In recent years, there has been a massive increase in medical practitioners offering hormone therapy to patients. Since insurance doesn’t cover these treatments other than for very specific medical conditions, most patients end up paying cash, leading to big profits. These treatments are usually promoted as “wellness” products, intended to make patients feel younger, stronger, thinner, and just all-around better. But the truth is that there is no clear evidence hormones cause these benefits, and when used improperly, hormone therapy can cause serious risks to patient health, and even cause death.
Today we are joined by Dr. Joyce Varughese, a gynecologist oncologist. As a doctor treating women with gynecologic cancers, she has seen serious harm caused by patients from using unapproved therapies and is here to share important safety information for patients. Dr. Varughese, welcome to the show!
Get the book!
https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/
PhysiciansForPatientProtection.org
In recent years, there has been a massive increase in medical practitioners offering hormone therapy to patients. Since insurance doesn’t cover these treatments other than for very specific medical conditions, most patients end up paying cash, leading to big profits. These treatments are usually promoted as “wellness” products, intended to make patients feel younger, stronger, thinner, and just all-around better. But the truth is that there is no clear evidence hormones cause these benefits, and when used improperly, hormone therapy can cause serious risks to patient health, and even cause death.
Today we are joined by Dr. Joyce Varughese, a gynecologist oncologist. As a doctor treating women with gynecologic cancers, she has seen serious harm caused by patients from using unapproved therapies and is here to share important safety information for patients. Dr. Varughese, welcome to the show!
Get the book!
https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/
PhysiciansForPatientProtection.org
Welcome to'patients at risk' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard, and I'm joined by my co host and the co author of our book patients at risk the rise of the nurse practitioner and physician assistant in healthcare. Dr. Niran Al-Agba.
Niran Al-Agba MD:Good evening.
Rebekah Bernard MD:In recent years, there has been a massive increase in medical practitioners offering hormone therapy to patients. Since insurance doesn't cover these treatments other than for very specific medical conditions, most patients end up paying cash leading to big profits. These treatments are usually promoted as wellness products intended to make patients feel younger, stronger, thinner and just all around better. But the truth is that there is no clear evidence that hormones for wellness really cause any of these benefits and when used improperly. Hormone therapy can cause serious risks to patients and can even cause death. Today we are being joined by Dr. Joyce Varaguese, a gynecologist oncologist, a doctor treating women with gynecologic cancers. She has seen serious harm caused to patients from using unapproved therapies and she's here to share some really important information for patients. Dr. Varaguese Welcome to the show.
Joyce Varaguese MD:Thanks so much for inviting me.
Rebekah Bernard MD:can you start us off by just explaining what a gynecologist oncologist is?
Joyce Varaguese MD:Sure it's a long term. And so basically gynecologic oncologists we take care of women with cancers of the gynecologic organs. So that's the uterus, the cervix, ovaries, the vagina and the vulva. We also often take care of women with pre cancers also of the cervix, the vagina, the vulva, sometimes of the uterus or something called hyperplasia when it's in the uterus. In order to become a GYN oncologist. Essentially, after medical school you do four years of an OB GYN residency, and followed by three to four years of a gynecologic oncology fellowship. After that, essentially, to become a board certified gynecologic oncologist, you have to take two standardized written tests, and two standardized oral exams because we are board certified in both obstetrics and gynecology as well as Gynecologic Oncology.
Rebekah Bernard MD:When I'm sending my patients to gyneco-oncologist, because they have either cancer or I'm suspicious of cancer, I usually tell them, these doctors are just about the best surgeons that you can possibly find, because you guys have been trained to operate not on normal anatomy will that as well, but on people who have really distorted anatomy because of these kinds of cancers, and so you really have to be really good at what you're doing. That took a lot of training to get to that point. So I applaud you for going through all of that. And thank you for what you do for patients.
Joyce Varaguese MD:Thanks so much.
Rebekah Bernard MD:Are you seeing a rise in women coming to see you because they have been prescribed some of these hormone therapies? Or what are your thoughts on hormone therapy as used for wellness?
Joyce Varaguese MD:Sure. So just for everyone who's So I have a couple of questions. And I'm going to go from the listening, I am a gyn-oncologist and I, I prescribe hormones for my patients. I think that hormone replacement therapy is a crucial piece actually, in improving women's quality of life, even after cancer treatment. So there's a lot of data out there on hormone therapy, there's many benefits for heart health, for brain health, for bone health, and for quality of life. So I'm not an anti hormone doctor by any means. However, I am anti non evidence based treatments and things that are promoted as wellness or preying on women's insecurities are not a great word. But it's sort of you know, as women age changes occur naturally. And what I think is really important is that women understand that these are natural changes that occur. And there are evidence based treatments that can help that. Now what my issue is with is when people who don't need these hormones are then advertised. As you know, you can feel better with these quack therapies truly. So one of the things that I've seen, and to be honest with you, I only saw it recently, like in the lot within the last four to five years, when I was in training, I actually had never encountered these pellets that are being inserted or they're being advertised. And what's really scary about these pellets, though, is number one, some of them just have estrogen or advertises just having estrogen. Some maybe have estrogen and progesterone, some have testosterone and estrogen. It's sort of really like Russian roulette as to what you're getting or what's being advertised and what's being given. And what they are just a small little like kind of almost like a grain of rice pellet that's introduced into like the buttocks muscle by these practitioners who were offering them. And these are not paid for by insurance, so women are paying out of pocket. But why I see these patients is because they then develop hyperplasia or pre cancers of the uterus, and in some cases, actually cancers of the uterus. Because the uterus needs both estrogen and progestin. thrown, progesterone essentially kind of stabilized in a very simplistic manner, um, stabilizes while estrogen leads to growth of the lining of the uterus. That's a very simplistic overview of the hormones of how they affect the uterus. But what's important to know is that a lot of women will say, Well, I didn't get any estrogen called I just got testosterone. But testosterone gets converted to estrogen in the fatty tissue. So as I discuss it with patients, I say that it's sort of like why when you see really overweight men, they look like they have breasts, right? Like our man boobs is like kind of the layman's term, right? That's not just fatty tissue, that's actually their testosterone getting converted to estrogen in the fatty tissue and stimulating their breasts to grow. So I have discussion on this discussion on a daily basis with my patients with uterine cancer, because obesity is a risk factor for uterine cancer. And so I talked to them about how testosterone gets converted to estrogen. But in terms of these hormone pellets, this testosterone that we don't know how much is in them, we don't know if there's any estrogen in them there. We don't know if there's any progesterone stabilizing the uterus, stabilizing the lining of the uterus. And so it can lead to these, this overgrowth leading to pre cancer or cancer. And that's how they then come to me in the past several years that I've, unfortunately, been treating these women who really, I would never have needed a hysterectomy. I mean, then they need surgery, which has its own risks, and then potentially close follow up if they did have a cancer. dumbest question to probably then the more informed questions as we go along. I'm a pediatrician, so nobody's doing any pellets in anywhere in my practice, just to be fair here. So could you say that again? Like I remember Suzanne Somers used to do something funny with estrogen, right? And she used to either topical or put it in her vagina or something.
Rebekah Bernard MD:She was the one that started that whole bio identical hormone. And she or she popularized it.
Niran Al-Agba MD:Is this different? Like, I actually have no clue. I've never heard of pellets? And I'm not sure where you just said they put them but I think that's the the dumb part of my question that I need you to answer before I can ask you, the more. So could you explain this pellet thing is I'm completely lost.
Joyce Varaguese MD:So literally, if you Google, like hormone pellets, depending on the person who is providing them, so there are some where they say that they specifically compound them and make your check your hormone levels and do a whole bunch of tests. And they specifically personalize that I am a big fan of personalized medicine, I think, you know, it's actually the future of cancer treatment. Right? But so they basically personalized, whether you need a touch of testosterone a little more estrogen, and maybe like, you know, a medium dose of progesterone, you know,
Rebekah Bernard MD:and that's not really something that they can really determine, right?
Joyce Varaguese MD:No, and nobody can, right. So like, I mean, in the sense that they can say that they're giving anything to you and there's no accountability, right? Nobody can hold them to like, yes, they, they put this much into that pellet, and now they're inserting it. It goes into the usually it's the buttocks muscle. So the gluteus for you know, for those medical folks who are listening injection, it's, it's inserted sided, like kinda in the subcutaneous tissue.
Niran Al-Agba MD:Oh, okay. Okay, sorry. I got it. Yeah. And who who's making them? So I'm assuming when you say, Okay, let's just say it's a third testosterone, two thirds, estrogen, just for simplicity sake, is there a person that's writing for a compound part pharmacy to then make what their? I mean, how could you explain that a little,
Joyce Varaguese MD:though, again, so there are companies that make kind of standardized pellets, I guess, if you want. And then there are this I actually recently learned, because I literally googled and I found like certain people who make their own like create their own compounded formula.
Niran Al-Agba MD:So not regulated then by say, a standard compounding pharmacy or anything along those lines. No, so no one is overseeing this. Is that what I'm understanding?
Rebekah Bernard MD:Yes. And then the other thing around is once they're in, they're in, you can't just take it out because it starts to dissolve. And plus, you know, how would you even find it necessarily, it's not like when you get the Nexplanon on your arm for birth control, then you can take it out. It's a little rod. These pellets just are meant to dissolve and you can't find them. So now they're supposed to last I don't know how long like what months at a time or something.
Joyce Varaguese MD:The ones that I've seen have been anywhere from three to six months that you're supposed to read.
Rebekah Bernard MD:So it could be a whopping dose and I actually had a patient of mine-I know a little bit about this only because one of my patients came to me after a pellet. She was having ridiculous vaginal bleeding, and then it turned out she had endometrial hyperplasia, which is a precursor to endometrial cancer. She actually did not have any health insurance, so she was seeing this practitioner and paying cash for it. Then she comes to me I'm a DPC doctor. So I take care of a lot of people without insurance. And I say to her,'Listen, this is not okay. This is not good. You cannot have this kind of bleeding. You know, you're 55 years old. We have to get this checked out.' So now she has to come up with money to go see a gynecologic oncologist ended up having to have I think she had to have a D&C or something like that and end up costing her quite a lot. money. But it was all because she was seeking this, like wellness and vitality and that sort of thing. And I don't think she understood the risks that could have happened.
Niran Al-Agba MD:And can I ask one more kind of dumb question, again, from the pediatrician in the room here? Why not just go on birth control pills? I mean, I'm only suggesting that I know, like, my mom went through menopause. That's my big experience, right. And my dad was an endocrinologist. So I've got some knowledge here. But, you know, she was on an estrogen patch for years, because she said her hair was more full, she had less bone loss, she just felt better. And it was it was regulated by her regular MD physician and in some sort of lower dose. So I mean, why not just do the standardized thing like that, then you are getting estrogen and progesterone, like you said, in a little bit more of a physiologic way.
Joyce Varaguese MD:I think a lot of that is because the public wants these bio identical or more natural forms of things. But absolutely, you know, like I said, I am not anti hormone in any way, shape, or form, I prescribe hormone replacement therapy all the time for my patients. And there are FDA approved, regulated forms of it. And there are multiple different forms of it. In fact, there are even forms of testosterone that are approved for women. It's not that those aren't available. It's just that again, it preys on the public's perception that these are more natural in some way or more these bioidentical hormones, and again, there's just really no data suggesting that those have any less side effects or any greater benefits than using the ones that are FDA approved.
Rebekah Bernard MD:But can you clarify this whole bio identical versus synthetic at all shed any light onto that and help patients understand that really, the prescription medications are probably safer, better, more monitored than something that somebody's just kind of whipping up themselves?
Joyce Varaguese MD:Right, exactly. So I mean, I mean, you you said it Dr. Bernard, right. So it's really that I mean, I could go to my kitchen right now and whip something up and say it's bioidentical and sell it, right. Like, I joke around I'm gonna like, when when insurance companies puts me off and like, on approving things I like joke around with my staff. I'm like, I'm gonna hang a shingle saying Joyce Varaguese, MD naturopath, or like cash only because sometimes, like I get it, you know, like I just in good conscience would never do that, right? Like, but I could whip something up and say, I'm selling bioidentical stuff for you. And I mean, could be some herbs from my garden.
Niran Al-Agba MD:I ask you what your patients say to you. So you know, you get a new patient they have let's just go with endometrial hyperplasia, because that is something that a lot of people are familiar with bleeding after certain age, etc. And usually precancerous are indicative of cancer. So what do they say to you, when you say, Wow, I suspect this that you've been doing with whoever you've been doing it contributed to this, like, what did they say to you?
Joyce Varaguese MD:So I have to say like, so most patients actually are not even aware of the risks. I actually, just recently, within the last two months had a patient this exact the exact scenario, you just said that she had really no other risk factors for developing uterine cancer, and had been taking these pellets and all and so she was very receptive to what I said. And she said, Look, do I need to report this, she was actually one of my only patients, I said, Is this something I didn't report or anything, but she had not been made aware of the risks of it. So whether this is all placebo effect, or probably not, because there is some hormone in it, because it's changing the the lining of their uterus, right for some of them. So they feel better on it, probably because they're getting some estrogenic effect. And they would feel better if they were on, you know, any sort of estrogen or, you know, hormone replacement therapy. So some are receptive, like this most recent patient, others are like, you know, the folks who are selling these things are very, I find are very charismatic, very, I want to say I have an hour to sit with the patients and kind of listen to them, but really are selling them a product, right? And so people like that, right, in a sense, like they feel like they're being listened to, they're getting this whole personalized approach to their symptoms. But to be honest with you, you know, there's a lot of data that yoga helps with menopausal symptoms, right. There's a lot of other things that are including hormones as well. But you know, there are a lot of other ways that women can manage the symptoms, but they you know, that require a bit more effort than just going and getting a pill or getting a patch or getting a pellet.
Rebekah Bernard MD:What you say makes so much sense to me when you talk about how well first of all people are, we're always looking for something to make us feel better, especially in today's day and age. You know, we're so stressed about everything we don't eat, right? We don't sleep, right. So you know, I want something that's going to make me feel better. So we all would like something and we may just be a little more susceptible to falling for those sales tactics, because we really want it to be true, and we want to believe in it. But the other thing that is a good point is that they have time to sit and talk. And doctors often do not because especially if we work in a system where we only have seven to 10 minutes with each patient patients aren't going to feel as listened to and heard. So I think that's just a problem with our broken system. And the other thing that you kind of alluded to the whole insurance thing. I see why a lot of doctors and non physicians are going into cash type practice. because they're so burned out with dealing with insurance denials, prior authorizations, that they're looking for some way to get out of that. And it's tempting, it's tempting, but it's not the answer, because this is not good for patients is not good quality care.
Joyce Varaguese MD:Exactly. No, absolutely. You know, I mean, you hit the nail on the head, right? Like, I completely understand why people are moving away from working within a system or taking insurance. Because, you know, like I mentioned, I bang my head on a wall, trying to get certain tests that are following national guidelines that I still can't get approved, despite me trying to talk with folks of the insurance company, but above all, do no harm, right, especially when there are safe alternatives. This really just doesn't make any sense to me.
Niran Al-Agba MD:So who's doing this again? Because I'm sort of like blind on this whole issue. I mean, is this MDS is this DOs? Is this non physicians? Is this naturopath like, who chiropractors like, who is doing this? Or who do you see in your practice? Who are they those patients seeing when they're seeing you for cancer?
Joyce Varaguese MD:All of the above. Essentially, truly, it's all of the above. So it's funny, because one of my first patients who really prompted me to look into this because I was like, What did you have injected? What like, what was that where, you know, and unfortunately, I found out that she that was being done by a Board Certified OBGYN. But if you again, if you just search, I mean, there are you don't have to really even have a medical degree to be doing this. You can be a nature path or a chiropractor, or just somebody who has access to these companies, and is one to solve them.
Niran Al-Agba MD:So have there been any sort of, I guess, investigations, or I can tell you in Washington state, there was this whole like thing in about 2013 to 2015, they took away the medical licenses of probably five to 10 Different doctors who were using human growth hormone for it sounds like bodybuilding, maybe or a couple of other ways. They didn't even show patient harm, although I know growth hormone also can be neoplastic. So we need to be careful of all those things. But again, they just they suspended them so merrily, these for three to five years probation. So is that's what is that what's happening where you are? Or is it just like this is an unchecked kind of thing going on?
Joyce Varaguese MD:I haven't heard of anybody losing their license for doing this, to be perfectly honest with you. And part of it is probably that they document patient counseled, while, you know, like kind of on potential risks, I really don't know. But I don't know of anybody who's lost their license because of it. And again, many people don't actually have licenses who are doing this. So what regulatory board Are you really going to report them to. And the other thing is, it's not enough to show that you've deviated from the standard of care in most states for a lawsuit to go to fruition, you have to also show evidence of harm and quantify that harm. And the issue is that some women develop uterine cancer, we never find a reason, like just completely sporadic. And so it's, it's really hard in the court of law to prove causation, you know, to really bring it to that point.
Rebekah Bernard MD:We had in our podcast some time ago, we talked about the case of Kevin Morgan, who was a nurse practitioner who was prescribing testosterone like crazy to men, and several of them died. And it took an incredible amount of effort to get his license removed. And I understand he's in the process of trying to get it back. And that was after we had deaths that were definitely associated with that. So I think it's going to be really hard to shut this down. And I think it's gonna be really hard for patients to get justice if they are harmed. And I think that's why it's really important to raise awareness about this. And patients need to ask questions, and really, they need to seek out obviously a physician and maybe even a second opinion, if they're not sure. And if something isn't covered by insurance, it's probably because it's either not considered standard of care, or it's considered experimental. And people really need to be skeptical about those kinds of treatment.
Joyce Varaguese MD:One of my colleagues, I was, I think, complaining to her in the car, because I was actually just patient about recently seeing who had the estrogen pellets. And I was like, I can't believe I'm doing this hysterectomy like could have been prevented. And she said that she had actually seen a patient who had had these pellets and had actually developed a micro penis basically, enlargement of the clitoris enough to cause like a micro penis because of the levels of testosterone she had been receiving. And she said that ever since then she brings it up to her patients who they asked her like I saw this person and I'm thinking about getting these. And that's something that's not just reversible in some ways, hyperplasia uterine cancer, almost not so bad. And you know, when you think about that, because that at least is curable with a hysterectomy as compared to growing a micro penis.
Rebekah Bernard MD:I didn't even think about that. Now, what I usually tell my patients is think about things that men get like hair loss, facial hair growth, you know, I say, you know, we had to think about those things. But now I'm going to add micro penis to that list of discussions.
Joyce Varaguese MD:Can I take care of women who have testosterone secreting tumors sometimes of the ovaries and you do see clitoral enlargement their voices get deeper they have like male pattern baldness, you know, testosterone secreting tumor at least once I remove that ovary and with that to work their testosterone levels normalize. I'm like we get that taken care of. But this is a pellet that nobody can dig out, like, you know, who knows how much longer they're going to have that testosterone floating around. So I when she told me that I was shocked, because I've never seen that. But one more thing in my armamentarium to talk to patients about,
Niran Al-Agba MD:and what's the thought, again, one last question about this kind of hypothetically, I know I have patients who've done topical right on their skin. I had, I had one case, this is quite a few years ago, were both kids that were like way pre pubertal developed breast growth, essentially, your gynecomastia. And I went through everything. And finally, the mom was like, Well, I do have this topical estrogen I'm using and I do snuggle the kids at night, but I wait, you know, like I put it on, I don't really understand all of it. But she put it on, and then she waited like an hour or whatever it was, well, clearly, some of it was rubbing off on the kids. So obviously, when I'm like, okay, stop that, you know, their breasts went away, you know, they were like, eight and six or something. And so again, what's the thought? I mean, just a pellet, just you don't have to put it on? Is that kind of a thing? You just instead of having to rub it on them?
Joyce Varaguese MD:I mean, it's like, you know, they're, it's good for like three months, right? It's sort of like, you know, a depo. Exactly, right. It's just like, you know, you do it and like you forget about it. It's like the IUD. It's like, you know, all of these longer acting things that you don't have to think about something every day or every week to remember to do.
Rebekah Bernard MD:And it's also sold to patients like it's the greatest thing since sliced bread, I mean, the things that my patients come in, they with their promise that they are going to all of a sudden lose 50 pounds, they're going to look so much younger, their sex drive that people a lot of women come to you with concerns about their sex drive, so they're definitely sold on the libido issue. So they're told if you get this pellet, you're gonna have all these amazing effects from it. So that's why they do it. I find exactly that. And I want to talk a little bit about that whole salesmanship. Because when we were talking about this with some of our physician colleagues on social media, there were some comments where one OBGYN said that she was at a conference and there were spokespeople for these pellets and for different hormone therapies. And she said, quote, they make it sound so glamorous and scientific. Sadly, many physicians and mid levels lined up to learn more about it. And another one said at a compounding pharmacy came to her office and visited her and told her about how great it was. And when she asked, Well, what about the risk increased risk of cancer, the furnaces just seemed to look at her blankly and didn't seem to really be aware of any increased risk. So I think that there's definitely a lot of promotions. But the thing that really worried me the most was, we talked a little bit about the elite nurse practitioner before. And this is a nurse practitioner who has a goal of helping other NPs set up their own cash base clinics. And he has all sorts of different courses, but one of them is the women's health and hormone replacement therapy course. And so what it says is, this course is designed for the nurse practitioner who wants to open a high revenue, low expense practice that can be done part time, or for the nurse practitioner who simply just wants to learn about the most in demand women's health topics, then it says women's health, especially hormones has been a very hot service line for years and for good reason. And then in all capitals, women want to feel better. And what does that mean, high profit potential for the astute nurse practitioner entrepreneur and making an impact on the health of the female population. But I mean, they're laying it out right there. And then they go on to say that one of the best parts is that it can be done on a part time basis, and, quote, The aging female demographic, which that includes me so the agent female demographic are willing to drop cash in capitals cash on these niche service lines, which results in a high revenue practice that can be done in only one to two days a week. And then it says, Sorry, I gotta keep reading because everything is just more and more shocking to me. This course will teach the nurse practitioner who has zero experience with women's health, zero guys zero, and hormones, how to practice this niche service line and how to open a practice from the ground floor. And it will teach you everything. And then you mentioned Dr. Varghese about how they have signing consent forms and say you know that they understand all the risks. And so one of the things that this includes is nifty treatment protocols that you can use as a quick reference. And also they said that they have how to create bulletproof documentation to cya and cya means cover your ass for those of you don't know that acronym. So this is all about how to sell and capitalize on the aging women demographic. And I'm very insulted by that as part of that demographic.
Joyce Varaguese MD:Well, I'm very insulted by it because let me tell you that even after four years of an OB GYN residency in your first couple of years in practice, you're still I mean there is such nuances to hormone replacement Have you know, do they have a uterus or not? Do they need the progesterone or not? Like, you know, is it sex drive that's the problem? Is it vaginal dryness? Is it vasomotor symptoms? Like, do they need testosterone? In addition, there's so many nuances to it, that it's one of the things that I find that like Junior OBGYN, actually look to their more senior partners for, like advice on for those first few years, you know, because it really is a very nuanced thing. So I'm insulted because, I mean, despite all my training, I'm still like, you know, there's still newer products coming out that are FDA approved that I'm still having to learn about, there are newer non hormonal options that are great for some of my patients who can't use hormones because of because of certain prior cancer diagnoses. And so it's, but instead, I could what, learn this in how many hours of courses that, you know, it's just like, I don't, I need zero experience. And then I can like, learn all of this. It's just, it's scary that somebody who goes through this course is then being unleashed on the public
Rebekah Bernard MD:Well you're going to get really mad now, because I just found it. It's four hours.
Niran Al-Agba MD:And it's $499. Yeah, it's a four hour course.
Rebekah Bernard MD:It's somebody that knows absolutely nothing he says about women's health is going to now be certified to use hormones that we know can cause cancer can increase cardiovascular risk, and cause micro penises. There's a lot of bad things that are involved in this and you're not going to learn it in four hours. And it took you a many, many years to learn how to do this properly. And you're right, it is insulting.
Niran Al-Agba MD:I do want to say this I and maybe I'm wrong. And maybe I'm old fashioned. I'm you know, third generation primary care doc in a small area. So bear with me, but it's it's really a sign of a completely shattered system. It's not even broken. It's like the glasses on the ground. And now people are jumping up and down on the broken pieces of glass in there, turning them into these tiny little splinters. And I guess my thing is, I really hate selling stuff. Like, I think it's totally different. The DPC, Doc's do their own medications, right. And they they charge to cover the cost of their medications. And I, depending on what I'm doing will sometimes do the same. If I've ordered a bulk medication for someone and I'm handing it out. Sometimes they don't even charge them at all, because I do it much more rarely. It's just not worth a couple dollars. But the thing is, I don't sell vitamins, I don't sell minerals, I don't sell I just I don't sell stuff. Because for me and again, this is no insult to anyone else. You know, if you sell something you really like or whatever I mean, I make recommendations. I say like this is a great book with recipes for baby food. This is a great this, I get no kickbacks. This is the vitamin D I use on my own kids. It's liquid, it's easy to give really simple things. But what bothers me is I don't want to sell you products. I don't want to sell you on me. I just I hate that. And I see that happening. And I guess it is just a sign of a broken system. But I don't know, how do you feel about it just being where you are where you are seeing these women that have been harmed by this stuff?
Joyce Varaguese MD:Right. I mean, again, I think it's that the DPC doc, so for the most part are still following evidence based guidelines. Dr. Bernard said, right, like 100%. If insurance doesn't cover, it wouldn't cover, it doesn't really cover it, it's likely because not standard of care. And that's not what they are trying to do or trying to know. It's again, I think it's it's like you said it's a shattered system. And we as physicians are, especially those who are still working within hospital systems and have to, for whatever reason are forced to see a certain number of patients are, you know, given a certain period amount of time to see patients, I'm fortunate that I am a sub specialist. So I actually get it a little bit more of an extended period of time, it can actually have these conversations with patients, but it's that patients want to feel like they've been listened to, right. And so it's like the things we learned in medical school sit down, you know, even if it's for two minutes, like they feel like it's been much longer, right, like, but that's what these other folks are selling to them. It's this idea that we're gonna listen to you and give you this really personalized medicine approach. And yet, it's vitamins that are probably just going to be urinated right out, you know, like to be perfectly honest, like, it's just going to be really expensive urine, or hormones that are just not that may or may not be what they're actually telling you you're getting without potentially understanding the risks of it.
Niran Al-Agba MD:My Dad used to say that Americans have the most expensive urine in the world.
Joyce Varaguese MD:I mean, the list of supplements and vitamins that patients take now where again, like people are often just looking for the quick fix. And so rather than eating their vitamins through how healthy diet or maintaining a healthy weight and reducing the risk of menopausal symptoms, even like a hormone, a pellet or a pellet is much easier, right?
Rebekah Bernard MD:Well, I think you're so right. And I think doctors need to make sure that we are giving patients what they need because patients don't know, credentials. They don't know that a lot of times the difference in training and education. What they do know is whether they're listened to whether the person that's talking to them is compassionate and kind and showing empathy. The system does make that really hard for some of us to do, but we need to do our best to do that. And maybe some of us need to get out of the system. That makes it impossible to show empathy, which is what I did in DPC. And just a little funny story about the the meds I do dispense medications in my little dispensary. And I was under a deposition for one of my patients is suing somebody. And so they deposed me. And they were trying to make me out, like, I make a lot of money off of patients. So they asked me about some medicine that I had given her. And they said, how much was that medicine? And I said, Oh, that was $7. And they said, $7 per pill. And I said, no, $7 for 90 pills. Just, you know, they just couldn't answer that. Because really, it is about providing evidence based care at an affordable price. I wrote a mission statement for my practice. And I wrote a policy and procedure manual, which I recommend all doctors do. And in my mission statement, it's no gimmicks because I need patients to trust me. I need them to believe in what I'm saying that I'm if I'm recommending something, it's because it's for their good, and not because I'm personally profiting off of it. So I think that's really the key.
Joyce Varaguese MD:I see a lot of patients with cancer, right? Who were asking me about high dose, vitamin D, or high dose vitamin C, or, you know, whatever, the most recent thing that's out there, and the lay presses. And I all I've always said was like, and how much is that person charging you for that infusion? Like truly right? Because I tell them when there is evidence and when there isn't evidence.
Niran Al-Agba MD:And so it's really important that we make sure patients understand I guess that to me, that's probably the most important point of this is just, I often tell people, when I refer them to get a film or send them for a lab, I'm like, I don't get a penny out of this. And I'm so happy about that. And our vaccines are state supplied. So again, I really don't make money off of it. And I'm thrilled with that. Because I think patients should ask, like you said, How much money are they getting out of recommending this? And if they're getting nothing you can probably trust that's a fairly reasonable recommendation. So I think of all the things if you feel like you're being sold, that's the time to ask questions are not the time to figure out if someone's profiting.
Rebekah Bernard MD:you know, it's so interesting how many people think that doctors make money off of giving vaccines, they don't realize that actually most doctors lose money when they give vaccines or at you know, at best, they just break even so it's not a money making operation for us.
Joyce Varaguese MD:It's funny because I often will give people websites or books to look at and things and I but I preface it by saying I'm like, I have no stake in this game. Like you know, if you go there don't doesn't matter to me. I don't know, I don't like I get nothing out of it. Because I really don't want them to think that I have any other incentive except their health in mind.
Rebekah Bernard MD:And that's what we should have. And unfortunately, that's not what we're seeing with some of these hormone clinics. And I want to thank you very much, Dr. Joyce Varghese for joining us to shed light on this issue. And hopefully, patients will learn the kinds of questions that they need to ask and make sure that they don't get taken advantage of, and that they can also save themselves from harm. If you'd like to learn more about this topic, we encourage you to get our book. It's called patients at risk the rise of the nurse practitioner and physician assistant in healthcare, it's available@amazon.com, and at Barnes and noble.com. We also would love for you to subscribe to our podcast and our YouTube channel. It's called patients at risk. And if you're a physician, and you'd like to work with us more on getting the word out about physician led care, and truth and transparency among healthcare practitioners, we really encourage you to join our group. It's called physicians for patient protection. You can visit our website physicians for patient protection.org Thank you so much, and we'll see you on the next podcast.