Breaking the System: Dr. Jackie Piasta on Fixing Women's Healthcare

This week, The Dusty Muffins – Dr. Aoife O’Sullivan (PsyD, MD, MSCP), Dr. Christine Hart Kress (DNP, MSCP), and Dr. Rebbecca Hertel (DO, MSCP) – sit down with revolutionary women's health expert Dr. Jackie Piasta (DNP, WHNP-BC, MSCP) to expose what's really wrong with menopause care - and how to fix it.

In this eye-opening episode, you'll discover:
💊 Why the current medical training system fails midlife women
💰 The shocking truth about insurance-based menopause care
🔄 Why Dr. Piasta switched to a membership model (and why it works better)
⏱️ How overbooking destroys patient care - and what alternatives exist

About Our Game-Changing Guest:This "millennial-pausal" powerhouse is:
✔️ Founder of Monarch Health
✔️ National Menopause Foundation advisor
✔️ Using social media to reach women beyond clinic walls
✔️ Fighting for systemic change in women's healthcare

Connect With The Muffins Instagram:
✨ The Dusty Muffins: @thedustymuffins
✨ Dr. Aoife: @portlandmenopausedoc
✨ Dr. Rebbecca: @drrebbeccaherteldo
✨ Dr. Christine: @christinehartkress_dnp
🌳 Linktree: https://linktr.ee/thedustymuffins

Guest Social Links:
✨ Dr. Piasta Instagram: @jackiep_gynnp
🌳 Linktree: https://linktr.ee/jackiep_gynnp 

This isn't just another menopause chat - it's a call to action for better care. Tune in to learn how we can all demand (and create) better healthcare for midlife women.

Subscribe for more no-holds-barred conversations about revolutionizing women's health!

Become a supporter of this podcast: https://www.spreaker.com/podcast/the-dusty-muffins--6539849/support.

Episode Transcript

Speaker 1 (00:03):
Welcome to the Dusty Muffins, where menopause meets sisterhood and strength.
We're three menopause specialists coming together to laugh, share, and
empower you through the wild ride of menopause and perimenopause.
Whether you're curious, confused, or just looking for a real talk,
you're in the right place. We're here to answer your
burning questions, educate, and advocate all with a dash of

(00:26):
humor and a lot of heart. So pull up a
chair and join the conversation. Before we dive in, Please remember,
while we're doctors, we're not your doctors. This podcast is
for educational purposes only and is not a substitute for
medical advice. We encourage you to partner with your own
medical clinician to address your unique health needs. This is

(00:49):
the Dusty Muffins. I am doctor Ifa O'Sullivan, a Board
certified Family physician and Menopause Society Certified practitioner, and I
see patients through my Telly Medicine practice here in Oregon
and Washington.

Speaker 2 (01:04):
I'm doctor Christine Harcrass, a Board certified Women's Health Nurse
practitioner and Menopause certified practitioner, and I see patients via
telemedicine in several states as well.

Speaker 3 (01:14):
I am a doctor, a Remerca Hurdle.

Speaker 4 (01:15):
I'm a Board certified osteopathic family medicine physician and a
Menopause Society certified practitioner. I have a private tele medicine
practice and I see patients in several different states.

Speaker 2 (01:26):
Good afternoon, everyone, We have a treat for you today,
none other than Jackie Piasta.

Speaker 5 (01:33):
She is a self proclaimed.

Speaker 2 (01:34):
Millennial puzzle woman who is rewriting the rules of midlife
women's health. A Board certified Women's health and gender related
nurse practitioner, a certified menopause practitioner, podcast co host and
founder of Monarch Health, Jackie brings over fifteen years of
clinical expertise to every conversation. She serves on the Medical
Advisory Committee for the National Menopause Foundation and several other

(01:58):
committees for other leading women health organizations, while also using
the power of social media to reach women beyond the
clinic walls.

Speaker 1 (02:06):
Welcome Jackie, Welcome jack Thank you so much for having me,
so look you to have you here. We all love
you and we've all learned so much from you over
the years, so it's a real pleasure to have you
here today.

Speaker 5 (02:22):
Well, thanks.

Speaker 1 (02:23):
One of the things we wanted to talk to you
and ask you more about was your DNP that you're
doing at the moment, because what you're doing is so interesting.
It's about setting up a menopause clinic within a primary
care clinic, isn't it.

Speaker 6 (02:39):
Yeah, So probably the most interesting, well, the best thing
about it was that the primary care office I found
actually wanted to do it. We're very motivated to you
and to found the need. So I think that was
really kind of serendipitous in a way. But I think
that we're all recognizing and that the need for menopause
care is too big for the obgi N office, right.

(03:01):
So essentially what we did is we implemented so quality
improvement work where essentially you find a problem and then
you try to implement reasonable measures to try to fix
it and see if it can be adopted without being
too much of a train wreck, and then sustaining it
is the biggest hurdle, right keeping it going after you're

(03:23):
not there to baby it anymore. So one of the
when we look at the literature of what some of
the gaps in menopause care are actually like at point
of care is basic stuff like screening, just screening women
for menopause and just symptom screening. I mean, like, how
basic is that we screen for so many other things,

(03:45):
and yet we first of all, our screeners are really outdated.

Speaker 5 (03:49):
We need new screeners.

Speaker 6 (03:50):
We're still using screeners from like the nineteen seventies. If
we're even using screeners, that's where they're from. One of
the problems is it's really hard to get a screening
tool that like validated, to actually validate it and make
sure that it is acceptable to use them in a
large population. And so we haven't updated the screening tools

(04:12):
in many, many, many years, and so a lot of
them are incomplete. So like the one that we really
like is called the Menopause Rating Scale. It has eleven
categories of the top menopause type symptoms, brain concerns, vaginal concerns,
hot flashes, night so it's of course all those, but
it's missing like joint pain is you know, missing what

(04:33):
you know, our friend and colleague, doctor Bonde write and
their paper that they wrote on the muscle scaledal syndrome
of menopause, so it's missing that. And then there's another
screener out there called the Green climactoric scale, which is
really nice too, but it's also.

Speaker 5 (04:47):
Missing some fundamental things.

Speaker 6 (04:49):
And so I actually for this project created my own
screening tool, and I called it the MENO ten and
so the MENO ten Q, and it ten symptoms of menopause,
and we broke it down vasomotor symptoms, joint pain, brain fog,

(05:10):
difficulty concentrating those types of things. Oh my god, there
we go, there's my brain fog. Sexual yeah, sexual health
symptoms like so vaginal dryness, urinary urinary complaints, pain with sex,
and a lot of those typical ones that we hear
about and then and then we broke it down even further.

(05:33):
And so another hallmark of this is patient making sure
that your care is patient centered and you're involving the
patient and all aspects of the care. So not everybody
wants to discuss their menopause things. I think that's one
of the best things about us. One of the most
important things about being screened for something is we can
be screened for it, but whether or not we want
to discuss it further or two very different, two different things.

(05:55):
And so also part of the screening tool that I
developed is whether or not the patient wants to discuss
these symptoms further, and so that kind of ended up
prompting whether or not we took it one step further
in the project. But it was really cool to screening
just implementing screen So we implemented it to all women
forty forty to sixty five years of age that came

(06:18):
in for their Women's Like Wellness Exam, and it was
really neat because so many of the women reported that
like they didn't even know half the symptoms were part
of the menopause transition, or they were so grateful that
they were being screened for it. So that was a
really cool part.

Speaker 5 (06:38):
Of the project.

Speaker 6 (06:39):
So simple, something so simple is just asking people a
question or to check a box.

Speaker 2 (06:45):
Did you did you do like a number like the
like in the green mantything more than fifteen? Did you
devise like a number system to sort of be able
to explain to women, you know, how deficient they were.

Speaker 6 (07:00):
Yeah, so I did stratify it similar to the way
the menopause rating scale is where zero is not concerning
or only very minimally concerning, and then four all the
way up to four was debilitating symptoms. But I didn't
you know, and then I did stratify it as far
as like anywhere from like a zero to let's just

(07:21):
say eight, I can't remember, I's talk my head right now,
but zero to eight was mild symptoms. Eight to fifteen
was moderate and any But we didn't really utilize that.
We utilized that to say, okay, was the symptom burden
amongst our population mild, moderate, or severe? For this target population,
it actually was a moderate symptom burden. I think the

(07:43):
average person it came around a score of about fourteen
twelve to thirteen, which equated to a moderate symptom burden.
But I thought our population was actually ended up being
on the younger end. So most of the people in
our study were in the quality provement study were ages
forty to fifty and so it and actually leaning more

(08:05):
on the forty to forty five. So it makes sense
that the symptom burden would have been relatively mild to moderate.
But our biggest, our biggest conversion ticket item was whether
or not they just wanted to talk about their symptoms.
More so, it wasn't whether or not the symptoms were
of course debilitating, Yes, we were flagging that, but even

(08:28):
if the symptoms were mild, we were still just looking
at whether or not they wanted.

Speaker 5 (08:33):
To discuss it further.

Speaker 6 (08:34):
And if they wanted to discuss it further, then we did.
And then we developed a we called it a pre
planning tool. And so the whole purpose of the quality
Improvement project was to move women into a dedicated menopause
visit away from their wellness. So it was to probe

(08:55):
the start, start the conversation, or facilitate the conversation that
was already get to be asked, right, because like one
of the biggest things that healthcare clinicians like their skin crawls, right,
is when somebody's coming from like just a basic wellness
check and they want to discuss other things. And it's
not because we're not empathetic. It's because we're burnt out

(09:15):
and we have too many other things right on our schedule.

Speaker 5 (09:18):
We just simply don't have the time.

Speaker 6 (09:20):
So the whole purpose of the visit was to start
the conversation, make it be patient centered, and then move
those individuals into a menopause follow what visit. And so
we gave them this patient pre visit planning tool to
prepare them, and it basically it had information about menopause.
It had what are your goals, what are your priorities,

(09:42):
et cetera. And then when they moved into a follow
what visit, it sort of was already a roadmap for
how to get through that. And this is insurance based medicine, right,
This is not like concierge medicine where we can spend
an hour. So it was all about making it as
facilitating that discussion as best as possible within the confines

(10:02):
of an insurance based model.

Speaker 4 (10:05):
So they went in for their for their physical they
had were they given it to in like the waiting
room when they went and checked in the kiosk? Or
was it while they're in the room waiting for the
whatever clinician to come in and then they were filling
it out?

Speaker 6 (10:20):
Uh, So we did it where that actually the when
the medical as system brought them back for their vital signs,
we gave it to them h during that time. But right, right,
But there was some you know, there were some like
things that we couldn't do, Like ideally I would have
loved to have it electronic and send it to the
patients the day before right via our like pre visit,

(10:44):
but we I just couldn't do that for the purposes
of this project, the doctoral project. We had every we
had to have everything in writing, we had to have
like paper trail of everything. But in the future that
was one of kind of the future considerations. It was
making sure that this is part of your pre and inventions,
just like the GAD seven and the PHQ nine, which

(11:04):
that's the Patient Help Questionnaire nine and then the GAD
seven is the General Anxiety Disorder Screening tool and a
lot of times we have patients build these out before.
So that was the whole thing, is just incorporating it
into that model. But we did it at point of
care when the medical assistant was running through.

Speaker 4 (11:22):
That was easy for them to do that, you know
before because I think about like Medicare wellness. You know,
they're always sent their questions before when they like the
day before and if they remember, they'll fill it out
online or you know, just prepping for anything. In an
insurance based model, most of like your bigger systems will
have all of that electronic. So then you know, yeah,

(11:44):
based on that, do your wellness visit or whatever, and
then okay, let's make that follow up visit for menopause
or payimenopause visit.

Speaker 5 (11:54):
Yeah, yeah, like in depression.

Speaker 1 (11:56):
You know, people don't realize that a change in their set,
their appetite, and irritability can all be connected to depression.
You know, so just like you know, especially boiling it
down to ten questions is great as the green climacteric,
which is twenty twenty something twenty three.

Speaker 6 (12:17):
Yeah, it's correct, yeah, right, so it yeah, it gives
us more than the mrs. Right, but we're lacking a
lot in the mrs. So any who, Yeah, no, it's great.
I mean it's simple stuff. This is it like rocket science.
We're not like but we you know, it doesn't have
to be difficult or catastrophic for it to make a

(12:40):
huge impact. And that was one of the coolest things,
like I said, is just how much the patients we're
so grateful for the conversation to be started and to
have some just just to questionnaire listing.

Speaker 5 (12:52):
Symptoms was.

Speaker 6 (12:56):
Thought of at like highly thought of in terms of
like information providing information.

Speaker 1 (13:03):
So it's a very d yeah.

Speaker 6 (13:06):
Right right, right right, and not reinventing the wheel, like
our little planning tool that we you know, the clinicians
once the patient said we want to discuss these further.
We used this planning tool. We gave it to them
and sort of started it and they took it home.
There was a QR code to already, the Society for
Women's Health Research has a beautiful, like thirty page PDF

(13:27):
packet all on menopause and it was linked to that,
and so not the tools are out there. We just
have to know where they are and guide our patients
into those so that they could get good, reliable information
because as we all know, there's menopause is one of
the biggest areas in this and that has muddied itself
all up.

Speaker 3 (13:48):
Yeah.

Speaker 2 (13:48):
Yeah, were those clinicians then prepared for those follow up visits?
Where did you find that they were adequately trained or
is it or did you find them there was?

Speaker 6 (13:58):
Yeah, so that's it. That's a great question. So I
would say is about fifty to fifty. That was one
of the areas of the audit tool of the auditing,
so I had to audit everything. So you know, once
this is all, you have to go in and actually
see like who's not getting it, who wasn't given the questionnaire,
who wasn't given the tool, who didn't schedule a fall

(14:19):
up visit when they marched that their symptoms were high, high, high,
up on the burden scale, and so you had to
go through And I actually want.

Speaker 4 (14:26):
Of want the Dusty Muffins at your next event.

Speaker 3 (14:29):
We do panels, live podcasts and talks that bring the
heat literally corporate see me or retreats.

Speaker 4 (14:35):
We've got you, So hit us up at the Dusty
Muffins three three three at gmail dot com or dms
on Instagram at the Dusty Muffins.

Speaker 5 (14:42):
Back to the test of change.

Speaker 6 (14:44):
Yeah, so what I what we saw initially is that
the questionnaires were being handed out and the conversations I
think were happening, but they weren't being documented in the chart.
And actually this is a there's another study out there
that actually Stephanie Fabion, who as the medical director of
the Menopause Society, they have a paper I want to
say from twenty twenty four, twenty twenty three or twenty

(15:06):
twenty four, but basically it talks about how documentation of
menopause symptoms is nowhere, there's no documentation and they actually
this was through the Mayo Clinic. They looked at the
Mayo Clinic records and so that was a huge thing
that we were finding is nothing was being documented. Well,
we all know when patients come back for a follow
up visit, if it's not documented, I mean, ah, we

(15:27):
need to like, why are they here, Let's go back
to the last visit.

Speaker 5 (15:30):
Let's document this.

Speaker 6 (15:32):
So part of it was helping with that and facilitating that,
and we added again not rocket science, we added a
smart phrase in the charting system that said this was discussed.

Speaker 5 (15:44):
This was the You literally type in.

Speaker 6 (15:46):
The number on the symptom burden in the blank space,
and then patient blobbity blot. But as far as whether
or not they were educated, you could certainly tell which
ones were less comfortable than others because there were more misses,
there were few follow up visits, fewer follow up visits,

(16:08):
so certainly. And then so another one of the tests
of change we had was an in service. We had
a teaching in service and then we also built I
built out a big folder for them which had a
toolkit essentially the closest thing that we can get to
an algorithm. And that's one of the that's another problem
that we have in menopause care is everybody once dropped

(16:28):
down medicine and menopause is one of those things where
there's not necessarily a right way to do something. There's
a lot of wrong ways to do it, but there's
not necessarily one right way, and so I think people
get really tripped up on you know, we go to
these conferences or we go to these lectures and they
teach us the concepts of these medications and these but

(16:50):
then we're stuck with a patient in front of us,
and we're like, wait, but how do I actually do this?

Speaker 5 (16:55):
How do I actually prescribe to this person?

Speaker 6 (16:57):
So we sat through that and we did some training,
so I would say fifty to fifty Christine, we had
about fifty percent of the clinicians were pretty well versed
and comfortable with it, and it was pretty obvious which
ones were maybe not needed a little bit more hand holding.

Speaker 4 (17:12):
So you almost need it in because I think, you know,
in my primary care there are templates for annual wellness
physical for a female and so if it's like forty
and over and they'll do it by age, you almost
could have it like part of that template, so you
don't forget to ask the question, and you kind of
like f two through the whole exam and these you know,

(17:36):
phrases will come up, and that would be a nice
way something like that, where you know, you're asking about periods,
you're asking about your paps, you're asking about mammograms, and
then it comes down with okay, hot loss, night sputs,
you know, mood changes, changes in periods, whatever it is,
and it would help to prompt clinicians then to ask
the question, you know.

Speaker 5 (17:57):
Yeah, I mean we have to find a way.

Speaker 6 (18:00):
I mean, I know us all here, we have our
small private practices and stuff, but we do have I mean,
the populace. We have to find a way in order
to jam this round peg into a square hole a
little bit. I mean, we have to figure out how
to get menopause taken care of in an insurance base model,
at least while we still are working within this structure.

Speaker 5 (18:22):
And somehow we've.

Speaker 3 (18:24):
Got to do it.

Speaker 6 (18:24):
And it's not going to look like what it looks
like in an hour long concierge visit, and that's different.
That's a different sort of medicine. But it can also
be done in this way. But we have to be
strategic about it, and we have to be a little crafty,
right and find ways and tools in order to facilitate
within the constraints of.

Speaker 4 (18:44):
This, and it's going to be more than one visit, right,
I mean, that's going to be really what it comes
down to with patients is just saying, listen, we have
to do all the things. We have to first identify you. Second,
then we need to educate and or get you to
someone if it's not in the same area, you know,
or to maybe if they're to practice with more than
one clinicians. If someone's doing menopause in there, then we

(19:06):
get you with them. And it's going to be more
than one visit, just because of the time constraint, you know,
to talk about the education and the risk, the benefits,
all the options, you know, all the things that you
know in that we can do in an hour or
an hour and a half or however long the initial
consults are.

Speaker 3 (19:22):
This is going to be more than one visit.

Speaker 4 (19:23):
And I think once they know that they're they're okay
with that, it get that a little bit more knowing
that they'd rather come back more than one time so
they can get everything that they need.

Speaker 1 (19:33):
Before me get that far though, we have to actually
there has to be some mandated education of clinicians because
most people out there do not I mean, we still
hear it on a daily basis. I don't believe.

Speaker 5 (19:48):
In hormone therapy.

Speaker 1 (19:50):
I mean, our patients tell us that they've been told
that all the time. I don't believe in hormone therapy.
So how do you get to a place where you're
asking about it at each visit and able to manage
in an insurance based model when you've never even been
taught about it. We have to have some type of
mandated education for clinicians.

Speaker 6 (20:10):
Yeah, it's got I mean it has to have representation
on the board exams. I mean, I think that's another
big issue, is that there's not there's not good representation
I know for sure on ours. I mean I would say, Christine,
we have fairly decent representation on our board exams.

Speaker 5 (20:28):
But it's still not great.

Speaker 6 (20:30):
I mean our I think the women's health nurse practitioners
do a fairly good job of having some menopause curriculum.
But in all fairness, we don't have to study surgery.
We don't have to study you know, electrics, you know,
delivery medicine. So for our obstetric gynecology colleagues, in all fairness,
our board exam can focus a little bit more on

(20:52):
those areas because we don't have to focus on some
of these other other areas.

Speaker 1 (20:57):
But of family physicians, they send us twenty five questions
a quarter, so one hundred questions a year, and I've
been doing them for years. And this past year, maybe
the last quarter or the last quarter of last year,
there was one question on menopause and the answer was
completely wrong.

Speaker 3 (21:19):
I'll have to look for that too, because you do
the same thing every quarter.

Speaker 1 (21:23):
Yeah, And I just re sat for my research for.

Speaker 2 (21:29):
NCC my recertification exam, and I was really glad that
I was a menopause practitioner because almost the whole thing
was midlife and menopause care. And it was the first time,
I think I've said this before. It's the first time ever.
I did not owe any extra continuing education, not one
extra hour, because it's all based on how you score.

(21:50):
But you know, I don't know if everybody saw Current
Men's you probably everybody probably did her interviews at a
club all of news. I was thinking, Okay, we are
finally hitting our stride, Like there is so much, you know, discussion,
and you know, many of us are educating nurse practitioners
and physicians and to hear the third and fourth year

(22:13):
medical students say that they they didn't know what GSM was,
jenitor your nurse syndrome, amenopause, or you know anything about libido,
and they really didn't get any menopause training. I thought, oh,
my goodness, we are not even We're not going to
see the light of day for decades.

Speaker 4 (22:35):
Yeah, well, my daughter's a second year med student and
they've had one hour now. It was but done by
an MSCP. I looked at it, I looked at our lecture.
It was it was better than anticipated, but it was
still one hour, and so she'll probably not get any
in her third and fourth year rotations unless whoever she
rotates with actively is involved.

Speaker 1 (22:57):
Yeah, it's getting harder to defend, harder to know that
there are guidelines out there and algorithms and all these
courses and they've been around for years and years and years,
and yet clinicians don't know about them and aren't using them.
It's getting much harder to defend to your patients.

Speaker 4 (23:18):
Well, it needs to be in some of those courses
that are you know, incentivized for them to take, right,
So it needs to be in if it's family medicine.
It needs to be part of you know, the at
least for me, for osteopathic it's ACOFP. It needs to
be part of they have conferences once or twice a year.

Speaker 1 (23:35):
You know.

Speaker 4 (23:35):
It really needs to be part of that curriculum too,
and not where you have to like seek it out
and spend you know, how much money have we all
spent getting extra training in sexual health, I'm going a
pause health and in life care right and so we
did it because we love it, but it's not they're
not incentivized to do that.

Speaker 1 (23:55):
No, I would have had to leave work unpaid for
a year or to learn what I've learned over the
last few years. You know, if I was going to
throw myself into it and really just learn about it,
it's not easy and it's a long process, and it
takes seeing a lot of patients as well, because you
learn so much from your patients coming back to you

(24:18):
telling you how they're doing. So it's not even something
you can rush like. It really has to be from
day one of your training that this is incorporated.

Speaker 6 (24:27):
I think there's another really essential concept within all this too,
is that I think that we have to there has
some degree of humility that has to take place amongst
yourself as a practitioner, because everybody asked me, well is
your best course that you ever took or what you know,

(24:48):
and always say the best course I ever took was
sitting in the exam with my patient and opening up
my ears and my heart.

Speaker 5 (24:54):
Not to be.

Speaker 6 (24:55):
Too cliche, but like if you open up your ears
in your heart and you sit there and you listen.

Speaker 5 (25:00):
Your patients will teach you. They'll teach I mean, I
still remember back to like Patho Fizz.

Speaker 6 (25:05):
In my first Ancient History and Physical class and in
peace school, and the instructor said, if you listen enough,
your patients will tell you what is wrong. And it's
still it's like burned into my brain. That's like day
one H and P class and nothing is changed. Again,
this is not rocket science. If you just sit down
and you listen to people, they will tell you what
is wrong, and they will tell you how to make

(25:27):
it right. You can And that's I feel like it's
so true, especially if you are going like the menopausal
hormone therapy route.

Speaker 5 (25:34):
There's not one way to skin that cat. There there
are a million different things.

Speaker 6 (25:38):
That's the one of the hardest things about even let's
just take our friend estradal. We have six different doses
of patches, three different doses of oral pills. We have
three different four or five six different oral pills to
choose from. But we've got a patch, but we've got
to patch it as a combination patch and a regular patch.
Oh but now we've got this weird spray thing. Oh,
we've got a ring like there. To us, we know this,

(26:01):
we know these therapies like the back of our hand.
But to somebody who's not, it's but most of this,
most of how you get good at this is just listening,
trying listening, how did that go?

Speaker 5 (26:14):
How did that work?

Speaker 6 (26:16):
And not being afraid to not to not to seem
to flippant about it, but to play around a little
bit and to have this co creation, make this partnership
with your patient and trust women that they know their
bodies enough to be able to tweak doses here and there.
And these are really hard concepts for those of us
that are trained in a traditional medical model where we.

Speaker 3 (26:39):
Tell them this is what you have to do.

Speaker 5 (26:41):
You are very uncomfortable for us. Yeah, like it.

Speaker 4 (26:44):
Is your partners Yeah, like right, And so when You're like,
I'm a partner with you.

Speaker 3 (26:51):
They're like, what feeling off in midlife?

Speaker 4 (26:54):
I'm doctor Becker Hurdle, and I offer concierge telemasine across
multiple states focused on hormones, eight, libido, ands and longevity.
Let's get you thriving. So visit www dot aopathicmidlife health
dot com.

Speaker 5 (27:06):
Yeah right, it's wells really hard concept.

Speaker 1 (27:10):
We see some of the doctors in academia, right, and
they say, but the studies, the studies, the studies, the
studies don't show this. The studies don't show that. And
our point is, well, we're seeing patients, and our patients
are coming back telling us the same things over and
over and over, past twelve weeks, past that placebo period,

(27:32):
months and months down the road. And so are we
supposed to not trust our own clinical experience and expertise
and our patients. So we shouldn't trust what our patients
are telling us. We should only trust what these small,
tiny studies have shown, many of which are years old.
Is that what you're saying to us, no, medicine is
an art and a science, right. It takes all of

(27:55):
us to give us the information that we need. And
it's driving me a little bonkers on us lately with
some of the peeps in academia saying, no, don't trust
your patients, don't trust your experience. Just go buy these guidelines,
Go buy these papers. Does it bother you, guys as

(28:17):
much as a pope?

Speaker 2 (28:19):
I mean guidelines people, you know, providers act like guidelines
are laws because they're afraid to be sued, and they
don't protect you from being sued. Being nice and listening
to your patient that protects you from being sued. Right,
And you know, if I don't even think you could
put midlife care in a good guideline because there are,

(28:40):
like as Jackie said, so much individuality and so much choice,
and it depends on what you know your patient wants.
But you certainly are not going to optimize their hormones
and get them feeling their best if you put yourself
in a little box of this is the only things
that I can do. I mean, boxes on guidelines are
really small. It means there's not a whole lot of variability,

(29:02):
there's not a whole lot of choices.

Speaker 5 (29:05):
No, I think, and we get so.

Speaker 6 (29:09):
Yeah, I mean I think we've gotten ourselves in And again,
this is not just one reason why we're in a
space like this where we've got a big hill to
climb to get ourselves. There's multiple different layers, like the
societal context, right, the the differences in philosophy, you know,
medical philosophy, right, Like we don't all agree. Like what

(29:31):
other area of profession does everybody agree all the time?

Speaker 5 (29:38):
Like how many?

Speaker 6 (29:39):
That's the whole practice of law, right is that like
the law is the law, but the interpretation of the
law might be different depending on who you are saying
for other business, economics, all these other professions, Like I
don't know that it is is so taboo for people
to be like, yeah, I have a different opinion than you,
or I have a different view. But for whatever reason,

(30:00):
when it comes to medicine, these medical guidelines are thought
to be some frickin type of like Rosetta stone, and
there's only there's no way to read between the lines
or to like apply it in a real world setting.

Speaker 5 (30:12):
That's another thing that I always tell my patients.

Speaker 6 (30:14):
I'm like, I love randomized clinical you know, randomized controlled
clinical trials. We love them because essentially, you take a
placebo and you take an active pill and you give
it to somebody and you see if it works. But
these are petrie dishes. People don't live in petrie dishes, right.

Speaker 5 (30:31):
Like we have. You know you're being watched, you're coming
into the office, you know you're in a clinical trial.

Speaker 6 (30:37):
You don't just like you don't just get like a
secret like serum injected into your body that you magically
forget you're in a clinical trial. Like, there's influences on
these these as well. That's why studies have limitations and
certain things in they're analyzed. So that's the whole point
of these clinical trials is for us to take the

(30:57):
information that we learn within these clinical trials and then
apply them right to a real world setting. That's the
whole practice of medicine. So I don't understand why we disagree.
Why there are such you know, contrasting thought.

Speaker 5 (31:15):
It's like schools of thought going on right now.

Speaker 6 (31:17):
It is really infuriating, a fa to your point, it
does make you feel a little bit like create like
you're living in a twilight zone a little bit.

Speaker 5 (31:24):
Sometimes.

Speaker 1 (31:25):
Yeah, I did hear a doc suggests the other day,
you know, we could do a study on giving women
vaginal estrogen and giving them a placebo and then doing
a trial on that to see if that cut down
on things like UTIs. And I was thinking, but a
woman would know within a week or two that she
was on a placibo is so amazing, she would still

(31:45):
be having all her symptoms. There's no way she'd keep
putting vaginal estrogen in twice or three times a week
and not working. You know, Like there are limitations to
these randomized placebo control trials that we can do. And
then there's ethics involved as well. Is it ethical to
give a woman a placebo when you know you have
a medication that can protect her heart and protect her

(32:09):
bones and everything. So there's ethics and morals involved as well.
And again, if we wait for all of these studies,
these perfect studies that are never going to be fund
and are never going to happen, will all be dead?
Will all be long dead? So will our patients.

Speaker 6 (32:23):
Yeah, well, there's certain things that we just don't need
studies for, like we already like we know these truths, right, what.

Speaker 5 (32:32):
Harm partner control?

Speaker 6 (32:35):
A trial of vaginal estrogen for UTI? Who can we
know the answer?

Speaker 3 (32:39):
Yeah?

Speaker 1 (32:40):
And if there's one more national estrogen work for does
it get absorbed into the bloodstream? It's going to lose
my mind. There must be three hundred studies on that
now about absorption of estrogen into the bloodstream, and we
know the answer, like, please stop spending our money on that.

Speaker 4 (33:03):
You know, Like I was saying, I think a lot
of it. I wonder with some you know, of the
clinicians that are on one side and the others on the other.
If again, it's it's being afraid to partner with your patients, right,
so you know, it's not like a paternalistic relationship. We're
partnering with them. We're helping them. We're giving them all

(33:25):
of the information and knowledge that we have our opinion
aside unless they ask for it, and you know, in
hopefully an unbiased way, and saying I mean every single
day I see a patient, I say, you know, what
are your thoughts?

Speaker 3 (33:40):
You know, what are your thoughts?

Speaker 4 (33:41):
I want to because I truly want to know what
their thoughts are on this?

Speaker 3 (33:44):
What do you want to do? What are your thoughts
on this?

Speaker 4 (33:46):
And I can tell you every day at least one
person is like, what do you mean you're the doctor?

Speaker 3 (33:52):
No I am. I mean I'm here to help and
to facilitate you.

Speaker 4 (33:55):
But you know, and I'm going to give you all
the information that you need, but you know, we need
to be partnering with patients and giving them the tools
to make these decisions for themselves, because when they have
all those I do agree, and I know it's been
said so many times they can make really great decisions
for themselves when they have all of the information. And
I just wonder if some of that is that old

(34:16):
way of thinking of like, I'm supposed to tell you
what to do, and these are the guidelines and that's
the law, instead of here are the guidelines, is what
we go by. These are options, These are off liable options.
We are in a partnership together, and let's make this
decision together.

Speaker 3 (34:33):
What are your thoughts.

Speaker 1 (34:37):
Do you find, Jackie, that by the time a patient
comes to you, they've already seen quite a few other providers.

Speaker 6 (34:46):
You know, I think it's the nature of my practice
is not within an insurance based model anymore, and so
I do feel like by the time most of my
current patients have come to me, they have that exhausted.
Are options within an insurance base model of care. So
most of the time I am, you know, the second
or the third or the fourth opinion, but it's not

(35:07):
always true. They're not always coming from the insurance base model.
Sometimes they're coming from again the grifters and the pellet
mills and the wellness practices, which again, not all wellness
practices are bad, but some are unfortunately ill informed and
are taking our patients down roads that frankly just are unnecessary.

(35:30):
So I do I get a lot of second opinions now.
Prior to opening up my practice three years ago or
two years ago, I worked in an insurance base model,
so I did menopause within an insurance and I always
say I'm the unicorn. I'm the nurse practitioner that was
hired a gyn and OBGN practice.

Speaker 5 (35:50):
To only focus on menopause.

Speaker 6 (35:52):
My physician bosses weren't breathing down my neck to see
the pregnant patients and the wellness exams, and like, I
literally had to go ask the manager let me do
wellness exams because my menopause patients would get so attached
to me they didn't want anybody else to do their
wellness exams. So I would say, okay, one day a week,
I'll do wellness exams and like iud's and like general stuff.

(36:14):
But that's that's a unicorn. You can't get higher. I mean,
I remember when we moved. My husband's in the Air Force,
so we move and we moved from where I was
living in Arkansas, where I had my job as a
menopause NP within a big objo in practice to Atlanta,
and I started interviewing at a couple of OBEDUI N
clinics in the area and I'm like, yeah, I'm going

(36:37):
to you know, women's health NP, but I do menopause
care and I've been doing that exclusively for the last,
you know, the last many years.

Speaker 5 (36:46):
And so many people just laughed straight in my face.

Speaker 6 (36:49):
They were like, absolutely not, No, we control your schedule
and you have to see everything and everyone. And so
again this goes back to kind of like the systemic
issues right as that insurance based obgin care is there's
so many demands, There's so much and same for family
practice physicians, internal medicine physicians.

Speaker 5 (37:08):
There's so many demands that fall on our plate.

Speaker 6 (37:11):
I think this is why a lot of us are
sort of picking ourselves up out of that model and
going into these these different practice environments because of that.
But a lot of my patients, even in that insurance
based model. If I would, I would get a lot
of a lot of second opinions, or I would get

(37:34):
people that already had gynecologists and sort of had their
well woman exam with their kind of cologists and sort
of knew like they weren't going to get very far,
and so they would keep their gynecologists, and then they
would just they knew that I only did menopause care,
and so they would make an appointment with.

Speaker 5 (37:51):
Me for that. And that's just kind of how that lived.

Speaker 6 (37:54):
But that is not a typical That is not a
typical thing that exists.

Speaker 2 (38:00):
I mean most Yeah, when I was in private practice,
it was the same time I really started being focusing
on midlife and menopause care. And the only way that
I could work it was to see the last patient
before my lunch and the last patient of the day,
which meant I never got lunch and I always left

(38:20):
late because it required more than the traditional fifteen minutes
or twenty minutes appointment time.

Speaker 6 (38:27):
Yeah, you know, well, and that's the part I left
out too. I mean, we were paid, we you know,
not to get to and much. But I think it's
important for people to understand the economics of this right.

Speaker 5 (38:38):
Like why this is the way it is.

Speaker 6 (38:41):
And you know, my colleagues there were I had seven
physician colleagues and ten advance practice colleagues, so nurse practitioners
and physicians assistants, and we were paid the advance practice
clinicians were paid a salary based on an hourly rate.
We were paid a salary, and then we were bonused

(39:02):
as a percentage of that are our revenue.

Speaker 5 (39:05):
So what we brought in and we were we were
given or not given.

Speaker 6 (39:08):
We were entitled to a percentage of what we made
above above our of our salary. And guests who didn't
bonus the person that was only seeing the menopause patients
because a you can't see as many patients because the
appointments take longer. Even if you're trying to rush it
through an insurance based model.

Speaker 5 (39:29):
You just can't.

Speaker 6 (39:30):
I mean, when a woman sitting in your office crying,
you can't, Like it's just you just can't. And so
we saw less patients. We didn't do procedures. You make yeah,
you make money in medicine off of procedures and certain
billable codes and and so that's a big This is
a lot of people say, well, Why is my person

(39:52):
not not going to get trained on this?

Speaker 5 (39:55):
Why are they not motivated to do more of this?

Speaker 6 (39:59):
Or or why are all all of you people abandoning
ship to only take cash.

Speaker 5 (40:02):
And it's like.

Speaker 6 (40:03):
Because the maths doesn't matter, and it's unfortunate, it's really.

Speaker 5 (40:09):
Broken, and I don't have the answers.

Speaker 6 (40:12):
I don't have a master's in business administration or degree economics.

Speaker 5 (40:16):
I don't have the answer. That's why we brought you one.

Speaker 1 (40:20):
Sorry, you're gonna have to get in a.

Speaker 6 (40:24):
Well. Yeah, I think it's idiots frustrating because I've lived
both worlds, right, I live the concierge medicine world now,
and I've lived the insurance based model.

Speaker 2 (40:33):
And even in our you know, concierge model, all of
us have pivoted a little bit in how we you know,
in our pricing structure and the way that we set
up our programs and delivery, you know, all of us
starting originally with fee for service and then pivoting to membership.

Speaker 6 (40:57):
You know.

Speaker 2 (40:57):
I I think that's something that boats some discussion because
I think, you know, patients are a little surprised when
we're you know, when it's a you know, monthly membership
fee and why we chose to set up things like that,
which you know, truth be Told is a little bit
more expensive than the feed for service. Jackie, what are

(41:20):
your thoughts on pivoting to a membership model and what
did that do for your patients?

Speaker 6 (41:26):
Of course, I think anytime you talk about right, it's
like the standard stuff is like you don't talk about religion, politics,
or money at a party rate. That's all the good
manners that we learned from our parents and our grandparents.

Speaker 5 (41:37):
So it's always awkward.

Speaker 6 (41:38):
Talking about money and financials and things. But you know,
it's a business and at the end of the day,
we have to remain as intact we're human, right, healthcare
workers are human and I think we saw right the
extent of how we could push ourselves in the pandemic
and what that did to many of our call leagues, and.

Speaker 5 (42:02):
Just that we are human and burnout is real.

Speaker 6 (42:05):
And you know, even if you are in a cash
based model, it doesn't mean that you're immune to being
burnt out. I think we most people in healthcare are
impaths at heart.

Speaker 5 (42:16):
We are givers. We want to take care of others, I.

Speaker 6 (42:20):
Know, and no shade on my doctor colleagues here, But
you know, nurses at our like are really notoriously terrible at, you.

Speaker 5 (42:28):
Know, doing things at the expense of themselves.

Speaker 6 (42:31):
And then women we are like notoriously awful at doing
the expense.

Speaker 5 (42:34):
I think that's why the.

Speaker 6 (42:35):
Female physician burnout is worse than male physician burnout, because
we take it home with us. We don't let it go,
and it doesn't It's not like water off a ducts back.
I think generalizing here, but a lot of our male
colleagues are like, if I know you've said this about
your husband, like he would like, it's the emotion is
just less right. We get very emotionally attached. And so

(42:58):
what a lot of people don't understand is that it's
unique about menopause care and why probably a lot of
people roll their eyes at menopause caare and don't want
to get involved in it is because there's a lot
of care that happens behind the scenes and outside of
that directing counter right, And I think Christine, that's kind
of what you're highlighting on is why so many people
are pivoting to a member shape ship based model because

(43:18):
so much of it happens outside of that fifteen to
twenty to an hour long amount of time, and there's
only so many messages on a patient portal that you
can answer having good attitude before you're just over it.
And as much of a good of a person as
you are, or much well meaning as you are. I mean,

(43:39):
at the end, there's so many hours in the day.
We all get twenty four hours. That's so again, this
is an evolution. I think we're all One of one
of my best friends is a physician assistant or associate colleague,
Christina Saldana, and she said, I remember when I talked
to her about my business model, and she's mentored me a
lot through this, and she said, Jackie, we're all just putting,

(44:00):
you know, assembling the car while we're driving it, you know,
like putting it. You're all putting it together while we're
driving it, trying to figure this out.

Speaker 5 (44:06):
And because we were all trained and brought.

Speaker 6 (44:10):
Up into the medical field within this insurance based model,
we don't know how to do this. We're not business
people unless you've got a business degree along with your MD.

Speaker 5 (44:19):
Some people do. We don't learn how to be entrepreneurs.

Speaker 6 (44:23):
And I think that's why you're seeing this move from
physicians either going physicians and advanced practice clinicians going to
kind of what we have done in this small, mom
and poppy kind of like concierge based model, or we
are just cogs in the machine and going to large

(44:44):
privatized hospital based systems and we just go and punch
the clock and we leave, right. I mean, that's what
medicine is turning into.

Speaker 1 (44:55):
I was shaking my head there when you brought up
my husband, not because of my poor husband, but because
of that topic of the difference being in medicine is
between being a woman or a man in this field
of medicine, right, it's very difficult, Like these studies have
been done. Patients expect more from more empathy, more time

(45:16):
from a female clinician than they do from a male clinician.
My husband has been in medicine the same amount of
years as I have, and no one's ever called him Dave.
They always refer to doctor Cosgrove, so do all the staff,
whereas I'm often referred to as EFA or you know

(45:36):
other things. And yeah, it's just there's a stark difference there.
They were saying, you know, the burnout rate for and
I hate that word as well. I know we all do.
But like that moral injury or or rate of burnout
is so much higher for women than it is for
men because the expectations are so different, which is not fair, Ymie.

Speaker 6 (46:01):
Is this yeah, well, and it's it's the mentality rate
that if you if you are aware of your value
and you ask for that in dividends financially, then you're
not a good person, or you're doing something wrong, or
you're taking advantage of somebody else. And so these are
these are all very difficult concepts that we all. I mean,

(46:22):
I remember when I first went in to start my bid,
I mean and I charged like one hundred and not
nowhere near what you know, what I ask for now,
And I remember sitting in this exact chair like bawling
my eyes out, and my husband just being like, what
the f Jackie, Like, what is wrong with you? He's like,
no emotional attachment to this. He's like, you're offering a service,

(46:44):
You're providing a service. This is and but again this
is not this is We are in a very troublesome
environment because the insurance space model has totally built a
Ponzi scheme out from under us, and we have just
all been led to believe that that is the way

(47:05):
things are done. And so how we get ourselves out
of this pickle? I don't again if I don't have
the answer, but it's hard, it's all very difficult, challenging concepts.

Speaker 5 (47:14):
But I do think that for those that we can.

Speaker 6 (47:22):
Partner with and take care of, and you know, we
can sort of pass that on in other ways. So right,
there's through these podcasts, or through social media presence, or
even through educating those individuals that are our patients, and
then they can go back, you know, tell their friends
and their friends can go to their insurance space. And

(47:44):
the more we hear it, the more it gets sort
of force fed down their throats.

Speaker 5 (47:48):
We'll get there. And that's why we can't be deterred
by this.

Speaker 6 (47:51):
We just have to continue to be obnoxious and be loud.

Speaker 5 (47:57):
There's other ways to kind of contribute.

Speaker 6 (47:59):
I think again, I can't be of much help if
I'm not around because I allowed too much of myself
to be expended.

Speaker 1 (48:07):
Along the way, And you leave altogether outside the realm
of medisone do you? What do you do in your
spare time?

Speaker 5 (48:16):
Jackie?

Speaker 6 (48:18):
So my doctorate program robbed me of a lot of
my hobbies.

Speaker 5 (48:25):
Graduate Jackie, Yeah, what when do you graduate?

Speaker 6 (48:29):
Like, I am, well, we don't graduate until September because
it's a weird, like they do one graduation a year
because they have rolling admissions, so they graduate all of
us at the same time. But I am done in
like three weeks, thank god.

Speaker 2 (48:42):
Yes, yes, so yes, yes, and then begins huh and
then your fun time with you go back again.

Speaker 6 (48:52):
So I went to hot yoga this morning, so that
was exciting. So I love I Actually, in my past
life was a yoga teacher, so I love to do yoga.

Speaker 5 (49:02):
I love to guarden.

Speaker 1 (49:05):
When was the yoga teaching? Was that a college or
Laton for punishment?

Speaker 5 (49:10):
It probably was during COVID. It was during COVID.

Speaker 6 (49:13):
Yeah, I probably got certified as a yoga teacher in
twenty twenty twenty.

Speaker 5 (49:20):
Nineteen twenty twenty.

Speaker 6 (49:23):
Because I can't just like go to a yoga class
and then not be like I want to learn all
the things about this and then go to a training
and all the things.

Speaker 5 (49:31):
Like we can't just like be normal, right, So.

Speaker 2 (49:34):
That means when we go to the Menopause Society meeting
in October, you and Rachel Frankenthal need to need to
have a class where you guys.

Speaker 6 (49:45):
Yeah, yeah, so I have a yoga quote unquote, so yeah,
that's I don't have a ton of hobbies. I like
to travel and go places with my family and Christina
and I bond over our Golden Retrievers, even though it's
not a hobby.

Speaker 7 (50:00):
But if you you know, there's a lot of pages
of videos, and.

Speaker 6 (50:06):
Yeah, I like to drink wine, although perimenopause has not
been very friendly to me in that hobby.

Speaker 7 (50:13):
It's not dogs, Jackie, you dogs or somewhere else they
were barking the wine fiasco.

Speaker 6 (50:24):
Oh there's always wine everywhere. That's why we can't have
nice things. Because their tails just knock things off tables
all the time.

Speaker 1 (50:32):
And your girls keep you right, you two little.

Speaker 6 (50:35):
Yes, two little girls who give me great hair, run
and all the time.

Speaker 1 (50:43):
Yeah yeah, so yeah, every every five weeks with mine.

Speaker 6 (50:50):
Yeah it is you know, we're all just trying to
get through, right, I know, yes, and uh yeah.

Speaker 5 (51:00):
I'm not super fun. I wish I had more fun.
Everybody always asks me, what are your hobbies? What do
you do?

Speaker 1 (51:04):
I'm like, oh, I'm the same.

Speaker 3 (51:06):
Yeah, I wanted to Yeah, a lecture. I was like,
I listen to a new.

Speaker 5 (51:11):
Lecture and I'm like, I like to make ower point
can touched me.

Speaker 6 (51:18):
I was a kid that like during grade school when
you were like, you need a threefold poster board to
make a project. And I was like, I know, I'm
really creepy, but no, I know.

Speaker 5 (51:30):
It is weird when we love our job, right, we
love we love what.

Speaker 1 (51:33):
We do, and so yeah, we're total nerds, totally.

Speaker 4 (51:38):
I'm always texting them. I'm like, I totally nerd it
out over that lecture.

Speaker 3 (51:42):
It's so good.

Speaker 2 (51:45):
Yes, all the time. She listens to everything on one
point one.

Speaker 3 (51:49):
Point discuss So.

Speaker 2 (51:52):
I never finished it.

Speaker 6 (51:58):
Yes, yeah, but.

Speaker 1 (52:02):
Well it was great having you Jackie.

Speaker 5 (52:04):
Yes, it is great. This is a great conversation. No,
that was such dynamic and a little bit controversial.

Speaker 6 (52:14):
But I do think it's important to talk openly about
this stuff because I feel like a lot of us don't,
and it's kind of why we ended up in this
in this place in the in the beginning.

Speaker 5 (52:25):
Right.

Speaker 1 (52:26):
Yeah, I was gonna say, we've been so busy with
our back turn taking care of Patience that all this
other stuff has happened while we've been doing that and
now we have no control over anything anymore, and we're
just cogs in the wheel.

Speaker 5 (52:41):
Yeah.

Speaker 6 (52:41):
Yeah, we're gonna take medicine back. It's ours, yeah, taking
it back, So.

Speaker 3 (52:47):
We have to take it back. We spend a lot
of time in it for sure.

Speaker 1 (52:51):
Well, it's great having you, Jackie, Thank you so much.

Speaker 5 (52:54):
Yes, Lady Sunday.

Speaker 1 (52:57):
Yeah, bye Jackie. Thanks by eh