EP. 81: MYTHBUSTING MEDICINE

WITH JEN GUNTER

Sep 26

WITH JEN GUNTER, MD

A gynecologist and leading health communicator shares how she addresses overlooked issues in women’s health and how she combats medical misinformation, both through her massive online presence as well as through day-to-day patient care.

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Episode Summary

Despite advances in medicine, issues in women's health are still often mired in stigma, shame, misinformation, and disparities in access and societal standards. In this episode, we are joined by Jen Gunter, MD, who is perhaps the most well-known and outspoken gynecologist in the world. She has made it her life's work to dispel potentially dangerous myths about women's health and, more broadly, the wellness industry. Dr. Gunter is the author of The Preemie Primer, The Vagina Bible, Menopause Manifesto, and the upcoming book Blood: The Science, Medicine, and Mythology of Menstruation. She is also a columnist on women's health at the New York Times and the host of the podcast Body Stuff. Over the course of our conversation, we discuss her work as an early pioneer in chronic pain medicine and vulvovaginal disorders, how experiencing a challenging childbirth led her to write her first book, the various spars she's had with celebrities over medical misinformation, the importance of discussing uncomfortable topics such as sex with patients candidly, and how she builds trust with her patients.

Jen Gunter, MD is an OB/GYN and pain medicine physician who advocates for evidence-based medicine. When her infant children were critically ill, like many people she turned to the internet. She was shocked at how easy it was to be led medically astray and wondered: If it was so hard for her as an experienced physician, how did everyone else manage? She decided to "fix the medical internet" and help people separate fact from fiction with her writing and activism.
In addition to being both a doctor and a mother, Gunter hosts the TED Audio Collective podcast Body Stuff with Dr. Jen Gunter and is a writer and host of the show Jensplaining. She has been called Twitter's resident OB/GYN and the world's most famous gynecologist. She is a fierce advocate for facts and tirelessly calls out those who exploit pseudoscience for financial and political profit.
In this episode, you will hear about:
• 2:20 - An early accident that led Dr. Gunter to pursue a career in medicine
• 5:02 - Dr. Gunter’s experience as a woman in medicine
• 8:13 - What led Dr. Gunter to specialize in the intersection of pain medicine and women’s health
• 11:37 - How Dr. Gunter validates her patient’s experiences
• 16:19 - The unique ways in which OB/GYNs are “fluent” in both medical and surgical management
• 21:24 - The very challenging childbirth experience that led Dr. Gunter to write her first book, The Preemie Primer
• 26:38 - The ways in which doctors need to strive to do a better job communicating medical information with patients
• 31:07 - The growth of Dr. Gunter’s media presence since she began sharing her writing publicly in the early days of Twitter
• 36:34 - How coming of age as a doctor during the early years of the HIV epidemic made Dr. Gunter committed to normalizing conversations about sex with patients
• 41:18 - Dr. Gunter’s advice for dealing with misinformation on a daily basis
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] Despite the advances in medicine, issues in women's health are still often mired in stigma, shame, misinformation, and disparities in access and societal standards. In this episode, we are joined by Dr. Jen Gunter, who is perhaps the most well known and outspoken gynecologist in the world today. She has made it her life's work to dispel potentially dangerous myths about women's health and, more broadly, the wellness industry. Dr. Gunter is the author of The Preemie Primer, The Vagina Bible, The Menopause Manifesto, and the upcoming book Blood: The Science, Medicine, and Mythology of Menstruation. She is also a columnist on women's health at the New York Times and the host of the podcast Body Stuff. Over the course of our conversation, we discuss her work as an early pioneer in chronic pain medicine and vulvovaginal disorders. How experiencing a challenging childbirth led her to write her first book, the various spars she's had with celebrities over medical misinformation, the importance of discussing uncomfortable topics such as sex with patients candidly, and how she builds trust with her patients. Jen, thank you for taking the time and welcome to the show.
Jen Gunter: [00:02:18] Thank you so much for having me.
Henry Bair: [00:02:20] This is the first time we've had a gynecologist come on the show. So we are very excited about that. To kick us off, can you tell us what initially drew you to a career in medicine?
Jen Gunter: [00:02:30] Well, I actually had a bit of a run in with the health care system when I was a child. So I had a skateboarding accident when I was 11 and I ruptured my spleen, which is a testimony to my bad skateboarding skills. And the long and short of it is my mother didn't believe that I was in pain, so I didn't get to go to the doctor till the next day. Suffice it to say it was a big brouhaha because people were like, Hey, I think there's something really wrong. And this was back in the day. So there were no CT scans, there were no ultrasounds, so this didn't exist. And I think it was really hard for a lot of people to think like, really, there was a time, yeah, I'm that old. So I had to have an angiogram to make the diagnosis. All right. And I'm 11 and I was a little precocious and I was like, I don't want any sedation. They were going to give me Valium, probably. And I was like, I want to watch. And they were like, Can you hold still? And I was like, You bet. And I'm going to guess the interventional radiologist talked me through the whole thing. I was fascinated. Fortunately, I got to keep my spleen, but the angiogram found out that I had kidney disease, so I ended up having to have all kinds of investigations over the summer for my kidneys and then ended up with a nephrectomy. So I had sort of like four months of lots of tests, lots of going back and forth to the hospital. My mother had left school when she was 12 or 13, and so a lot of this was over her head. And so the doctors just explained everything to me. And I thought, well, this is pretty cool. And that's how I got interested in medicine.
Henry Bair: [00:04:08] So when you were getting that angiogram, you were just awake and looking at the procedure happening?
Jen Gunter: [00:04:13] Yeah, I was looking at the fluoro monitor. Isn't that wild? Yeah, in pediatric radiology at the Winnipeg General Hospital in Canada.
Tyler Johnson: [00:04:24] Aside from everything else, I'm just trying to imagine an angiogram with no CT scan. I guess it would just look like the neon sort of outline of all of the vessels and looking for blood extravasate somewhere. That's really interesting.
Jen Gunter: [00:04:36] Yeah. You just see like a vascular flush and they were looking for I'm going to obviously I now know extravasation and due to my mother's neglect, I got to keep my spleen because they figured if I hadn't bled out, this was just when they were starting to manage -I now know this in retrospect- splenic ruptures conservatively. So yeah, if my mother had actually been on the ball and taken me to the hospital, I might have lost my spleen. So there you go.
Tyler Johnson: [00:05:02] Was there ever any doubt or digression between 11 year old not quite getting a splenectomy and then going into medicine? Like, did you think about going into other things or start going into anything else or you were just kind of a straight line from there on out?
Jen Gunter: [00:05:15] Yeah, it was pretty much a straight line. I mean, I loved science, I loved math. I liked, you know, I loved all that all the Stem stuff. And back in the day, I mean, there weren't that many women in medicine, but there was like no women in engineering. I knew of a couple of women in medicine. So I think knowing that it was kind of a possible route was also helpful. But yeah, I just I found it like really interesting and neat and I just never thought about doing anything else after that. And I think that it's weird to sort of be 11 or 12 and think, Yeah, that's what I'm going to do. And then along these way, all these adults are like, Well, that's too hard, little Miss. You won't be able to do that. And the more people told me how hard it was and the more I wouldn't be able to do it, the more I was like, Yeah, right, okay, double down here. I'm going to do that.
Tyler Johnson: [00:05:59] I mean, I think that just in terms of the demographics, right, if you look at the number of women who are coming into medical school, for example, now versus the number of men, those numbers have pretty much equalized, even though the numbers in leadership positions and chairpersonship and all those things are still not. But as you say, when you were entering medicine, there were women in medicine, but it was certainly the exception, not the rule. Can you just talk a little bit about how that dynamic of being a person who is visibly different from many of the people who are studying with you, how did that impact your medical studies, especially early on?
Jen Gunter: [00:06:35] Yeah, I mean, I think kind of my generation of medical students and, you know, probably like five years before me, certainly where I trained, it might have been different in different places, had quite an influx of women compared to, say, like ten years before. And in my medical school, they had pictures of all of the graduates going back to like when it first opened and whatever, like 1892 or 1902 or whatever. And I used to go down and walk the halls and look for when like the first woman appeared and there was like 2 or 3 years and there'd be another one, and then a few more years and then there'd be two and there wouldn't be any for a year. So I was very mindful of that legacy. You know, I think in my class, I think maybe we had a third women, which was considered like the highest at the time. And but then, you know, they were like fewer chief residents. So it was sort of less and less as you went up. And so certainly far fewer lectures from from female attendings. I have to say, I never really thought much of it because I've always had a very strong sense of self. The only time it really stuck home for me was when we were getting all our lectures about ob/gyn. And I was incensed that here in this one area of medicine we had like no parity. That yeah, I mean, yeah, we don't have any female anatomists. And maybe there was one female cardiologist like all that kind of stuff. But I thought, oh, for sure, our ob gyn lectures, they'll be more. And there wasn't. And it wasn't that any of our professors in ob gyn were awful people. They weren't, they, they gave great lectures. They were very caring. Many of them inspired me to go into ob gyn, but it really bothered me that it just seemed like, Boy, wow. It's like you'd think if we were making some inroads, it would be here.
Henry Bair: [00:08:13] Yeah. So ob gyn. Tell us more about that. Like, how did you eventually decide to pursue that as a specialty?
Jen Gunter: [00:08:20] Because I was pissed off about abortion. Okay, that's basically it. I do a lot of things because I'm angry. That's really like my motivation. So right about the time was when the abortion law, trained in Canada, and the abortion law was overturned when I was in medical school. And so when I started medical school, you had to get an approval from a three person panel that you didn't even get to meet your family doctor, plead your case. And depending on who the panel was, you got it or you didn't get it. And so, yeah, so that just started to really weigh on me, you know, the access and that, you know, Doctor Morgentaler's advocacy was very public and not that he was from Manitoba, but they had just they had opened a clinic a couple of years before I started medical school. And so so that was really on my mind. And so I just thought, well, I better go into ob gyn and I would put my money where my mouth is and try to help out.
Henry Bair: [00:09:12] But eventually, though, you come to Subspecialize in pain medicine, but like this intersection of pain medicine and women's health, like I think for many of us, we might be unable to even envision what that intersection looks like. Can you share with us what that work actually entails and what got you interested?
Jen Gunter: [00:09:30] Again, because I was pissed off. Nobody was doing it. So, you know, I graduated residency in Canada. It's a five year surgical residency and came to the States to do a fellowship in infectious diseases. This was when all the care with HIV was just starting to take off and there was some sort of areas that I thought were going to be super exciting. And I thought, Oh, I'm going to do that and get involved with HIV care and women. And what happens when you do a fellowship in infectious disease is everybody sends you their patients with vaginal discharge. And then I started to realize that nobody knew what they were doing. And there were all these people who were, you know, basically being driven to distraction over symptoms that had been sort of dismissed or not taken seriously. And so I thought, wow, well, there's something to that. And I guess if no one else is doing it correctly, then I'm going to figure it out. And then, of course, when you're able to treat the referring providers, patients who have difficult to treat vaginitis and they start treating people with pain and so they just started coming.
Jen Gunter: [00:10:25] I was in Kansas City where I had done my fellowship and I stayed on staff and all of a sudden I became this tertiary care referral person. And so I was looking up journals, spending my days in the evenings in the library trying to figure out, you know, so again, before you could just look stuff up online. And then I started talking to my pain anesthesia colleagues and I was like, Hey, could you teach me this block and could you teach me this thing? And they're like, Sure. And I was like, Well, if I can open someone's abdomen, I can do a hypogastric nerve. Block So I just learned how to do all the blocks with fluoro before people use CT or ultrasound, all that kind of stuff. And so I kind of got into it that way. And then I thought, okay, well, maybe I should get board certified if I'm doing all this. So I did the boards and got kind of grandfathered in. So that's kind of how it happened.
Henry Bair: [00:11:07] A quick point of clarification for some of our listeners who are not in medicine. What do you mean by a nerve block?
Jen Gunter: [00:11:12] Oh, yeah. So, you know, nerve blocks. So if you've ever been to the dentist and they have numbed your mouth for something that's a nerve block You put numbing medicine around a nerve and in chronic pain. We do that for two reasons one, for diagnostic purposes. So if we numb a nerve and the pain gets better, that tells us that nerve is somehow involved in the pain. And sometimes if we put steroid medicine around the nerve, that can help treat it. And so that's what a nerve block is.
Tyler Johnson: [00:11:37] So you're a little bit unusual in the sense that instead of following a sort of already laid out prescribed path, right. Where you just went through the training that somebody had already figured out, and then you just started doing whatever you were doing. You kind of did something and then you kind of went in another direction and then you kind of got these other board certification and you kind of cobbled together your own career. You sort of made your own specialty almost in a sense. Can you help us to understand once you were all done with all of your training and of course, then later you have this sort of career as a public intellectual and we'll get to that later. But before that, just in terms of your clinical stuff, what were the bread and butter patients you were seeing? Like who was getting referred to you and how were you helping them in a way that maybe they had not been getting the help they needed before?
Jen Gunter: [00:12:24] Yeah. So chronic vaginitis. So people with discharge itching, pain with sex, pelvic pain, endometriosis, interstitial cystitis, which we now call painful bladder syndrome; people with all these diagnoses that were sort of neglected diseases, I would like to say perhaps. And so really just trying to come up with treatment protocols. And there weren't really a lot of, you know, a lot of national guidelines for a lot of those things. But, you know, so then I would go to the infectious disease meetings and I tried to meet the people there. And I was fortunate enough to meet Jack Sobel, who's, you know, a leader in the field and, you know, just started asking questions and getting involved. And then there was an infectious diseases society in ob/gyn. And so I joined that society, a small society at the time, but super important because, you know, at the meetings you'd everybody was doing the same thing that I was doing. They had sort of like cobbling together this sort of information, filling these needs. Yeah. So kind of like a rogue band of people trying to help when there are very few guidelines and trying to come up with what would be some evidence based or logical pathways based on what we were seeing. Kind of my bread and butter would be chronic itch, chronic discharge, pain with sex. And a lot of times we would just send me symptom people who just had like they had no idea what was going on.
Jen Gunter: [00:13:41] And they'd be like, Well, I don't know, but you helped my last three patients that I didn't know what was going on. So maybe you can kind of figure it out. You know, I think that office gynecology, which is a large part of what you do, isn't very well taught in residency. And I don't know what it's like in other specialties. I mean, I'm sure pediatrics teaches office medicine really well because that's what it is. But when you're in a surgical field, you often don't learn office stuff well. And the idea is you're going to just kind of pick this up as you go along, which is sort of offensive because these are real conditions and real problems. And just because they don't merit surgery doesn't mean or, you know, a biopsy doesn't mean that they're not serious or bothersome or life altering. So I kind of ended up in that niche again because nobody else was doing it. And that made me angry. And it makes me angry when people get bad care. Like it really makes me angry. I'm angry for them. You know, I'm angry at my profession. I'm angry at all the people who didn't listen to them. So that's how it all sort of came to be.
Henry Bair: [00:14:38] Can you give us some examples of what you mean by bad care that you get angry about?
Jen Gunter: [00:14:43] Oh, sure. I mean, somebody will say, I've had a vulva itch for ten years and oh, okay. And nobody's done it like they've just told you. Like, suck it up, buttercup, like. And they have. I mean, I'm not I'm not saying I don't believe my patient, but it's like, well, there's nothing to do. There are actually lots of things to do. And that's one thing I think a lot of physicians forget about is giving somebody a diagnosis, is doing something. It's actually doing something big. Even if you don't have an answer, if you can tell someone what you think is causing their problem, that actually makes them feel better because then at least they're like, okay, I'm not making it up. This is a real thing. And then maybe once you have a diagnosis, then you can actually do something about it. So lots of people come to me without any diagnosis. So my analogy for that is imagine you want to go somewhere and going somewhere is improving, getting better. But how do you go there if you don't even know what your starting point is? Right. You have no point on your map to start from. Where are you? Who knows where you want to go somewhere? I can't tell you how to get there because I don't know where you're starting from. So things like that. Like how do you tell someone for ten years that their itch isn't bothersome? If it was on their face, you'd probably have done something about it, right? Is it less important because it's on their vulva? No. So that would be an example. Or people have pain with sex and they're just told it's normal. I mean, it's not normal. So there are things like that. It just, you know, people who just kind of have their symptoms belittled and don't have them addressed because they're considered lesser, which I don't even know how that how that definition comes about. But that's sort of my experience anyway.
Tyler Johnson: [00:16:19] One of the things that I think is at least strikes me as unusual when. So I work in the hospital a lot and there's such a bright dividing line in the hospital between internists and surgeons. Right. Like these are like two entirely different worlds and never the twain shall meet. Except that then you have obstetricians and gynecologists who do. I mean, not internal medicine exactly, but a version of internal medicine and surgery all the time. And then on top of that, also deliver babies, which is an entire like world unto itself. Can you just talk a little bit about what it's like to be fluent in all three of those domains of care? Because it like to me as an internist, even as an internist, who then went on and did further training, and I'm a medical oncologist in oncology and administers chemotherapy and whatever, it's just like the whole framework of being a surgeon or even a proceduralist just feels it's not even like branches from the same tree. It feels to me like a totally different tree. So can you talk a little bit about being able to have of experience and whatever level of expertise and all of those different domains?
Jen Gunter: [00:17:24] Well, I don't do obstetrics anymore, to be really honest. I think there's a difference between being a super competent generalist who does all of these things really well and then the way medicine has become so, so subspecialized now, right? So I do like quaternary care medicine for like the vulva, really like quaternary. I'm really like a quarternist. I would be like the best way to put it. The more specialized you become in one area, the more like I couldn't tell you what like the screening tests are for OB anymore. Like, I have no idea. I could look it up and learn it, but I don't know it anymore. And so I think that there's places for both. There's places for people that have this great broad knowledge, right? Who are the front line people, Like people working in community hospitals and rural areas and general practices. And then there's places for people that are more specialized and and super specialized. And it'd be great if we had a better interaction between all of them. I think that that's one of the problems in medicine. I think in many specialties or many areas is that we're in too many silos, you know, and there's not as much, you know, intercommunication as there should be.
Jen Gunter: [00:18:34] There's not as much teamwork as there should be. I think, you know, maybe it exists more like in an ICU setting where everybody kind of has to come in round and you actually kind of have to talk. Maybe you're more likely to talk face to face, although I don't know what it's like now. I mean, I'm thinking about what it was like when I trained in the Dark Ages. So but yeah, so I think that having a broad scope is really great. Although medicine also is so changed so much since I've been in OB You know what, what's expected for an ob gyn to know now is really a couple of specialties. And I think that's why we're seeing it kind of branch out into kind of the OB hospitalist kind of avenue and also other more gynecological fields. And I mean, we've had reproductive endocrinology branch off. I mean, when I was training, lots of doctors did except for IVF, but did a lot of their own fertility care. And it's much less likely now. You know, we have so many more mfms, we have so many more urogynecologists. So it's just it's becoming bigger as medicine becomes bigger as we learn more, right?
Tyler Johnson: [00:19:31] Yeah. You know, it's interesting because in the medical oncology world, I mean, there are to be clear, there are definitely still general oncologists, but even places that are not super ultra academic medical centers are starting to see some differentiation where a person will be mostly a GI oncologist or whatever, precisely because, as you mentioned, like I don't like as a GI oncologist, I keep up with, you know, about seven main diseases, the research in seven main diseases. And even that is a challenge because there's so much information coming out in so many different things. And so the general oncologists who have to keep up with all the research in everything all the time, I frankly sometimes don't know how they do it. And that's just one subbranch of internal medicine. So to the point about an obstetrician and gynecologist and as you said, I understand you don't do all of those things anymore, but that seems even more overwhelming to me. My hat is off to people, generalists who can bridge all of those domains.
Jen Gunter: [00:20:29] Well, and also, too, I mean, you have to look at your surgical skills because, for example, when I graduated, I was very competent in a lot of uro-gynecological procedures, which are now mostly done by specialists. But I graduated probably with, you know, I came from a very, very heavy surgical program. And again, it's a five year program. But as I started to do all this other specialty stuff, I would see less and less of those patients. And then at some point you're like, Well, I don't really think I should be doing those cases if I'm only doing like two a year. Like, I just don't think I should because there's this other person who's doing two a week, right? So isn't it better that they do it? I'd want to go to the person doing two a week than the person doing two year. Right. You know, so you have to have that kind of self-awareness as well. Now, obviously, if I practice somewhere where that didn't exist and I probably would have been busy enough doing all those other things that I probably would have done a fellowship. And it's just a different pathway.
Henry Bair: [00:21:24] Well, thank you for taking us through your kaleidoscopic career path. Now, of course, you are most well known for your health outreach and communications work with the public in a way that is entertaining and accessible. Your first book was The Preemie Primer. Can you share with us the circumstances that led you to writing that book and how that experience keyed you into the need for more accessible health information?
Jen Gunter: [00:21:51] Yeah. So, you know, I got pregnant in 2003. You know, we always like to say that obstetricians have the, you know, the worst outcomes. And yeah, I did I so I had a triplet pregnancy because of course ruptured my membranes very early and delivered my first son at 22.5 weeks who, you know, we elected to not resuscitate and then managed to stay pregnant for three and a half more weeks in the hospital and then got sepsis at 26 weeks and had a C-section. And my sons were 1 pound 11oz and 1 pound 13oz. And so all three of us were in the ICU at the same time. It's a good time. And then on top of it, Oliver gets severe pulmonary valve stenosis and a large ASD and needed to have that repaired. But it was too small to have it repaired because they didn't make equipment small enough for that. And and then my other son was diagnosed with cerebral palsy and they both came home on oxygen. And Oliver ended up having, you know, having a his valve ballooned, you know, when he was 3 pounds. Can you imagine that? I have to tell you that the interventional cardiologist who did that to me, that guy is like a god. I'm sorry. Like, that's a skill set beyond. Right. And so, you know, along the way, you're in the ICU, your kids are intubated, everything is terrible. But I could speak the language and I would see people have interactions because, you know, you're all sitting together, you know, all these same parents.
Jen Gunter: [00:23:12] The doctors would come in and they'd say something and the person would like look at me and say, I don't understand that. And I would start like explaining. And I was like, Wait, what is going on here? Like, how are you not able to tell this person it's their baby, They need to know about it. And then you get to know all these parents because you all go to the same follow up visits at the children's Hospital and you sort of all you know, you move through the system kind of together and, you know, I'd start like leaning over and saying, well, say this, use these words, do this. And then I started realizing that that there is this like massive communication gap. And I even had instances where I'll never forget my son was, you know, had just come off oxygen and he hadn't had his ASD fixed yet and he was sick. I took him to an urgent care and they called an ambulance. We took an ambulance to the emergency department and for the brief moment the attending walked in, he looked good, you know, like that brief, like he had that like sort of five minute window of looking good. But otherwise he looked terrible. And the attending accused me of of like wanting a social admission. And I was like, What are you even talking about, dude? Like, I have another kid at home. I don't want to be here. My son is sick and he was awful to me.
Henry Bair: [00:24:24] I genuinely don't know what a social admission is.
Jen Gunter: [00:24:27] Oh, you've never heard of that. So a social admission is basically you don't need to be admitted, but the parent wants a break.
Henry Bair: [00:24:33] Oh, okay.
Jen Gunter: [00:24:34] Yeah. Or like the parents over-worried or something like that. And I'm like, Dude, I only got four board certifications. I'm managing oxygen tanks at home. I'm like, I'm not here because I'm stressed out. I'm here because my kid's got Strider and I don't know what his respiratory was like. 45, you know, like,
Henry Bair: [00:24:55] That's a lot, by the way.
Jen Gunter: [00:24:56] And yeah, and they sent us from ambulance from the urgent care, right? Like it wasn't like the urgent care took one look. We're like 911 like, so you know, there was a lot of additional information that available to this provider right. About what was going on. And I was like, I'm not leaving. You're admitting us. He's sick. And of course, he spent a week in the ICU with he tested positive for influenza A influenza pneumonia. And I just was like, if I had been like if my husband had taken them in, he would have get sent home. So just these kinds of communication issues just started to really weigh on me. And so I thought, well, let me write that into a book for people. And so that's how the Preemie Primer came to be.
Jen Gunter: [00:25:38] I thought, okay, well, if I could give people some of the information that I've learned along the way and the tips and tricks might be that would be helpful. And then I had a chance encounter with somebody who was a PR expert. I have no idea how it happened. Maybe like we were in line at Safeway or something or somebody some one of those weird chance encounters. And she's like, You know what you should do If you have a book coming out, you need to start a blog and get on Twitter. I was like, Cool. I don't know what a blog is and cool. I've never heard of Twitter before. And that's how I got involved with social media was initially to kind of promote the book. And then I figured out that it wasn't just prematurity where there was that big gap. And then I started to think about all my own patients and all the troubles they probably have had in communication and dismissal. And and I just thought, okay, well, what if I could give people a textbook about their health that was written on their level so they could communicate better with their providers and get the care that they need? That's how it all took off.
Tyler Johnson: [00:26:38] Yeah. You know, I will always have in my memory this encounter that I had when I was a training to be an oncologist, the person who was my attending that day, my supervising physician, was this one of the most famous doctors I had ever worked with. Right. Like the world expert in a number of the diseases that we were taking care of. And so we go in to this patient whose first language was not English and who had just been newly diagnosed with a relatively rare form of cancer. And so we go in and the attending gives this kind of very erudite and, you know, good quality, I think sort of monologue about this is what you've been diagnosed with and this is what that means. And here's the chemotherapy that we're going to give. And this is the, you know, the treatment course looks like. And anyway, goes on and on and on and talks for, I don't know, maybe 25 minutes. Then at the end of all of this, the attendings sort of wraps up and leaves the room to go see a different patient. And I'm left to finish some of the logistics and whatever of checking the patient out and after the attending has left. The patient looks at me and with this just very clear fear in her eyes says, So is this contagious? Oh, and I just remember being like Wow.
Tyler Johnson: [00:27:55] I mean, we were just not even in the right zip code, right?
Jen Gunter: [00:28:00] Yeah.
Tyler Johnson: [00:28:00] I mean, even as a trainee in that setting, I was about ten years into the training cycle after having started medical school. And, you know, in a lot of ways that ten years is spent getting further and further and further away from remembering what it's like to be a normal person who doesn't speak in medical jargon all the time. And it takes an incredibly thoughtful and diligently committed attending to not have the jargon come up all the time because it's just how your brain works, right? All of which is just to say that I feel like it's such a strange thing to note that we have gotten to the point where I feel like doctors almost need interpreters, even if they speak the same language as the patient. Right. Which is functionally what a lot of your public presence is doing is just interpreting what doctors are saying and doing so that people who are not steeped in the jargon know what the heck is going on.
Jen Gunter: [00:28:55] Yeah, I mean, I think doctors need to do ultimately need to do a better job. Ultimately, though, there's also all these other terrible time pressures. Right? So your primary care doctor, you have like 12 minutes with somebody. How can you even hope, even if you're the best communicator in the world, how can you even hope to explain, like the complexities of hypertension in 12 minutes? Right. Something that most people have heard of high blood pressure. But you know what? You need more than 12 minutes to sort of understand the importance of taking the medication of even if you feel good, it's, you know, you can't count on feeling good. You need the medicine to protect your kidneys and to protect your heart. And then there's all the competing forces then on social media telling you that you could just take mushroom tea or something to. So why wouldn't you do that? Because who wants to have a disease when you could take a mushroom tea? Right. So it's hard and it's complex. And I think that part of the problem is, is that you're fighting sort of on several different fronts, if you will. Like you're fighting the misinformation online, you're fighting the time pressures, the billing pressures, all these other things that none of them are in your patient's best interest.
Jen Gunter: [00:30:10] Right. And so you're just trying to do your best. And I and I always think about so imagine two imaginary interactions. One is a patient walks in the door and you want to talk to them about vaccines and they're like, Yep, I read everything on the CDC page and I know this and I know that, and I know it's going to protect me. And I know I'm due for this booster and that booster and sign me up, doc, And you're like, Great. And then you have the patient that comes in who's was Joe Mercola site and you know, and is on Infowars and they come in with all that. Like we all want to have the person who comes in with the correct information because they can get much more out of their medical care, right? And so I keep thinking, you know, part of what I do is how can I get more people into that bucket where they're now being able to walk into the doctor's office and they're able to maximize that time in a way that's better for them?
Henry Bair: [00:31:07] So you started with this book and you started with the blog and then maybe a Twitter profile. Where are you now? Like, can you give us a snapshot of like some of the communication activities that that you engage in now?
Jen Gunter: [00:31:19] So I have what I like to call the Gunter Media empire. So so along the way, you know, just and again, like on Twitter, I'm just me and you see my tweets and how I am. When I first started. So this was back in the day, they were like medical professional societies said it was unbecoming of a doctor to be on social media. And I use the swears and I was like, fuck off. Like, people want a real doctor. They don't. They want a real person. They want to know the person who's seeing them isn't a robot. They want to know that, right?
Tyler Johnson: [00:31:51] Was that a generally accepted thing? I honestly didn't know that that medical society said you shouldn't be. Oh, really? That's so interesting.
Jen Gunter: [00:31:57] So when I first started, oh yeah, there were very few doctors online and I'm like, Wait a minute, it's okay for Doctor Oz to say what he says, but it's not okay for me. And then it was because I swore, I'm not kidding. And I'm like, okay. You can choose two doctors, one who swears but follows evidence based medicine and the other who doesn't swear and is a snake oil salesman. Who do you want doing your surgery? Who do you want prescribing your medications? Who do you want? Yeah. So I just had a presence that keep growing, growing and growing. And I was very persistent with my blogging. I just kept writing because I was doing it for me. You know, every time I read a new article or there was something I wrote about, it helps me sort of my own personal continuing medical education, right? And then, you know, I got attacked by a celebrity. So that helps. You know, Gwyneth Paltrow didn't like me because I would say nasty things about Goop and other celebrities, too. But so apparently, you know, having a celebrity hate you is really good for your public image. And people like Don't you care? And I was like, no, Like, why would I care? Like, it's funny, you know? Then for a while, I was writing for The New York Times, and then I did a Ted Talk, and that was the third most popular talk of the year. And then I had a TV show in Canada and then I had podcast, and I'm still blogging. So, you know, I'm persistent.
Tyler Johnson: [00:33:22] Parenthetically, I have to say that the entire idea that people who are famous must therefore have really valid opinions or know a lot about things or whatever is just so weird. Right?
Jen Gunter: [00:33:35] But it's it's very true, though. Tim Caulfield, actually, he's written quite a bit on this. I believe celebrities come with them, this influence. They have this aura of influence around them. That's why they use them in advertising, right? Like you don't see me selling a car. You know, you see Matthew McConaughey, right? Not that he knows anything probably any more about cars than you or I do. So, yeah, celebrities have that allure about them. And we all mistake that for accuracy, I think. Or we mistake it for validity or, you know, or to have worth.
Tyler Johnson: [00:34:06] There was a study that one of my colleagues at Stanford did a few years ago. I'm forgetting the celebrity's name now, but there was a woman who I think had learned that she had a BRCA mutation or something, who was a very famous actress and decided to have a double mastectomy prophylactically. In other words, decided to have both of her breasts removed as a preventative measure so as not to get breast cancer down the line because a BRCA mutation is a mutation that you're born with that predisposes you to breast cancer. And the person was very public about it. Right. And I think with the best of intentions, I think was trying to say, hey, look, like this is something that I'm doing for my own health. And I, you know, and I feel like this is important to get on top of this and whatever. But there are two things. The one is that the necessity or utility of doing that, depending on a whole bunch of other things, which we won't get into. But the point is just to say it's not like a it's not a straight forward decision that everyone who has that mutation needs to have that surgery. That's number one. And number two, what the study showed was that in the year after she announced that decision, the rate of people in similar situations getting a similar surgery spiked significantly and there was no new evidence. The only thing that had changed was that she had announced that she had gotten the surgery.
Jen Gunter: [00:35:18] Yeah. And I think that, you know, it's a double edged sword because in medicine we do often a very bad job at explaining things or people have trouble accessing because of health insurance or all these kinds of issues. Right. But then on the other hand, if a celebrity is not spreading accurate information, then what happens there? I mean, you know, so it's hard. And, you know, explaining all that and people have biases know, I think that's one thing I've certainly learned writing for a lot of publications is I would say, well, this is a really important point. I'd write this piece and then the editor would be like, Yeah, no, I think you should really focus more on this. And I'm like, Well, that's not medically important. And that's actually not what I want to emphasize. And if you're telling me it's boring, okay, I can fix that. But you're telling me that's not the direction you want to go in. And I've heard that from many editors and many publications. Right? And think about it yourself. Think about some big article in whatever field you're in, and then look at how CNN covers it versus The New York Times versus maybe Medpage versus The Washington Post versus USA Today. And they're not always all telling the same story, but it's all the same article, right? So it's it's just interesting.
Tyler Johnson: [00:36:34] So I know that we're well into our time and I want to make sure we don't miss. So on your website, you have a tweet that you quote from yourself that says, come for the sex, stay for the science. Come for the science, stay for the sex. So, you know, so okay to rewind a little bit, everybody in medical school, maybe not everybody, but many people in medical school. This is a significant it's like a thing that you have to get over. The idea of talking to patients candidly about sex or any of that kind of any related stuff. Right. Because in general, friendly conversation, we just don't do this very much. Right. You know, And then depending on what you're going into and if you're going to do that a lot in your subspecialty, then most people sort of become accustomed to it and then whatever, it's fine. But you have gone far beyond that discomfort to making a sort of a national brand that not or international whatever brand that not that is wholly based on that, but certainly a part of what you do is to discuss candidly things that other people don't feel comfortable discussing, even with probably their close friends or whatever, let alone on in such a public way. So can you just talk a little bit about that aspect of your career? How did that come about and how does that play out for you?
Jen Gunter: [00:37:47] Well, I think a large part of it is coming of age medically. And as a young person in the early ages of HIV and every day it seemed like there was some young man dying and we had to call a lot of times family and sometimes we'd call and they'd hang up. They'd hang up because their son was gay and had HIV. And I was just like, I just couldn't get over how awful. Like, you know, just imagine you're dying in the hospital and and you don't get to die in your own home. And I just, you know, so I think we had to, you know, we you be like, I wasn't going to have sex with them if they weren't going to wear a condom. And so it was all of this was very, very mindful. And you had to you know, we were very kind of upfront about risks and talking with people and about, you know, what happens when you can't talk about it, like the devastating consequences. So I think for me it comes from that comes from those experiences. I can still see the faces of some of those those young men. When I was on AIDS service at the Health Sciences Center in the 1980s. And it just really, really affected me, this sort of this consequence of shame and how terrible it is, how terrible it is to be shamed over something that's so natural, like who you love or who you want to have sex with, like.
Jen Gunter: [00:39:13] It's just ridiculous. I just never really felt any sort of shame or anything. I just never it just seemed to me to be as normal to talk about that as it was to talk about your elbow or your toe or whatever. And then as I got involved in gynecology, I started to see how. What do you mean you couldn't tell your gynecologist you had an itch for six years? Your gynecologist. Well it's my vagina? Well, yeah, but you can tell, like, you know, where you see women coming in, and they're, like, embarrassed because they're on their period, and you're like, if you're a gynecologist and you're, like, upset that your is on your period, you're in the wrong field, Right? Like, that's like being a gastroenterologist and being upset that your patient has diarrhea, Like, that's why they're seeing you. So yeah, So I just think it kind of came from that. And also, my parents were my parents. You never, never talk about sex in the house. So I think I really enjoyed that. It really annoyed my parents, my mother specifically, because she wouldn't tell people I was the doctor.
Jen Gunter: [00:40:12] Never. She would say something else or I was in medicine, but she wouldn't say what it was. And she was still alive when my book The Vagina Bible was going to come out and she was just like, horrified, like, horrified. That was the title of the book. So, I mean, some of it might have been that too. One of my sons is gay and I was, you know, right on like, hey, you know what? We got to talk about Prep, let's talk about it. He's like, oh, I saw that on the bus. Great. You know what it is? Because they have ads for it everywhere in San Francisco. And let's talk about it and let's get you started. And, you know, I've coached lots of other friends with with kids who are going off to college. Hey, did you ask them about Prep? You should ask all your kids going to college. You just never know. And wouldn't you rather be safe? And it's so amazing. It's like a vaccine for HIV. But you take it orally and, you know, I just talk about it because once one person talks about it, everybody talks about it. And and why should you be ashamed?
Henry Bair: [00:41:08] That's actually really powerful to think about. Like once one person talks about it, it just you normalize it and, you know, people start realizing, oh, everyone's thinking about the same thing. It's this affects all of us, right? So what the last bit of time here, I'd love to ask about some advice you might have for our early career clinicians, our medical trainees, students, Pre-meds, What have you? Initially in my head, these were two questions, but actually they were kind of two sides of the same question, which is about misinformation and trust. So if you're in medicine, you're going to deal with misinformation that patients bring to you. You know, just today I had that, you know, I had actually this patient was was a nurse. She worked in health care. We were about to discharge her. And she asked me all these questions about all these supplements she was taking, many of which I have no way to address them because we just don't learn about them. I don't know what these supplements are, right? So it happens like on a daily basis. What advice do you have for dealing with misinformation respectfully with patients? And then I guess that would segue into having dealt with these delicate questions, these issues from patients throughout your career. What advice do you have for building trust with patients?
Jen Gunter: [00:42:20] So I would actually reverse it. So you have to build trust to be able to talk about misinformation. And I didn't realize that early on in my career, like when I first started talking about it might be like if I just give people the good information, they're going to take it, but then, like, why should they trust me? I mean, even though they're coming to see me as a doctor, like, you know, Oprah is telling them something else. Dr. Oz is telling them something else. The person selling a supplement is promising them something else. Right. So how does that happen? So I would actually say, unless you think that misinformation is like going to, like, harm them today, like urgently like, okay, that supplement we know interacts with whatever, your Coumadin and this is like super dangerous and we've got to like address this right now because if you fall and hit your head, it could be a problem, right? So unless it's something like that, I would actually say let it go and invest in being the person that they trust. So take the best care of them that you can, answer all the questions that you can, and maybe table those other things. Unless they come up as something that person really wants to discuss once you've built some trust. So you can kind of have that discussion because alternative medicine is a religion. It really is. If it was science, we'd be doing it right. And people align with the influencers. They're called influencers for a reason. Taking the pills is in many ways like taking the sacrament. There's a lot of ritualistic stuff that's part of it, right? There really is.
Jen Gunter: [00:43:50] Think about all the language that alternative medicine uses purity, goodness, cleanliness, getting rid of toxins. If you think about medicine, 200 years ago was all about the hunt for purity. Medicine and religion were very similar. And they only really separated in the 1800s. Right. That's why it's very evocative for a lot of people because we all want to get back to that natural state, that pure state, that unaltered state. And those are things that medicine doesn't offer. We want to treat cancer. We want to. So we're using these what are called devil words or devil terms and rhetoric and alternative medicine is the hunt for purity and goodness and natural. So I encourage people to think about it more like that. And so if I were to tell somebody like I would never go up to someone and say, you know, talk smack about their religion. Right. But that's how it comes across to somebody. If you just start talking about what they're doing because they've invested their time, their money, their beliefs in this system, and you're just not going to get anywhere. And so unless it's an urgent issue, I usually just let it go. And I do my best for the patient that I can in that moment. And then as hopefully they begin to trust me, then I'll say things. But obviously, you know, if they come in with a slew of labs or naturopath once, I'm not going to do them. I'm like, Your naturopath needs to have the credentialing to order those tests if they're important because I don't believe they're important. So I'm not going to do them.
Henry Bair: [00:45:14] What are naturopath labs?
Jen Gunter: [00:45:16] Oh my God. All kinds of hormone testing and things that each specialty has their own. I'm sure problems with that or alternative labs and stuff. And or they come in with microbiome testing and I'm like, there's no clinical studies that tell us what to do with those results. So I'm sorry that you spent all that money on it, but I can't I can't interpret them because the company hasn't done any studies to tell us what it means. And if I sample your vaginal microbiome at eight in the morning and ten in the morning and 12 in the afternoon and six in the evening, it's probably different every one of those times. So I don't know what these results mean. And we can cause harm in medicine by trying to treat things. You know, giving antimicrobials when they're not indicated can often cause a ton of harm, right? So I try to invest in the visit. I try to invest in doing the best I can for somebody. And then hopefully along the way, then people start asking more about supplements, more about this, or what do you recommend about that? And I'll tell them. And so I think there's a difference between someone who, for example, in oncology is like going to go to some clinic in another state and get IV vitamin C, you know, for their cancer, which is completely treatable. Maybe if they had radiation or chemo or whatever. And I get that right, like chemo and radiation. That's super scary, right? It's very scary. It's like, why wouldn't you want to go to a natural clinic that tells you they can cure cancer with that? So unless it's something like that where I think like my patients in immediate harm, you know, I try to invest in the return.
Henry Bair: [00:46:48] Well with with that we want to thank you again for taking the time to join us in conversation and for sharing your stories, for being so open and vulnerable. We really appreciate it. And thanks for all your work combating all the misinformation out there. It's been a true pleasure talking to you.
Jen Gunter: [00:47:02] Oh, well, thanks so much for having me.
Tyler Johnson: [00:47:04] Thanks so much. We really appreciate your time.
Henry Bair: [00:47:08] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:47:27] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:47:41] I'm Henry Bair.
Tyler Johnson: [00:47:41] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.