Your Primary Care Clinician Should Help You Navigate Women’s Health

The hardest part of health care isn’t always treatment, it’s figuring out who should treat you in the first place. Speaking of Women's Health Podcast host Holly L. Thacker, MD sits down with Laura Lipold, MD, Director of Primary Care Women’s Health at Cleveland Clinic, to map out how primary care, OB-GYN care and consultative women’s health specialists can work together across every life stage.

They talk candidly about why so many patients feel stuck right now, from limited access to primary care to the long shadow of menopause misinformation after the Women’s Health Initiative. You’ll hear practical guidance on what primary care can often handle (Pap tests, HPV and cervical cancer screening, mammogram orders, chronic disease management, obesity and metabolic health, behavioral health support) and when it’s time to bring in a specialist for complex menopause and hormone therapy decisions, severe osteoporosis, cancer survivorship, blood clots, transplants, or major cardiovascular history.

Transcript

Welcome And Guest Introduction

Dr. \ 0:11

Welcome to the Speaking of Women's Health podcast. I'm your host, Dr. Holly Thacker, the director of Speaking of Women's Health, and I am back in the Sunflower House for a new podcast here in season four with a colleague, Dr. Laura Leipold. And let me tell you a little bit about her. Several years ago, she wrote this great column on Speaking of Women's Health about when you should see your primary physician versus when do you need to see a women's health specialist. So that's what we're going to talk about. But she's actually bridged both worlds in a lot of respects. She practices as a primary care physician at the Cleveland Clinic, and she's got academic appointments. She went to Albany Medical School, and then she came to the Cleveland area and uh did her family medicine residency at Case Western Reserve University in Cleveland. And then she went on and did a one-year fellowship in women's health at Case and also the VA. And she's been on staff for several years. Her primary care practice is closed. Sorry for those listeners out there. I know so many women are trying to find good primary care physicians in the area. And she's the director of our primary care women's health. So welcome, Dr. Leipold. Thank you for having me, Holly. It's great to be here. And you are a mother, and uh tell us a little bit about your yourself personally, things you like to do.

Raising The Bar In Primary Care

SPEAKER_01 1:49

Sure, sure. So um I'm originally from Buffalo, New York. Um, and so I moved to the Ohio area, Cleveland, Ohio, for my training back in 1997. I've been in Cleveland ever since. Thought I might be moving on beyond training from Cleveland, but yeah, I ended up meeting my husband here and the rest is history. Um, really a wonderful community to raise a family and to have a profession. So it's really been wonderful.

Dr. \ 2:13

Yes. And and tell us about your work in the primary care institute, what you do being in charge of women's health.

SPEAKER_01 2:20

Yeah, I'm happy to share about that. Um, because I I know I often get this question so what what do I do as far as my role as medical director for primary care, women's health? And the way I like to think of it, I really feel like I I am the advocate for raising the bar as far as women's health care quality experience and access at the primary care level. So primary care physicians and um and APPs and physician assistants, I'm gonna kind of group that together and call them clinicians. We really are the point of access for women for a lot of healthcare services. And so I really like to think that we can really optimize that experience and that quality of care through the work that I do.

Dr. \ 3:08

Well, that is just absolutely uh terrific. And it was very helpful when you wrote that column on speaking in women's health about when you should see your primary care physician, when you should see a um specialist or a subspecialist even. I know in terms of menopause credentialed experts in the country, there's probably only about a thousand. And we have millions of women that are uh in midlife and thousands of women who cross through menopause uh every day, and then you know, a large group of uh much older women. And uh I was just talking to a colleague about how we see sometimes older women and they're told by their gynecologist, oh, you're over 65, you don't need a PAP, and that's not true. Or, oh, you know, you have had a hysterectomy, so you don't even need gynecologic exams, which of course is not true because a lot of women do access their women's health through their gynecologist or sometimes through a nurse practitioner, and some don't see OBGYN anymore if they're not having children, and they see their primary care physician, and some primary care physicians like yourself are comfortable and do, you know, complete exams, breast and pelvic, et cetera. But then others are not. So do you want to speak to that?

When To See A Specialist

SPEAKER_01 4:27

Right, yeah, and certainly I agree that um menopause and hormone therapy is a highly neglected area of training and education for primary care physicians historically. I think it's getting better. That's a whole nother separate topic for conversation. But the consequence, the downstream consequence of that is a lot of primary care physicians may not feel comfortable with maybe providing that care altogether. So again, I, you know, some physicians have more of an expanded scope of women's health care services at the primary care level. Some it might be more basic, some it may not be much at all. So I know that can be really difficult to navigate. And I'm trying to even that out a little bit and really try to provide a lot of education services to our providers around this gap area. But I think the important thing is that as that having a relationship with your primary care physician, somebody that you have that continuity with, somebody who you can develop a relationship is really important because I think either way, what that primary care clinician can do for you is help you navigate a lot of these important health care needs as you transition across the life cycle, right? So there are going to be different care needs as maybe an adolescent female, and then you get into more of your reproductive years, and then you move into perimenopause and menopause and postmenopausal and then elderly years. So, I mean, there are kind of a lot of different care needs, and I think the primary care team can help you to transition to that. And then it also gives you an opportunity, maybe better understand and feel what your primary care provider is comfortable as far as care services that they provide. So you might have somebody that very easily can provide, can do your PAP tests, can order your mammograms, will manage your osteoporosis, and feel comfortable with your hormone therapy. Um, there may be others where they say, well, you know what, this is just not my level of training comfort level, and then you may need to partner more with a gynecologist. So this is for, in my opinion, basic woman's health care. We are not consultants. And then there are patients who have complex care needs when it comes to their women's health care, and that's where somebody like you, Holly, comes into play. So you are not somebody who's providing, you know, kind of bread and butter women's health care. You are providing care at a consultation level. You have a level of expertise to help guide us in those more complex cases when it comes to menopause, hormone therapy prescribing, um severe osteoporosis, etc. So that's kind of the way that I see the main differences altogether.

Dr. \ 7:16

You know, it it seems like so. We're both old enough that we lived through um, you know, July of 2002 when the Women's Health Initiative just splashed onto the newspapers. And I think that was kind of the time period that people looked online and looked to the media for health advice. I mean, it was really quite a time. It was a very scientific study, but unscientifically interpreted. And a lot of people just threw the baby out with the bathwater and those threw the menopausal hot, hot, flashing women out too, um, into the hot sauna, maybe, with their flashes. And so it was a really very disruptive time. Um, and I think a lot of training programs in family medicine, in internal medicine, in um OBGYN just stopped even teaching about menopause and perimenopause. So I think that's one reason we find ourselves in the crisis that we're at in. And so that's great. And kudos for you for educating um uh primary care uh clinicians uh to feel um able to deal with some of the basic stuff and advise their patients and help direct them like they do in many other issues with many other medical conditions. And I think looking at the life cycle, the age, um, the values, the needs of what that person wants, whether they want or need another women's health person, uh like a gynecologist in their um in their care plan. And of course, some people have lots of folks and some don't. The one thing that I've noticed, you know, practicing this long is that it seems like the women that I'm seeing now are actually many of them not getting primary care, not getting follow-up on their issues. Um, even if they see a gynecologist, sometimes they're not even getting gynecologic care and that this, you know, spacing out of the PAPs. People, I I see women who haven't even had a PAP in eight years, and they just thought they didn't have to. Before women were like trained, you gotta come in every year and get the exam and get the PAP. And we've had prior podcasts on uh cervical cancer screening and and other types of female cancer screenings. Um, you know, we've had this explosion of metabolic syndrome and obesity, and of course, there's increasing demands. Um, I read the other day that one in eight Americans are on injectable weight loss medicines. So that's a lot. And so I'm sure that's a big demand that people are are coming into the practice with. Um any advice to patients, because it's great that, you know, on the physician side, you're, you know, having CME courses and you're doing mini, mini trainings, and you're having lectures for the the Cleveland Clinic. But we, you know, we're in 100 countries and we have healthcare people listening to this podcast, um, and we have people who aren't obviously in this northeast Ohio area. Do you have some like advice that you can give to the individual patient themselves, you know, the woman, or actually, you know, I we have some men who listen too. How can they prepare better for their visits with primary care? Because I just see patients when I ask them when's the last time you saw your primary care, oh, it's like a year and a half. And I'm like, well, you can't go into a visit, especially with an employed physician that's not in direct primary care or concierge care, with a long list of 12 different things in your past due for your health maintenance. And so I think some of the responsibility needs to come, you know, to the person themselves. And I wonder if you have some advice for preparing.

Preparing For A Better Visit

SPEAKER_01 11:01

Yeah, no, I think that's a really great question. And um it's you really got to the um to the the main issue there, the core of it, the heart of it is that there's just so much information out there, um, misinformation, some of it may be correct, but really difficult to navigate all of that. We've gone and and I'm with you. I was when I was in training in the 90s, we prescribed a lot of hormone therapy, and then the pendulum swung 180 degrees with the women's health initiative, and it really left a lot of primary care physicians um in limbo. What, you know, what what you know why, you know, this doesn't make sense. You know, the we just had a very different experience with the studies leading up to the women's health initiative that just really seemed strikingly different in term of terms of expected outcomes, and it left us in limbo because we were being told you can't prescribe, right? And then, as you said, the other consequences were, then the training programs may have been backing away. I I'm not, you know, family medicine, I think they really kept up with that, but I'm not really sure with an internal medicine. Yeah, medicine, no, and I and GYN no either. Yeah, yeah. And I and so it was a really difficult time period. And then, you know, thanks to the New York Times article, I think that really sparked things three or four years ago. Now we've done another 180. So a lot of people are very interested in hormone therapy, but the source of information is very different. So my advice is to patients when you come in, please come in with your list of questions and really allow your primary care clinician to be a source of truth. So sometimes I just have patients that seek care outside, haven't even seen me and are going to providers that are not practicing evidence-based medicine that are coming in with, in my opinion, dangerous hormone therapy regimens, yeah, that have been concocted pellets crazy stuff that have been concocted based on a I mean, they said this person ordered like a hundred different tests, you know, and and so it's it's really and then then we're really then we're working backwards, right? So um that's a really difficult situation. Um, so again, allow your primary care clinician to be your trusted source of health care. Come in with your questions, they can really direct you as far as reputable places to get more information about the changes that your body are going through, about the perimenopause transition and menopause altogether. So that would be that would be my first suggestion. And you know what? We're we do we do a lot of services for you. I mean, we really I mean above and beyond making sure that you're up to date with your screening services for cancers. Um, we do a lot of chronic disease management. We can really help you navigate the healthcare system too as well. We can really be that, you know, gateway to get you into the correct person at the right time based on whatever your specialized care needs are. Um, you know, we we deal with a lot of obesity management. We do certainly manage a lot of behavioral health issues. So we can be that one-stop shop for a lot of your care needs.

Concierge Care Pros And Cons

Dr. \ 14:18

So that's great. I think for people who can develop a really great relationship with a primary care physician to guide them that they trust and who that physician knows who the experts in a whole myriad, you know, area uh is. I've done prior podcasts on um concierge medicine and and direct primary care, because I think that's been a big uh growth in the last several years. And I wondered if you had any comments on that. I mean, of course, you and I were both employed physicians, and and most physicians in the past were in their own practice, um, and now it's almost all entirely employed corporate uh practices, and now we've seen this kind of pushback and um uh especially with you know uh primary care physicians in demand to go into direct primary care or concierge care.

SPEAKER_01 15:16

Um so for um so for and that's really I think an individualized personalized decision. I you know, I I certainly see um with um uh concierge medicine that um you know for some for some individuals um the the the payment the cost up front is person is for them worth the benefit of having that level of access to a personalized physician. So you know, so again, I feel like it it it plays a role for you know certainly individuals in the US healthcare system, which is so complex and broken, um, that you know what there it there is a niche for it, right? There's a demand, um, and and there's you know, there's going to be um there are going to be some individuals that are gonna be served very well by that model of care. Um and I think for, I think you might have uh mentioned um like executive healthcare services, uh again, you know, that is something that is um certainly I think a benefit that some individuals may have with their employer. Uh it's certainly something they can take advantage of. It gives them great access, I'm sure, to some wonderful um healthcare systems like Cleveland Clinic. Um I don't think it replaces a primary care physician just because, again, acute care needs come up. Um, chronic care needs to be managed, and I don't think it's really a model of care that allows for that. So that would still have to be, you would still have to have a primary care physician with that too as well.

Online Care And Hormone Risks

Dr. \ 16:55

And you have been listening to the Speaking of Women's Health podcast. I'm your host, Dr. Holly Thacker, and in the Sunflower House with us is guest Dr. Laura Leepold, who is a primary care board-certified uh family physician with academic appointments at CACE and the Cleveland Clinic Learner College of Medicine. And she actually did a one-year fellowship in Cleveland. And of course, I've been directing our fellowship for specialized women's health, which is two years, um, for gosh, over 29 years. I think I had just delivered my third son and was carrying him in while he was breastfeeding and needing to be changed. And I couldn't even hardly sit down because I had a postpartum UTI, and Dr. Fishleader was right there saying, You've got to start a fellowship. I'm sitting around a table of men with my third son. So I dramatically remember that. Um and my goal has always been to train physician leaders who can provide consultative specialty care of these complex patients. Like I have patients in my practice with organ transplants and breast cancer survivors and uh uh cancer previvors, uh, because we have a big genomics institute, and I see a lot of women who've had cardiovascular events, heart attacks, strokes, dissections, um, complicated uh histories, um, very active rheumatic disease and blood clots. And so those patients which have such a high burden of disease, uh, I, you know, you would not expect the average OBGYN or nurse practitioner or a busy family medicine doctor who's seeing patients of all ages and all genders with, you know, many times chronic diseases and um needs for health maintenance and behavioral health and metabolic and obesity health, like you mentioned. So a lot of this can be regional too. Um I've seen this big proliferation. I wonder what you think about online care. I mean, it certainly started, um, you know, you see the ads in women's health and men's health, and some of it seems focused on hair loss or impotence in men or hormones or uh cosmesis in women. So we have been speaking with family medicine uh expert Dr. Laura Leipold, and uh I was talking about this proliferation of online medical care. Um, we've seen it with advertisements about for men, oh, if you have hair loss or sexual dysfunction, which of course men can have many other issues besides that, and we've seen it in women, and it's really kind of um hit the ground going in terms of hormone therapy because back in 2025, after many of us um working very hard to uh have the FDA lift some of the box warnings off of things that we don't think should have been on, like warnings of cancer on vaginal estrogen, which those box warnings have been lifted off of, and lifting off the boxed warnings that imply that menopausal hormone therapy is going to increase death rates of heart disease and cancer, which if anything, the research shows inappropriate patients at the right stage of life, it actually prolongs life. So now we've had this complete flooding of so many people's uh offices, OBGYNs, family medicine doctors, endocrinologists, uh, dermatologists. You know, people are asking for facial estrogen cream, which uh for those of you listeners who want to hear some of the stuff on how to improve your appearance with aesthetics, with cosmetic dermatologists, we have several of those podcasts. Uh, but I assure you, if you're going to be using hormones, you want they're very potent substances, and you really want someone who knows what they're doing. That can be a primary care doctor, it can be an OBGYN doctor, and sometimes it may need to be with a consultative referral specialist in complex women's health care, such as myself. Um and so I wondered what you thought about this proliferation of all this online care.

SPEAKER_01 21:14

So uh there are probably a couple of different models when it comes to the online care. So if you're talking about direct primary care, um there could be a niche for that. So there could be the convenience factor, um, and it could be very affordable for some people who don't otherwise have insurance. So they would pay a certain fee, they would get access to primary care providers that would include some online access, um, and it would be very convenient for them. So they would be able to access care in a convenient modality at a convenient time. Um, and I can see how this might be attractive to notably maybe you know, generations that really love their devices and and love convenience of care. You're talking about the Gen Zers? Yeah, maybe. And millennials. And millennials, but I also do have some 80-year-olds that are probably more tech-savvy than I am. So the caveat there is that it should be with licensed providers. If it is, there are some opportunities with these direct medical care practices where you do develop that continuity of care. But there are some where if there's just that convenience of getting online quickly with a provider who's providing more of that acute care access, there's really not going to be the benefit of any continuity of care. And then when you think about other online care models, you do worry on the back end. What are they licensed providers? What is their training? What pharmacies are they dealing with, right? Is any of this really trustworthy? And that I do worry about altogether. So a couple of different pros and cons when you're talking about different types of online care that people might be seeking.

Dr. \ 22:55

Exactly. I mean, I was a quote digital leader well before COVID because I started offering virtual visits. Because after I had seen and evaluated a patient in person and they were stable, even though I always tried to take the care back to the referring physician or the local OBGYN or the internist or the family medicine doctor or the APP, whoever they're seeing for their general care, and women couldn't get prescriptions. Now I think that's going to be less of a problem now that finally, you know, we've righted a lot of the wrongs of the media misinformation and the negative hype about hormones. But that's why I started that. But it was for very specific reasons. And I think that, you know, the dermatologists have some funny stories about doing virtual visits when the patients want to show them the rash and they're bending over and falling over sometimes. You you cannot do a physical exam, you cannot put a speculum in, look at the vagina and cervix, get that PAP and HPV. There are limitations. You can't do palpation. I mean, you can tell things about a person's uh mentation and their socialization and their background in terms of where they're, you know, doing their virtual visit from. But I do think there's some serious limitations. And I think it was done way too much during the pandemic, and there was a lot of things that weren't done correctly then, and we're kind of coming out of that. But people do want convenience. I I just had a virtual visit myself as a patient, and the physician had to call me because they said it's set up that you're the physician and I'm the patient. I don't know why that is. I am a physician, but I was being the patient then. And so there can be a lot of technical problems.

SPEAKER_01 24:42

Right.

Dr. \ 24:42

Um, but people can be sick and it'd be off hours or um that. So what percent of your practice and do would you say the average primary care physician in the primary care institute does in person versus virtual?

Telehealth Limits And Red Flags

SPEAKER_01 24:56

Yeah, that's a really good question. Um, I probably um am a little bit more traditional in that I really like to bring my patients into the office. Less than 5% of my visits are virtual. But I do make them available if a patient feels like that is appropriate. But to your point, I feel like the onus is going to be on the physician and the schedulers and and other care providers to make sure the patient is appropriate for that telehealth or virtual visit. Um, because you're right, there are some, for example, if I'm concerned about pneumonia, I'm not examining that patient with a virtual visit. And my office knows very well why did you why did you offer them a virtual visit? They need to be in person. So I really feel like the onus is really also going to be on the provider and the care team to make sure that they are, again, getting in with the right person through the right venue at the right time.

Health Literacy And Using AI

Dr. \ 25:55

And also, you know, acute medical problems, shortness of breath, chest pain, bleeding, like you don't send electronic messages or text messages or ask for phone visits or virtual visits. I mean, that's really important. If if your life is in danger, you actually need to get to an emergency facility, and that does need to be emphasized. Just like we're not giving out medical advice here, we are just giving education, uh, a little edutainment, and we're just wanting to empower our patients to be strong, be healthy, and be in charge. I was just having this interesting conversation with a physician colleague just about some care experiences uh of you know, family members and other people close to me had. And I was musing if we can have difficulties when we are insiders and we know the system, I sometimes can't even imagine how it is for patients that are not medically savvy. They may be very savvy in lots of other things. I always like to talk about my husband, very intelligent man, but his medical IQ and lingo is really not there. And and I've had patients who tell me that, like when I'm asking a medical history, I just was doing that today, and uh my patient said, I don't really know any of that medical lingo. I know my mom has problems, but I really don't know what they are. My two sisters who are nurses, they do and they talk that language. But it's almost like sometimes being in a foreign country and not speaking the language. Correct. Um and so I advise like patient advocates or preparing for the the visit or letting people know up front what you think your, you know, your your knowledge and awareness is.

SPEAKER_01 27:38

Right, right. That's a really good question. And I think health literacy is something new that we're trying to better recognize, identify, and to meet the needs of the patients, right? Kind of meet them where they are. Um so I your question is very interesting because I I know how to answer the question when it comes up with medical students and trainees. You know, how do I sell assess for health literacy? You know, you can ask the question, do you ever need help reading any healthcare materials that you take away from your doctor's office or information you get from the pharmacy?

Dr. \ 28:13

So, you know, your recommendations about navigating, you know, through the complex health care and having perhaps a navigator or a friend or an advocate with you is helpful. Right. Do you ever have patients ask you if they can tape what you're saying, or do you tape and use AI, or do people bring AI into their visits with you? Yeah, I do.

SPEAKER_01 28:38

And when we started using AI, um, you know, there's certainly been scenarios where I always ask permission, are you okay if I pull this up to make sure I don't miss anything? They're like, yeah, do you mind if I record at my end? I'm like, no, that's great, you know. So we kind of laugh about it. So no, I have no problems with that. Um, and I actually think it's a helpful tool for some patients. And again, um, if you're feeling like you're at times maybe not always grasping everything, um, having a companion with you could also be helpful just to have that additional set of ears. And then always asking for written information or something in my chart is another way too as well.

Dr. \ 29:13

Yes, and the electronic medical record um can also have things printed in other languages because, of course, we see people from around the world. Uh so that is interesting. I'm pretty much a stickler. I really emphasize that my patients keep hard copy records of important things because it's amazing. I was talking to an orthopedic surgeon who said that they can sometimes take up to an hour when they're seeing a patient who might need revision surgery of an implant or a device orthopedically, but the patient doesn't have the records of what exactly was done and what models and what screws and all that technicality. And, you know, people have uh pacemakers and implants of lenses and implants of devices for chronic pain uh stimulation. So I think anything that's really critical, we we rely so much on technology. We talked about how uh people that are tech savvy many times would prefer a virtual visit just quickly on their phone as opposed to in-person, and sometimes that is appropriate, of course, sometimes that's not. But um, I just think any critical biopsies, because a lot of healthcare institutions don't even have to keep records after so many years that I have women who can't get their results of their why they had a hysterectomy or even what part of organs they had removed. So I think keeping a file of really critical things is good. And if you are on the medical record, even if you think the medical records talk between institutions, sometimes they do, sometimes they don't. We have cyber attacks. Um looking at your an entire visit, not just the aftervisit summary, which is maybe directed for patients, but even the clinical notes, because I'll have patients who really read through things, and then they'll send me a message, actually, this isn't exactly right. This is when I was diagnosed, or no, I don't have that symptom anymore. So I like it when patients are engaged in their in their care. Um, I don't like it when people want everything off their records because they they they think it's a personal insult that they have a medical issue. I mean, we need medical diagnoses, even screening for breast cancer to order a mammogram as an example. Like you you need these codes. I even sometimes have medical people say, take that off my problem list. I'm like, no, you don't understand. I need this to make associations for orders.

SPEAKER_01 31:33

And and I also make the point that it's important as a means of communication to other members on your healthcare team. So it's critical to have this as means of communication.

Shared Decisions And Real Consent

Dr. \ 31:45

You know, I was giving advice to uh to a friend who's not a patient, but who's who is a patient, who's not my patient, but is is not medical. And they assumed that the doctor they would see were going to know about their prior history of trouble with substances. And I said there's so many places to look in the record. And so that if you know that you can't receive certain pain medicines or numbing medicines or uh benzodiazepines or whatever, you know, for procedures or diagnoses or evaluation, you kind of need to be upfront with that because even if things are in the record, uh, as one of my um spunky nurse practitioners loves to say, there's a thousand different places to look. We could be here for eight hours if you want me to look at every little section of your medical record. So that's something I think that on the other end, people don't always uh know. Um getting back to our discussion about you know primary care and concierge care, when I was having this discussion about um how difficult it is that our system is so complex and it's good to have an advocate, it's good to have a good relationship with a primary care if person in order to help guide you through the complex maze and who you might need to see or who you maybe don't need to see, that they can take over that care. Um with the re with the range of um cash pay, online on pay, direct primary care, online. I guess Amazon's getting into the business, like so many people are getting into the business of health care. One thought that I had, um, because as a physician, certainly when I'm being seen as a patient, people know I'm a physician, or when I'm going with my family member or when my kids were little, and I, of course, wasn't a pediatrician. I really appreciated when I was able to say what I thought needed to be done, but then there was appropriate, respectful pushback. Like, um, my son, I didn't think he had a positive PPD, and I'm like, I don't think he has that. And the pediatrician said, Well, we're gonna do a confirmatory test, and sure enough, he did. And he needed INH, you know, for six months. And I'm glad that I didn't just blow it off and say, Oh, I think this is a negative test, because it was a little outside the time. I was out of town, I kind of felt guilty, I wasn't there to read a skin test myself. So even though you are medical and we do have medical people listening, other people have other expertise, and as long as you know what your limits are, but if if someone really thinks that something needs to be done, like I had the pediatrician tell me, no, I really think your son needs to go on Accutane, I'm like, oh, I've heard bad things about that, because I'm not a dermatologist, and I just read the little media clips, and they said, no, no, this is an effective treatment, and your son should be on it. And he was, and it was really good. So if I was thinking, if I was paying for a concierge doctor and I said, No, I don't think this needs to be done, or I'm concerned about this therapy, maybe they would back off because it's cash pay. And and so I think that there is pros and cons, but I see so many women who come to me and they've seen a physician and they said, Well, my doctor says they don't feel comfortable, you know, giving me this therapy. And I think that's kind of ironic and a little inappropriate to say, because our comfort as the caregiver and the physician, we're there, of course, to take care of the patient and how they feel. And so I think that if they say I think this treatment is too risky for you, or I don't know enough about the other options, and because I feel that you're at higher risk and this may not be the best therapy, then let's bring someone else into the care. I think that's a better way of dealing with it. Because I I have patients and I I'm seeing thinking of one of my patients who's been through a lot of different things, and the treatment she was asking for me was not standard and um is higher risk than other things, but she tried those other things and she's like, I'm willing to do this, and I understand that it's not standard and that it's riskier. And so I documented that. I said, Yeah, it's not really standard, but I understand you're very different and unusual, and you've already been through so much that I'm happy to prescribe this for you because I want to take care of you and you understand that it's not standard, but it would probably be best if I see you sooner and we monitor you a little closer. Right. And so I think that kind of relationship is better. And I know I've personally had that experience myself when I found something that worked and it was it's cheap kind of therapy. And I'm like, I know it's not really standard of care, probably because no pharmaceutical company can make money off of it to patent it, you know, but I kind of maybe like to consider this as chronic treatment. And and the response back I got was, well, I don't feel comfortable with this. I'm like, well, it's not your comfort level. I'm the one having the symptom. And so I'm like, uh it's it is a give and a take. And and um I think that you know, everybody kind of needs to be up front with um their expertise, certainly in issues of, you know, substances of abuse. Obviously, you know, you're in pain and for chronic pain, sometimes, you know, there's a whole issue of of addiction and substance issues, and um there's been that whole pendulum, doctors gave too much because they were being judged on if the patient was happy with their experience. I mean, there's sometimes people I know aren't that happy uh with the their experience with me because they don't want to hear what I have to say. Um, and I think sometimes that's really what's best for them. On the other hand, we've seen this, you know, people with chronic pain and cancer pain, and because of the opiate epidemic, there's been all these restrictions on physicians. I I wonder if you wanted to comment on that as a as a primary care physician for your patients, seeking pain medicines and seeking um pain relief.

Pain Care After The Opioid Crisis

SPEAKER_01 37:46

You know, I yeah, and I and I do just want to comment on what you said around patient-centric shared decision making, right? And I think the the key thing that you said was um the patient was alluding to the patient making that informed decision. So as long as the patient fully understands the the risk and the benefits, and again, the onus is on us to make sure that they're making a fully informed decision. We have to make sure we're providing them with that necessary education in order to make the decision. So I I agree with you. I think that's a really important piece of the care that we provide. Um, you know, regarding the opioid epidemic, I I will tell you that I've this has made me the one circumstance where there's been positive, a positive downstream effect of the media and the opioid crisis. I think nowadays everybody knows somebody who's been touched by a heroin death or an opioid overdose, right? Absolutely. It's terrible. So I have so usually the conversations, we tend to just, at least myself and I think a lot of my colleagues practice this way too as well. As we're getting into pain management, um, you know, we don't, we do the first line things. And if we're starting to have the conversation about, you know, they're at a level of pain with what's working, what's not working, we engage early in that discussion about these are the real risks about with opioid-based medications. And the patients often, as soon as you start to bring up the I don't want that, you know, and you know, just so starting to have that conversation early on in their pain management treatment plan, I think can be very, very helpful. Um, and I often see that really most I mean, most of my patients are like, I don't really want that. That's not really something I want to do. And we often can find a lot of other tools to help manage their pain. And we've learned so much about pain management, especially as a result of the opioid pain management, the opioid crisis.

Finding Care And Closing Advice

Dr. \ 39:50

So and we have an excellent pain management department, and there are so many modalities, and we've had podcasts on acupuncture and functional medicine. And sometimes even if you have a physician who's giving you a prescription, I'm thinking about um a colleague whose uh partner had severe pain and they had to come in every you know, four weeks to get the medicine, and you know, because of all the restrictions, and they were just complaining about that. And I thought, you know, maybe it's time to take a look at a second opinion. And she said, like, well, our insurance doesn't cover it. I'm like, Yeah, I know, and you've just gone overseas on a trip. I think you can afford cash pay. Went out to a different physician, it was only a few hundred dollars, got the actual real diagnosis, was told what needed to be done, which was a surgical procedure. Now it's not on chronic pain. So I think I've seen people who need pain medicines and that you know they're denied, and you've read stories about people killing themselves because they had chronic pain and they couldn't take it anymore. Um we've talked on the podcast about ketamine and uh with with different physicians, and that has provided relief for some of my patients with chronic pain. On the other hand, you know, read about prominent cases of people overdosing on it. Um so it is really tricky, and I think having a trusted primary care physician to help guide you, push back maybe. Maybe instead of just giving you this, you need to do that. Uh, on the other hand, you have done everything, and you know, you're gonna work with me and maybe um sign a contract or be willing to accept what these risks are, and then we'll we'll do that. And so it's been really such a great discussion talking with you about all these nuances and all the changes in the field and and helping people navigate through this. Any resources or online sources or ways people can contact you or or your colleagues if they're you know in the Northeast Ohio area and looking for a primary care physician?

SPEAKER_01 41:49

Um, so I you know, I really think the Cleveland Clinic website has improved as far as providing. We still are trying to find someone, I think. Yeah, um, but that that can always be helpful. Um as far as um we we do have a call center too as well if you're looking to get access to care. Um so I think that's always something. And then you can certainly talk to your trusted friends and colleagues to see if they have a recommendation by word of mouth, because often it can just seem overwhelming if you, you know, if your insurance company gives you a list of a name of primary care providers, like who do I well, who do I go to?

Dr. \ 42:23

Um so uh so Clevelandclinic.org. And then of course, I always recommend our website, nonprofit, speaking of women's health.com, for women's health-related information. But we have some other information just on general health too, not only exclusively women's health, but mainly. Well, thank you so much, Dr. Leepole, for joining us in the Sunflower House. Uh, to our listeners, thanks for tuning in. Uh, if you enjoyed this, give us a five-star rating and you can share this podcast. We're on Apple Podcasts, Spotify, Amazon Music, Podbeam, wherever you uh catch podcasts, we're on YouTube and Rumble, and we have some clips on Instagram. So thanks for joining us, and remember, be strong, be healthy, and be in charge. Thank you, Dr. Thacker. Thank you.