaker 2 (02:30):
Doctor Nathan Fox, Can you introduce yourself?
Speaker 3 (02:33):
We are friends, we are co authors, and that is
by far the most important thing in my professional life
right now. Secondary toll that I am a doctor. I
do see patients pretty much every day I'm an obgyn
and a maternal fetal medicine specialist, which some people call
a high risk ob colloquially. I practice in New York
(02:54):
City and that's what I do pretty much all the time.
On the side, I also have a podcast and I've
you know, other wonderful things in my life.
Speaker 1 (03:05):
How much of the time do you spend delivering babies
as opposed to doing prenate all stuff.
Speaker 3 (03:10):
It's varied over the years. You know, when our practice
was smaller, I was probably doing twenty percent of all
of our deliveries, twenty to twenty five percent. We do
about one thousand deliveries a year. And then as our
practice grew bigger, probably now on the labor floor once
a week, give or take somewhere there it's gone. As
(03:32):
one ages, he or she tends to do slightly fewer deliveries,
which is pretty typical. But I'm still actively there, like
I'm there a lot. I'm on call this weekend, for example.
Speaker 1 (03:43):
Christmas babies. We're recording this before Christmas. This will be
Christmas babies.
Speaker 3 (03:47):
This the New Year's babies. Those are the ones that
people are looking for.
Speaker 4 (03:50):
Oh yeah, yeah, those who want the glory of delivering
the first baby of the new year, and those who
want the tax break for delivering the last baby of
the old year.
Speaker 2 (04:03):
There are so many important reasons.
Speaker 1 (04:05):
For birthdays, all right, So let's talk first about hyperamesis
because this, for me, is an example of a place
where we hit a question that's actually quite common in pregnancy,
which is, like, is my.
Speaker 2 (04:19):
Experience outside the norm?
Speaker 3 (04:22):
So?
Speaker 1 (04:23):
You know what, Like everyone knows that vomiting, nausee and
vomiting is common in pregnancy, and some.
Speaker 2 (04:30):
People vomit more than others.
Speaker 1 (04:32):
And I guess the way I would I would say
this is people are worried about bothering their doctors, and
so they somehow want to know, like how do I
know if I should if I should call? How do
I know if things have gone off the rails or
if I should just sort of just suck it up.
Speaker 3 (04:47):
I'm surprised to learn that people are worried about bothering
their doctors, are you? None of them, like a major
none of them seem to be my patients. Not I
mean that in a negative way. I think I don't
you know, I think different people are different. Maybe it's
a New York City phenomenon that or New York. I mean,
I'm from the Midwest, so I was brought up politely,
(05:10):
I would say, and then I came to New York
and people are just a little more assertive, I guess
as a way to put it right practice and not again,
not in a bad way. I love New York. I
guess that's possibly true some of it, maybe that people
are just they don't want to bother their doctor. But sometimes, unfortunately,
maybe they're conditioned to believe that because of their experiences
(05:33):
with doctors, and maybe not the person the doctor, but
sometimes just the way someone's office is set up. It's
difficult to reach a doctor, you know, the visits are short,
you can't get them on the phone, it's hard to
get them through the portal, and so you're sort of
turning to Google. And that's a much more global issue.
(05:54):
I would say, medicine that we're not going to solve today.
But you know, I think that it is definitely a
challenge if you don't have access to your doctor or
your midwife wherever that is. But I would say that
you know, everyone has prenatal visits, that's for sure. And
(06:15):
if you have a question that you can't get answered,
over the phone or over a portal or whatever it
might be, see if you can make a visit, like
just show up, right, just say I'm not feeling well,
and usually I mean and usually if you call and
say I'm not feeling well, I'm pregnant, They'll want you
to come in and be seen, and so you're gonna
get FaceTime typically.
Speaker 1 (06:35):
Maybe, although I think what people are really struggling with
here on the sort of nausea pieces, like I know
this is there is some amount of this that's normal, right.
I was told it's like regular to be nauseous, and
so then you know, I've I've a nauseous in every
day I vomit and I vomit ten times a day?
Speaker 2 (06:53):
Was that too much?
Speaker 1 (06:54):
Is that like a too much amount of vomiting? Or
is like fifteen too much? Or is one too much?
Speaker 5 (07:00):
Like?
Speaker 1 (07:00):
How do I know that that I not just that
I could call the doctor, but that I should is maybe.
Speaker 3 (07:06):
Fair a way to say it? No, that's a it's
a good distinction. I would say. There's sort of two thresholds.
And this is true with vomiting, this is true with pain,
this is true with really anything. The more critical threshold
is Am I in danger? Right? Am I in danger?
As my baby in danger? Something like that. So that's
(07:28):
a critical threshold where you must call right, you have
to be seen because there's a possibility. And so that's
one threshold. And the second threshold is much more subjective,
which is, do I feel not well and I want
to get better? Right? And so what the average amount
of vomiting is or quote unquote normal amount of vomiting
(07:50):
and nausees is completely irrelevant for the second one. Right,
for some people there like, yeah, I'm nauseous and I'm vomiting.
What's today, And that's fine. I'm okay with this. I
don't need to be tree and I can walk around
like this and be fine. And other people are like,
this is debilitating. I hate being nauseous all day. I
hate vomiting once a day. I can't work, I can't
take your mayor their kid, whatever it might be. And
(08:10):
so for the second threshold, I would say it's subjective.
If you are nauseous or vomiting to the point that
it's distressing you, that it's affecting your life, that you
want to look into ways to make it better, then
that is reason enough to start doing that and whether
that's you know, calling the nurse, calling the doctor, whatever
it is. In terms of the threshold the must I
(08:32):
call so for vomiting and nausea, it's generally things like
can I keep nothing down? Am I dehydrated? And so
how would you know you're dehydrated? Well, if you're not
peeing anymore, or when you pee it's really dark, like
it's the color of iced tea versus the color of
lemonade or water. Am I losing weight? Can I knock
(08:54):
get out of bed? Right? Those are possibly dangerous signs
and those need to be address. So if you're having
one of those things again you're not peeing, or it's
very very dark, or you can't keep anything down and
you're losing weight, you should not be waiting. You should
call and say I'm very sick. I need to be seen,
or this needs to be addressed. If it's short of
(09:15):
that and you're just not feeling well, make a decision.
Is this something like I'd rather take nothing and just
have this and sort of you know, muscle through it
until the end of whatever. Fine, that's okay. Whereas if
you're like, no, this sucks, I really want to get better.
Then make an appointment and that's totally fine, and that's subjective.
Speaker 1 (09:31):
Yeah, I mean I think that's exactly right, and thank
you a piece of it that I think is exactly right.
The piece of it is that is hard, and I
always struggle with sort of how and I suspect you
struggle with how to express this to people also, is like,
how do you say that without it coming across like, well,
if you can't tough it out because you're like a
(09:54):
whiny loser, you know what I mean, how does it
not be like just try it until you're at the
edge of your like you know capacity fair.
Speaker 3 (10:03):
No, I mean, I definitely understand how it could come
out that way. What I'm trying to say is actually
the opposite. What I'm trying to say is we're here
for you, Like our goal is to make you. Obviously
top goal is you know, healthy mother, healthy baby. Fine,
but the next is we want you to feel well,
Like it is our goal for you to feel well.
And Okay, if someone calls me and says they're having
(10:24):
knowledge that they're having vomiting again, not severe to the
point that I'm worried about their health and well being,
They're just it bothers them. It's upset understandably, So what
am I gonna be able to offer them. I'm going
to offer them, you know, maybe some dietary changes, which
rarely do that much. And then we're talking about various medications,
and so people sort of know from the outset. Am
I the type of person who would like to take
(10:47):
a medication to feel better? Am I the type of
person who's like, I'm out, I don't want any meds
unless I'm like horribly ill, I don't want to take anything.
And so we're here for you. If someone is not
feeling well and they want to try something, I don't.
It doesn't matter to me how not feeling well they are.
If it's a little bit, I'll try something because they're safe.
It's not like we're talking about dangerous treatments or anything
(11:08):
like that, and so any amount is totally fine on
my end that I don't judge people. I hate being nauseous.
It sucks. It's like one of the worst feelings in
the world. And so even if you're not vomiting, I
don't like God, being nauseous is terrible. And so it's
not like we we advise people to tough it out
as much as you can, and then when you hit
a breaking point, call us.
Speaker 1 (11:29):
No.
Speaker 3 (11:29):
If you're disturbed in any way whatsoever, call us and
we'll try to sort it out. But if you know,
you're the kind of person who's going to say, no,
I don't want any medication for it, all right, I
can you know, we can talk and I can try
to be empathetic, but not much is going to change
in that sense.
Speaker 2 (11:44):
Yeah.
Speaker 1 (11:44):
Yeah, I like this or idea of kind of thinking
for yourself even exanty about you know what, what are
the things I'm going to be willing to do here
and therefore, like what could come out of this conversation?
Speaker 3 (11:54):
Yeah? Yeah, And different different people, different people feel differently
about this, and I don't. Again, some people are like, listen,
I'm just I'm just not a medication person. I'm not
into it. I don't, you know. Find that's perfect again,
unless we're in a danger situation where I have to
really like, listen, we gotta we gotta do this, or
bad things are going to happen. If someone says I'd
prefer to vomit once a day than take a medication
to not vomit, that's reasonable. I'm okay with that, And
(12:17):
as someone says, I'd prefer to take a medication rather
than vomit once today, I think that's reasonable. Reasonable too,
That's what I would choose personally, But that's me.
Speaker 1 (12:25):
Yeah, I vomited once in my pregnancy in like an
ikea bathroom. Is the only one time I ever and
I'm like, if it happened again, I was gonna do
something about it.
Speaker 3 (12:38):
My wife vomited on Lexa ninety sixth Street, which was
pretty gross. Uh, vomiting, people look at you. Vomiting is horrible.
It is. It's a horrible, horrible experience to everyone who
has it, and when you're pregnant you have it a lot.
It's it's pretty gruesome. So yeah, I'm I'm in favor
of helping people with it, but I don't twist people's
arms unless I think it's dangerous obviously, all right.
Speaker 1 (13:00):
Second thing I want to talk about is postpartum depression
and and on the one hand, it is quite different
from from vomiting. But on the other hand, I think
this same general idea about sort of how do I
know that this is something I should get help with?
And I think in that case it's it's in some
ways even harder because it can be hard to see
(13:22):
when you're It can be hard for you to see
when you're depressed.
Speaker 3 (13:25):
I don't know, you don't know you're vomiting exactly exactly.
Speaker 1 (13:29):
And so so let me ask to begin with, because
I think this is something people are just confused about.
Speaker 2 (13:34):
Do you see some depression start in pregnancy?
Speaker 3 (13:37):
Definitely? Definitely, and so is, Yeah, there's there's everyone is
hopefully everyone has heard of postpartum depression. Many people have
heard of postpartum anxiety, right, it's sort of it's a
parallel to postpartum depression, just different symptoms. But there's also
a concept called peri natal depression and peri natal anxiety,
(14:00):
which just means instead of its starting after you deliver,
it starts before you deliver at some point in pregnancy.
And then obviously there's people who come into pregnancy with
sort of pre existing depression, anxiety, or any other mental
health condition. Doesn't have to be those two obviously, So
definitely can happen during pregnancy. And in fact, nowadays, not
(14:20):
only do we screen routinely for postpartum depression and anxiety,
they're sort of these standardized their questionnaires is how they
play out, But it's a standardized screen that we do,
and pediatricians do it. You know, a lot of people
do it nowadays. Fortunately, we also do one during pregnancy,
standardized for the same reasons, and most people will be
(14:41):
able to tell you I'm not doing well, but not
everybody a feels comfortable with that, and also not everyone
realizes that they're not doing well, because, like you said,
all these times are very challenging. Being pregnant is a
stressful time period. Having a baby's a stressful time period,
and it's hard for some people to understand and differentiate
(15:03):
is what I'm feeling and how I'm responding to it,
sort of typical slash normal, slash whatever, versus like, am
I in a bad place? And I think there is
a parallel to what I was saying about the vomiting
in terms of thresholds, because it's some of it is
similar that there are thresholds where where someone is unwell
(15:26):
and they really really need to be treated, and signs
like I can't get out of bed, there's nothing in
my life that I enjoy. It's affecting my relationship with
my baby or with my loved ones, or it's affecting
my ability to eat or to care for myself, or
obviously i'm feelings of self harm or harming others like
(15:47):
those are danger signs and those need to be addressed immediately,
and they're treatable, thank god. But then it's the same thing,
you know, someone's mood. There is some subjectivity to it
if no one has those danger signs, right if someone says,
you know, my mood is down, I'm feeling a little depressed,
(16:07):
or you know whatever however they express it to me.
But no, I can go to work every day and
I can function. It's not affecting my relationships. It's not
affecting my ability to take care of myself and to
eat and to exercise, and you sort of do what
I need to do, and I just, you know, I
just don't feel so great. You know. Do they need
to be treated? Do they not need to be treated?
It's you know, there's some subjectivity there, and there's some
(16:31):
patient choice there. Obviously. The one difference I would say is,
as opposed to nausea vomiting, you don't always have to
go to medication to be treated, right, you can have
a for lack of a better term, let's call it
minor mood disorder, right, it's not really a good way
to put it. But whatever, your symptoms are less and
(16:51):
you're functioning, and you might benefit from things that are
non pharmacologic, like therapy, right with the professional therapist that
might be beneficial, or just other things like some anxiety
reducing or stress reducing, you know, cognitive behavioral therapy or
yoga or just taking a break whatever. It might be,
(17:12):
something ranging from very small to more aggressive, but again,
all non pharmacologic, So there's more options, I would say,
than for nausee of vomiting.
Speaker 1 (17:22):
Nick, can you just give us a little bit to
sort of frame this conversation about why we see prenatal
or postpartum depression, why that's something that happens more in
those time periods than maybe other parts of life.
Speaker 3 (17:37):
Yeah, I think that, I mean, the short answers. We
don't know exactly why, right, No one's mapped it out
to like the molecular level definitively, but I think that
there's a lot of reasons that it is more common
after people deliver or you know, in towards the end
of pregnancy that do make a lot of sense as well.
(17:59):
People talk a lot a lot about hormones, right, and
you know, and pregnancy they're high and then after you
deliver they drop. And so you know, how could it
be that increasing hormones and decreasing hormones both do the
same thing. And I think that people's brains are used
to certain environments. And remember, mood and mood disorders are
(18:21):
organic brain issues. They're not like, you know, someone's fortitude
is harmed, right, it comes. These are organic medical problems
that originate in the brain, and the brain is used
to a certain hormonal balance, and when things change in
either direction, it can affect people's moods in sometimes very
(18:43):
unpredictable ways. Right, Why does one person get depression and
one person gain anxiety? Why does one person get nothing? Why?
You know, there's different things that can happen, and so
we don't we don't have it mapped out exactly why
certain changes in certain people do certain things. But it
makes a lot of sense. The changes can do certain
things to people. So that's one reason the changes of
(19:04):
sort of hormonal estrogen, progesterone and whatnot. But the second
is also there's a lot of other things that go
into mental health related to circumstances, things like stressors, right,
So if you have more stressors, you're more likely to
have one of these things. It's not that stress causes
anxiety and depression, but it's one of the factors that's involved.
(19:27):
So pregnancy and postpartum are very stressful times for people
for obvious reasons. Also, things like nutrition, exercise, sleep, things
that definitely impact mental health, and again hard to map
out exactly what they do to any given person, but
I don't think it's a big leap to say that
(19:48):
if you don't sleep well you're more likely to have
mental health issues, or if you don't eat right, or
if you're not able to exercise or whatever it might
be that they can impact it. And so I think
that all of those sort of come together in the
same time period. Your hormones change, your body physiology changes,
and your circumstance change, increase, stressors, decrease sleep, change in nutrition,
(20:09):
change in activity, and they happen, they like blow up
for people at the end of pregnancy and after they deliver,
and that's why many people have again not even full
blown postpartum anxiety or depression, but certainly they have effects
on their mood. You know, that people used to call
the baby blues or whatever it might be, that they
just don't feel the same, and that's all normal and
(20:31):
expected and at a certain point it probably should be treated.
Speaker 2 (20:34):
This issue of.
Speaker 1 (20:35):
Sort of treatment, pharmacological treatment, I think is ann comes
up in both of these cases, but it comes up
here particularly in the particularly in the in the perinatal
but also in the in the postpartum phase, because again
people sort of end up hearing like you can take
an SSRI, but you know, we don't know if it's
(20:56):
like we're not one hundred percent sure it's safe, or
you can take it if you really need it.
Speaker 2 (20:59):
That is a phrasing that people.
Speaker 1 (21:02):
Come sort of come back to me, say, my doctor
told me I can take this antidepressant if I really
need it.
Speaker 3 (21:07):
Yeah, that's a bad that's a bad phrase.
Speaker 1 (21:08):
It's a bad phrase because I think and I think
it's it's meant in a positive way. It's meant in
this way of like, you know, if you feel like
you like the sort of the way you put it before,
it's like, well, if you feel like you need it,
of course we want to help.
Speaker 2 (21:18):
But it comes out.
Speaker 1 (21:19):
As like if you feel like you actually you really
need it as opposed to you know, if you feel
like you're willing to sacrifice your baby for this, I
guess you can do it.
Speaker 2 (21:28):
Yeah that's tricky.
Speaker 3 (21:30):
Yeah, well it's tricky. It's unfortunate for a lot of
reasons because it's it's not the correct messaging. And again
I'm not impugning the doctors. They they probably don't mean
it to come out that way.
Speaker 2 (21:39):
I don't think at all. I think it's help people
are hearing something different.
Speaker 3 (21:42):
Yeah, I mean maybe some of them do, but I
assume not. I think there's a lot of reason. Number one,
the safety of these medications is so studied, right, there is.
None of the studies are perfect, obviously, but people use
these medications, many men. People use them for many, many years. Right.
And when you have that, it's exceedingly unlikely that any
(22:07):
of these is dangerous because it would come out right
one way or another. And so you're talking about is
there a one percent risk or is there not a
one percent risk? Like that's sort of the type of
numbers we're talking about, and the predominance of risk in
that let's call it one percent range is really if
you take it in the first trimester, it's not if
(22:28):
you take it at the end of pregnancy here right
after you deliver. And so my messaging to people is
not take it if you want it, but if we
think you need something, let's decide what it is you need.
Are you someone who just needs to maybe have a
little bit of change in your lifestyle, maybe work fewer hours,
(22:48):
or get some help at home or something like that,
and that's all you need? Okay, that's sort of like
changing your circumstances, or maybe you need some meet with
a mental health professional, do some therapy that could be enough,
or do you need that plus maybe some medication. And
it's not sort of like what can you tolerate? It's
like what's going to work for you? And when people
(23:09):
ask me about risk, I say, there's basically almost no
risk to any of these things, and any possible, hypothetical,
theoretical small risk there is to the medication is greatly
outweighed by the risk of you not being treated and
not being well. And it's not just because you don't
feel good, but all right, you can't take care of
(23:29):
yourself properly, you can't take care of the baby properly.
Not sleeping is not good for you, not eating is
not good for you, Like having just anxiety depression walking
around with those things is not good for you. And
so I would say it's greatly outweighed. So I don't
That's sort of how we try to approach it. I
think the other issue that people here not so much
the I feel like I'm a failure type of thing.
(23:52):
But there's such a stigma that people have. They feel
like if they take a medication, they've somehow crossed the
threshold and they're now a different person. And I get it,
like that's I'm not poo pooing that feeling, but it's
just so crazy because we never have that feeling with right, Yeah, Oh,
(24:13):
I don't want to take antibiotic because I don't want to
be called a person who has an infection. Like who
the hell says that? Right? No one says that, right,
And it's it's or anything like I have a headache
and I'm gonna take a pain medicine for I'm gonna
take up a motrain or tile and all, like no
one says, oh, there's a stigma now person with headaches
and you know, no one thinks like that. But since
(24:33):
it's depression or anxiety. People feel that somehow they're going
to be like branded, you know, in town square, And
I don't think it's like that anymore. I think that's
a problem with people of our generation, much more so
than like my kids generation. They're all much more comfortable
with their mental health diagnoses, which is a good.
Speaker 2 (24:50):
Thing, Which is a good thing.
Speaker 1 (24:51):
But I do think there's a general issue with sort
of medication during pregnancy, which is sure, like people, you know,
some medications during pregnancy are are dangerous, but so much
of the messaging around medication and pregnancy is sort of like, well,
you want to be like more cautious than usual, or
maybe there's some risk, but there's you know, and that
really puts people in a often in a situation that's
(25:15):
more brought than it should be, you know, because actually
in many cases, like it's fine to take tile at all.
Speaker 3 (25:21):
Yeah, I think some listen, it's appropriate to have heightened
concern or awareness over medications when you're pregnant, because yeah,
you're you know, you're pregnant with the baby, and they
get what you get to some degree, and there's always
the possibility of risk, right, There are medications that are dangerous,
So it's it's not, you know, implausible that something could happen.
(25:41):
But I think the important thing, you know, sometimes people
think it's all or none, and this is also true
with doctors and the messaging. They say, well, the medication
has risks, and not taking the medication has risks, and
so someone's like, well, how the hell do I balance that? Right?
And so they think it's well, either I'm harming my
baby or I'm harming myself. Like that's sort of the
black and white that they hear. And so I would
(26:03):
say the important thing to ask your doctor, and hopefully
you know he or she can answer this for you,
is can you quantify that risk? Like, what are we
talking about here? And we talk about a risk of
you know, fifty percent risk my baby's going to be
harmed or one in one hundred, one in a thousand theoretical,
but unknown, like what we like, what are we talking
(26:24):
about so we can try to weigh a versus be right,
there's no way to walk through life with no risk.
I leave my house on that cross the street, there's
some risk that I'm going to get run over by
a bus. Right, It's very very small, so it doesn't
really come into my mind every day, and I mitigate
that by waiting till the light screen and looking both
ways and all that stuff. But it could happen. And
so it's the same thing when someone tells me I
(26:45):
don't want to take zoloft because I'm pregnant, I'll say, Okay, Well,
let's what is the risk we're worrying about. We try
to quantify that, and when it boils down to it,
it comes down to a risk somewhere between let's say
zero and one percent that it's going to cause something
in the baby. That's like, it could be zero and
the high end it's let's say maybe one. All right,
(27:07):
what are you going to be like if you don't
take it? Like I'm a wreck, I can't get out
of bed in the morning. I'm like, well, then it's
a no brainer. Then you should take it, because how
could you go the whole pregnancy without getting out of bed?
Versus if they're like, well, I don't really need it.
I started it when I was in college because I
had a bat semester and I'm on such a low
dose and I took it. I stopped it for two
years and I felt the same, and I'm back on it.
(27:29):
I'm all right, that's a person who if they don't
want to take any risk of pregnancy, maybe they should
try to come off it. But those are two very
different people because they have different risks on the not
taking it side.
Speaker 1 (27:44):
More parent data, including Nate's tips for how to have
the best possible conversations with your doctor and how to
push back if you're actually skeptical of their advice.
Speaker 2 (27:53):
Maybe after listening to this podcast after the break.
Speaker 1 (28:04):
Listening to you talk about this leads me into the
sort of second set of things which I want to
talk about, which is when you and I talk about
this stuff, like, I get the impression that if I
were your patient, like, we would have interesting, nuanced conversations
about risks and benefits, and that would be very helpful
and I would feel good about making different choices. A
(28:25):
lot of people struggle to have this kind of conversation
with their providers. How do you think that people can
make the conversations they have with their doctor better and
to not have them feel out of people's control. So
I think a very common way for people to leave
(28:47):
a provider's office is to feel like I didn't get
I didn't think about the questions that I didn't ask
them right and I wasn't able to get to the
answer that I wanted.
Speaker 2 (28:57):
So let's start like big picture there.
Speaker 3 (28:59):
Yes, So that's a big, big conversation obviously, but an
important one, clearly. I think that first it's important for
everyone to sort of think about deliberately what am I
trying to get here? Like what am I looking for?
Because so you, Emily, if you were my patient, you
(29:20):
would come in, you would have very detailed data driven questions,
you know, asking me how to you know, navigate this decision,
or you'd have no questions because you were to know
what you're doing. But whatever it is, it would be
very because you know you you're like, I want the data.
I want to look at it, I want to analyze it.
I want to make a decision that's right for me
and my family, And that's what you're looking for. Other
people are terrified of that, and other people don't want
(29:42):
to talk about these things because it just scares them.
And so some people want to just be told I
literally had this conversation with someone yesterday because it happens
all the time, because I was asked here, you know,
we have this conversation about something and she said to me,
you know what, these kinds of conversations just freak me out, right,
So is it okay if we just go about doing
(30:04):
things sort of regularly and you tell me if I
need to change something, right? And I was like, yeah,
that's fine with me. Like that works. I could do that,
like and the same thing, she was trying to decide
if she wanted a doulah in labor, right, and so
she's like, what are your thoughts on doula's. I'm like,
duelahs are great, you know. And we go through this
and this and this, and she said she spoke to
doula and the duela's giving her all this information and
(30:24):
it actually freaked her out. She goes, I don't want
a lot of information, Like I just want to show
up in labor and I want you to tell me
want to push, and I want you to tell me
if I need a C section. I want you to
tell me if there's a problem with the baby and
what I need to do. I'm like, I could do that, like,
no problem, right, So I'm fine. That's what she wanted
to get out of this, Whereas other people are very
very different obviously, So I think the first thing is
(30:46):
get us, like, do some introspecttion, like who am I?
What am I looking for? Am I looking to try
to make a lot of decisions on my own? Be
given choices, choose A versus B versus C, to know
the risk and benefits or all them? Or do I
just want to be told what to do right? And
I don't. I'm fine with all of these options, Like,
different people feel differently about their healthcare, and I think
(31:06):
that you also need to make sure your providers flexible
with that. Some providers really like one model versus the other,
and I think everyone needs to sort of try to
tailor it to what the patient wants and needs and not,
you know, to what someone expects or something like that.
So I think that'd be number one and number two.
(31:27):
If you have specific questions that you want answered, they
don't understand, write them down, write them down, write them
down on paper, put them on your phone, tattoo them
to your arm, Go with someone and give them the
list and say don't let me forget, like because time
with doctors are limited, and prioritize the questions you want.
(31:48):
So you may have six questions and you're like four,
five and six. I could probably google, but one, two,
and three I need to answer. I need to ask
this doctor it's very important to me, or I need
a precise answer. I need to know what he or
she thinks specifically. And when you start to visit, tell them.
I have six questions, right so, and I always tell
(32:09):
them first, like before we begin. I just want you
to know I've got five or six questions. Some are important,
some are minor. Do you think we can get to
them today? Because otherwise you're let's say, have a fifteen
minute WIZO of someone and we're doing this, and we're
bantering and blah blah bah, and the examine this, and
fourteen and a half minutes in she pulls out a
twelve page list of questions. Right, I'll say, like, listen,
(32:30):
we don't have time for that right now. I got
someone waiting to see me. Well, I mean, if I'm nice,
I'll do the best I can and try to schedule
something else. But if she told me on the front end,
I could cut out some of the banter. You know,
you can sort of maybe tailor it best. So have
an agenda when you come in. What do you And
you might want nothing? If you want nothing, fine, go in,
be seen, and go home. That's cool.
Speaker 1 (32:51):
Also, okay, I'm now going to give you this is
a great overview, and I've now had an idea which
I'm going to give you some harder questions about, like
to navigate a situations that people tell me like I
didn't know what to do in this part of the conversation.
Speaker 2 (33:07):
Okay, so are you are you ready?
Speaker 3 (33:10):
Hit me? This is like this like speed round and
like Jeopardy speed Round or something sort of.
Speaker 1 (33:14):
We're gonna all right, try first of all, in order
to ask you this question, I need to know what
is something in pregnancy where you think doctors often recommend
something but it's definitely not right, Like I was gonna say,
bed rest.
Speaker 2 (33:26):
Can we agree bed rest is not a good idea?
Speaker 3 (33:29):
I think yes, I think it's being recommended less and
less but fair. Yes.
Speaker 1 (33:32):
Okay, So let's say let's say your doctor, you come in,
you say I've been having some you know, more Braxton
Hicks contractions, and your doctor says, what I recommend for
you is that you go on bed rest. You're thirty
two weeks, Just lay down in your bed, don't go
to your job, just lay down because I Braxton Hicks
contractions have some have some bed rest, and you know,
because you have read something or you're aware that that
(33:54):
is not a good recommendation, what do you say to
your doctor?
Speaker 3 (33:59):
All right, yeah, all right, now we're getting really we're
getting We're getting in it. I'm rolling up my sleeves here.
So yeah, I think the short answer is it depends, right,
So it depends on your relationship with this person, It
depends on the nature of the practice you're seeing, and
(34:20):
it depends on are you the type of person who
is comfortable not listening to your doctor, Like just some
people like, yeah, yeah, whatever, I'm not doing that right,
you know? Are you that person You're like, no, my
doctor says it, and I will like not sleep at
night if I'm not listening to him or her. So, meaning,
if you have a very good relationship with the doctor
(34:40):
and this is someone who you know and you trust
and you've spoken to before, and you really have a sense,
you can push back a little and you could say
I hear you, thank you. Question, is this something you're
just advising because you think it's going to make my
life easier or do you think this is actually going
to prevent me from having a pre term birth. You
(35:01):
could say, because I've read a lot that people are
questioning the efficacy of bed rest, and you could say,
you could push all your covets. I'm not trying to,
you know, question you. I'm not saying that I know
more than you at whatever, but basically you know I'm
and you can say, can I push back a little
on that and ask and just politely very you know,
(35:22):
if you have a relationship with the person, and then
they might say to you, if they're good doctors, they
might say, yes, you're right, I don't think it's actually
going to cause you to stay pregnant longer. But in
my experience, a lot of people feel better, or they
feel like they're doing something, or it just seems to
have been helpful to many of my patients. And then
(35:44):
you can say, okay, I appreciate that. If I'm the
type of person who really doesn't want to be on
bed rest because it would drive me crazier because I
have a I have to do some sort of work,
or I have a kid to take care of. Do
you think it'd be dangerous if I did didn't go
on bed rest, or if I did if we found
somewhere in the middle, and if they were a good doctor,
they say, no, that sounds perfectly fine. Let's come up
(36:05):
with something and then boom, you've had a productive conversation
leading to a individualized plan of care for yourself. On
the other hand, if this is someone you don't know,
you don't trust, you never met before, you could either
try to have that conversation and you don't know how
it's going to play out, right they you could offend them,
(36:27):
you know, obviously unintentionally, or it could end up the
same way. Or maybe there's another doctor in that practice
who you trust, and you'll say, listen, I met and
you know he or she said this, and I'm I'm
not trying to question them, but it just seemed a
little bit aggressive for the situation. Can you give me
a second opinion and again, old on politely and if
(36:48):
you have a relationship with somebody that they'll probably help you.
If you're in a group where the doctors always just
say do this and this and this, and you know that,
or have a very strong sense that those recommendations are
maybe outdated or not evidence based, or they're not explaining
to you, well, maybe you need a new practice. Maybe
they're not the right people for you. And that's obviously
another big thing. How do you switch? When you switch? Right?
(37:09):
Is it worth it to switch? I mean, that's that's
a big thing. And I'm not advocating people switch. I
think for most doctors, at least that I know, and
most patients, if they had the conversation I was talking
about in a way that's you know, polite, not you know,
not combative, but just hey, can we talk about this.
Most doctors know enough to be able to have the conversation.
(37:33):
It's just hard to have that conversation with everybody on
day one, and so you make a recommendation of what
you think is best, and if the person pushes back
in a play way, you find a way that works
for them. And I think most doctors would be very
receptive to a conversation like that, and if they're not,
that's usually a red flag about how they, you know,
just address patients in general.
Speaker 1 (37:52):
I mean, I think they're for a certain kind of question,
a certain kind of patient. Eventually, I think you have
to realize it's it's your fault. I had a I
have a colleague who at some point, you know, was
having something about what like when were they going to
induce and so on, and he and he texted me
and he was like, I don't think these doctors are experts.
Speaker 2 (38:09):
In a basy and statistical updating. And I was like,
they're not. That's your job, but like they will be
delivering the baby, and.
Speaker 1 (38:17):
It seems like maybe I should just listen to them.
At this point, Yes, I would have just want to
listen to them. And I was like that sounds great.
Speaker 3 (38:25):
Right, I mean, there's there's definitely you know, that's actually
a really good point because sometimes people expect doctors to
get out of their comfort zone. So for example, like
there's certain things that are done routinely, they're done by everybody,
they're recommended by everybody, and then someone brings in, like
I want you to do it differently, and they bring
it forty five research papers because this is how they're
doing it in France and this or this or this,
and it's and then you sort of you've now elevated
(38:48):
the conversation to like an academic one, right, And for
most doctors, like they need to just take care of you,
like they need to do what they're comfortable with and
what they're used to. You're like you don't want to
try to push your doctor out of their box, right
out of their comfort zone, because nobody, nobody wins in
that situation. And so at a certain point you have
(39:10):
to just say, this is the these are the parameters
my doctor has for better or worse, and if we're
going outside those, it's probably just not going to work
anymore because they're just not going to be comfortable. And
you don't want a doctor who's uncomfortable in the situation
that's not good for your care.
Speaker 1 (39:26):
Okay, I have one more question for you, and then
I think Tamor has a question.
Speaker 2 (39:29):
Uh So mine is the following.
Speaker 1 (39:32):
I imagine I'm at the doctor and they say something
and I don't understand what it is or what it
means in the moment. The question is sort of when
do I how do I try to come back from that?
So let me give you a specific example. So sap
into a friend of mine recently. The doctor's measuring the
fundel height and they they're thirty person thirty four weeks
(39:54):
along and the doctor's measuring the funnel height and she says, I,
you're measuring thirty two, and then she moves on and
she just says her measurement is thirty two, and she
doesn't say what that number is, how it relates, whether
they're considered just to measuring you thirty two, everything's fine.
And then reflecting on this later, my friend was like,
does that like, I'm thirty four?
Speaker 2 (40:13):
Should it have been thirty four? What does this number
actually mean?
Speaker 1 (40:16):
And you know that particular example, you could you could
sort of look it up. But the question of if
somebody says something I don't understand, how do I pull
it back into something I do understand?
Speaker 2 (40:28):
How do I ask that?
Speaker 3 (40:29):
Yeah? I mean I think in that precise situation. You know,
if I were the patient and the doctor said that
to me, I would just say, pardon me? Is is
thirty two good? Is thirty two bad? Right? What thirty two? What? Right?
Thirty two? What? And is that a good or bad thing?
And the doctor say say, oh, I'm measuring your the
height of your uterus and it's thirty two centimeters and
(40:51):
usually it's around the same as you're just acial agent weeks.
But if it's within two or three, that's perfectly fine,
and that's normal and everything looks good. Right, So thirty
if you're thirty four and it's measuring thirty two, thirty three,
thirty four, thirty five, thirty six. We don't make much
of it. It's very imprecise. That's a perfect screen. That's it.
That's all it takes.
Speaker 2 (41:07):
And I think in partly there is just like I
think people.
Speaker 1 (41:10):
Are just the message of like not being reluctant to ask,
just like if somebody says something, you know, understand to
be like what, sorry, excuse me, what does that mean?
Speaker 2 (41:18):
And she has anything from it?
Speaker 3 (41:19):
Yeah? Again, doctors, you know, we're we're an interesting bunch doctors, right,
So we have a lot of things we got to do.
We got a lot of things on our mind. There's
a lot of things that we're trying to do. In
every visit. We're always you know, not always, we're almost
always you know, busy or in a rush or this
or that. But we also want to take good care
of people and we want people to understand what's going on.
(41:41):
And we don't like it's not our intention to confuse people.
We just confuse people because we're not perfect people, right,
and so sometimes we say things and for us it's
it's like common sense or nature. We've done it a
million times in the past week. And we forget that
it's not like that for the person on the other end.
And again, because we're we're fallible, we're humans, and so
(42:02):
we don't always communicate in the way we're trying to.
But the goal is so that the person understands what
the hell we're talking about. And so if I'm saying
something and someone just like you know, interrupts me or
raises their hand and says, can I ask you a question?
And they say, I really don't understand what you're talking about,
or can you explain that again? Or I have a
question about what you said or this, I'm like great, Like,
(42:23):
thank you for telling me that. Let me explain it
in a way you understand, because I don't want you
to walk out of here confused. Number one, like, that's
not good for anybody. Number two, I wouldn't feel good
about myself. And number three, it's definitely not going to
work in the long run because you're gonna come back
with questions or you're going to like it. Confusion is
not good for anyone, even the doctor. No one wins.
Speaker 1 (42:43):
Yeah, And I think one of the issues here is
just an issue of language that, like when you are
doing something all the time, you develop a shorthand, you
develop a jargon, you develop a set of words, and
you use them, and sometimes you forget that like, not
everyone is managed this too. I told my team the
other day that I thought something was orthogonal to something else,
and they were like, that's not a word that like regular,
(43:04):
that's not how the regular people talk.
Speaker 2 (43:06):
And it was like, what is that?
Speaker 1 (43:07):
And I was like, Oh, isn't that That's not how it's.
Speaker 3 (43:10):
I would say that if again, if someone knows that
they're the type of person again who likes to understand
what's going on and be sort of on top of everything,
one of the ways to combat this issue is again
to ask questions and feel comfortable to ask questions, which
is greatly encouraged. But I would say the other one
is do a little prep work on the front end,
(43:31):
meaning sort of have a general sense of what's going
to happen in the prenatal visits. And that could be
from a bajillion sources. Again, whether it's one of your
terrific books, whether it's from this podcast, my podcast, a website,
you like, a book, you like whatever, anything that sort
of is useful to you and speaks to you. Have
a sense, like what normally gets done in the first trimester,
(43:53):
what normally gets done in a prenatal visit, what typically
happens when you're in labor and delivery, just general general
general stuff. Some people take classes like birth classes, Like no,
they're very rarely anymore like lamas because people since ninety
plus percent of people get up at durals, people don't
need all the like pain training stuff. So birth classes
now are very much like birth one on one. It's
(44:15):
like just education comes out of yeah baby and so yeah,
so like those types of things. So if you so,
if someone walked in knowing that measuring the height of
the uterus is something doctors do and what it means
and what's normal it's not normal, they would have then said, oh,
thirty two on thirty four, that's good, and they wouldn't
even had a question. And so that's another way to
(44:37):
try to combat that is a little bit of prep
work might reduce some of those confusions.
Speaker 1 (44:43):
So tomorrow is about seven months pregnant, and tomorrow do
you have questions for me?
Speaker 2 (44:49):
Do I?
Speaker 3 (44:50):
Yes?
Speaker 5 (44:50):
I did?
Speaker 3 (44:51):
Do I?
Speaker 5 (44:54):
Well, this was actually this was this was a good segue. Well,
in talking a lot about kind the fear of the unknown,
you know, I mean, these are a lot of new mothers.
You know, these are mothers who haven't been pregnant before,
and so all of this feels very brand new. And
the more kids you have, I've actually discovered, and the
(45:16):
more pregnancies you go through. I'm on my third right now,
some things I'm much more relaxed about, and others it
feels like this is just like more bites of the
apple for what could go wrong, and that I don't
want to get too comfortable thinking that I know pregnancy
and thinking that I know my body. And I've been
(45:36):
actually really surprised this time around how anxious I've been that,
you know, I've had two healthy pregnancies, but it could
all go to hell with this third, and I'll be
completely unprepared because I thought I knew how I you know,
what it was going to be like. And so I wonder,
you know, what do you say to your pregnant women
(45:57):
knew who This isn't their first rodeo, but they've still
come to you with these kinds of anxieties. Is it
a different kind of conversation? Do you kind of still
have to have the conversation about low risk. It's not
really a lightning round kind of question, but I'm curious
kind of you know, how do you handle people who
(46:18):
are still anxious even though they kind of know the
nuts and bolts of what's going on.
Speaker 3 (46:23):
So I don't think that what you're describing or experiencing
is particularly uncommon. I think that one of the joys
of being youthful is you're ignorant of all the things
that could happen in this world. And as we age,
and as we have more kids, and as we have
(46:44):
more life experiences, you start to realize, oh, dear, like
there's you know, things can happen. And that's true from
our own experiences and from family and friends. And so
while your knowledge might be greater now than it was then,
your experience is much different now than it was then.
(47:08):
And this comes up for example, this happens a lot
actually with like genetic screening. Right, So someone in their
first pregnancy might say, you know, all my screening tests
were normal. The chance this baby has a genetic condition
is very, very low. I'm done. I'm not doing an
invasive test, a CBS or an amnio, perfectly reasonable choice.
Second pregnancy, all my tests are normal. My screening test
(47:30):
is normal. Everything looks good, my chance having a baby,
the genetic abnormality is very low. I'm not going to
do an invasive test. And in the third pregnancy screening
tests are normal, everything looks great. Chance of having a baby,
the genetic abnormality is exact same, very very low. And
they're like, you know what, I'm doing an invasive test
and why, Well, you know, I've lived a little I've
(47:51):
got two kids and the impact of my family would
be different, or a friend of mine had a baby
with this and that, and so now I just think
of the world different or whatever it is. And that's
totally normal. Your risk hasn't changed, your knowledge is anything
is higher, but your experiences lead you to make different
decisions because you have different things that were you right.
(48:14):
So you might not be as worried about let's say,
you know this complication, but you're more worried about this
complication and that's totally normal. So definitely, I wouldn't have
any like angst over the fact that you feel that way,
because that's very typical, or maybe not very typical, but
it's common. A lot of people have that, and so
addressing is really being very focused, like what is it
(48:37):
you're concerned about right this time around, and trying to
address it and say, Okay, is it a concern that
has always been there and you just never knew about it,
and or is it something that's actually new, or is
it something where we can do something to mitigate that
that we didn't do previously, Like maybe in your first
(48:57):
pregnancy you had visits once a month and in this
pregnancy you'd rather have them every two weeks, you know,
or vice versa. Right, anything could be in any direction.
You can sometimes tailor some of the aspects of your
prenatal care to address your specific concerns in this pregnancy,
And that's totally fine, because concern is not always that
the data has changed. It could just be that your
(49:20):
impression or your analysis of the data has changed, because
a lot of it is subjective.
Speaker 5 (49:25):
Yeah, when I was actually trying to get pregnant, I
had a conversation with Emily about it because I'm forty
one now and it took just a little longer than
it did when I was thirty five, and Emily gave
me creat she's really her outs right now. She gave
me great advice, which is that the data and risk
(49:48):
don't care about juju, like it didn't care about how
I kind of felt like there was some sort of
karmic fear that you know, your luck runs out at
a certain point, and I needed to hear that.
Speaker 2 (50:04):
And then you immediately got pregnant, like the next day.
Speaker 3 (50:06):
Yeah, I like, so.
Speaker 1 (50:10):
There you go, Nate, this is a delight. Oh we
had a little prenatal visit. We had a little data.
Thank you for being here.
Speaker 3 (50:22):
It's my pleasure tomorrow. Feel well, you look great.
Speaker 5 (50:24):
Thank you.
Speaker 3 (50:27):
What a love louis saying?
Speaker 5 (50:29):
How much lovely.
Speaker 3 (50:33):
Having my favor?
Speaker 5 (50:37):
What a love louis.
Speaker 3 (50:39):
Say, Let you think of.
Speaker 1 (50:44):
Parent Data is produced by tamorro Avishai with support from
the parent Data.
Speaker 2 (50:48):
Team and pr Rex.
Speaker 1 (50:50):
If you have thoughts on this episode, please join the
conversation on my Instagram at prof Emily Astar, and if
you want to support the show, become a subscriber to
the parent a newsletter at parentdata dot org, where I
write weekly posts on everything to do with parents and
data to help you make better, more informed parenting decisions.
(51:11):
There are a lot of ways you can help people
find out about us. Leave a rating or a review
on Apple podcasts. Text your friend about something you learned
from this episode. Debate your mother in law about the
merits of something parents do now that is totally different
from what she did. Post a story to your Instagram
debunking a panic headline of your own. Just remember to
mention the podcast too, Write penelpe, write mom, We'll see
(51:34):
you next time.
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Kingdom of Fraud
It’s the unlikeliest of criminal partnerships: a devout polygamist from an insular Utah sect joining forces with a shadowy Armenian tycoon from LA. The result - a billion dollar fraud conspiracy. In Kingdom of Fraud, investigative reporter Michele McPhee traces the origins of the extraordinary alliance between Jacob Kingston and Levon Termendzhyan. Together, the two men trigger the largest tax investigation in American history and weave around themselves a web of dirty cops, influential political relationships and transnational money laundering. All this is set against the backdrop of Jacob Kingston’s clan – The Order. A powerful and secretive polygamist organization in Salt Lake City. To whom Jacob is desperate to prove his worth. Kingdom of Fraud is produced by Novel for iHeart Podcasts. For more from Novel, visit https://novel.audio/. You can listen to new episodes of Kingdom of Fraud completely ad-free and 1 week early with an iHeart True Crime+ subscription, available exclusively on Apple Podcasts. Open your Apple Podcasts app, search for “iHeart True Crime+, and subscribe today!