Podcasts Archive - Sanford Health News

Understanding gynecologic care for teens

Dr. Amy Kelley:

I think that this is not always the easiest thing for parents to talk about. And so having someone who’s super comfortable talking about periods, talking about body parts, that is something that is really nice for teenagers to have. I often tell teenagers, I’m like, if you have embarrassing questions, I’m the girl to ask. Yeah, I don’t get embarrassed. Really. It’s hard to embarrass a gynecologist.

Courtney Collen (host):

Hello, and welcome to “Her Kind of Healthy,” a health podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We want to start new conversations about age-old topics from fertility to managing stress, healthy living and so much more.

“Her Kind of Healthy” is designed to bring you the honest conversations about self-care, happiness and your overall well-being with our Sanford Health experts. We’re so glad you’re here.

In this episode, we are talking about OB/GYN care for teens. So, if you are a parent of, or caring for, a teen and just aren’t sure where to start, we’re here to help kind of take out some of the guesswork and make this feel a little less intimidating. Maybe you’re asking things like, is it too early? Is something wrong or is this just a part of a young woman growing up?

Dr. Amy Kelley is a board-certified OB/GYN and a specialist in pediatric and adolescent gynecology at Sanford Health in Sioux Falls, South Dakota. She is the perfect person to help us dive right in. Dr. Kelley, welcome. Thanks so much for being here.

Dr. Amy Kelley:

Thanks! It’s lovely to be here.

Courtney Collen:

We’re always glad to have you and your insights for conversations like this. So, let’s set the stage first and talk about what makes adolescent gynecology different from general gynecology care.

Dr. Amy Kelley:

Yeah, I think there’s two big things that make it quite different. One is that we typically have parental involvement in adolescence, and obviously when you’re an adult woman it’s just you and the doctor and that puts kind of a different dynamic on things sometimes, both for parents but also for teenagers because sometimes this stuff isn’t very easy for teenagers to talk about in front of their parents.

And so sometimes it’s one of the first times that they’re seeing a doctor and maybe we don’t have their parent in the room for the whole time. Or maybe it’s the first time they’re really talking to a doctor about things like, you know, their genitalia or their periods and so it’s just a little bit different, a different dynamic.

I think the other thing is that adolescents and young girls are not the same as adults. Their brains are not fully developed, and also their reproductive system isn’t fully developed. The first couple years after your period, that immature system can behave just a little bit different than it does when you get, you know, 3, 4, 5, 6 and beyond years past your first period.

Courtney Collen:

In a little bit, we’ll talk about what that first appointment might look like with or without an adult. And what those conversations, how they might flow. But first, what are some of the most common reasons or concerns that you see an adolescent going in for OB/GYN care? Why would they need that?

Dr. Amy Kelley:

Yeah, I think there’s kind of two big things that people come in for. One is the am I normal? Which is either like an anatomy issue or just a period issue where either Mom or the teenager for some reason is worried that something is wrong. And sometimes that’s true and sometimes it’s not. So that’s kind of, I call those the am I normal visits.

The other one is when they, the teenager or the mom or both of them really feel like there’s a problem like where something having to do with their period or reproductive health is interfering with their life and they need something done about it.

Courtney Collen:

What age or milestone – you talked about period, am I normal? So talk about like what age are we talking about and what age would you recommend a teen’s first visit?

Dr. Amy Kelley:

Yeah, so ACOG (American Congress of Obstetricians and Gynecologists) actually recommends that adolescent women be seen between the ages of 13 and 16 for their first visit. And I think that that first visit often just depends on if things are going well for the teenager or not.

So, you know, really people can get their period even as young as like 9, especially in non-white populations. And so sometimes we’re seeing adolescents and people who are going through puberty and they’re not even really teenagers yet. So anytime that there’s a problem or a perceived problem, we are happy to see someone.

I think you can always ask your pediatrician or your family doc first because sometimes parents just are not as familiar with what’s normal in puberty and what isn’t. They kind of only know what happened to them. So that’s a good reason to come in is if your family doc or you are worried that something is kind of going awry during puberty or afterwards or you’re having issues.

But if it’s just like I think that my daughter needs to have a gynecologist, then sometime between age 13 and 16 is a good time to just get established even if things are going well for her.

Courtney Collen:

Sure. So you say maybe you call them like, am I normal appointments? Those kind of routine 13 to 16 age group. Walk us through what that kind of appointment might look like. Who needs to be there? Is this you one-on-one with the teen? Walk us through what that might look like.

Dr. Amy Kelley:

Yeah, so if it’s kind of I’m getting established, like having some questions appointment, really it’s us sitting in a room and talking. It’s not very common that a teenager has to get undressed for us unless they have a specific concern about a specific body part. Most of the time we’re just talking about, you know, when they got their period, what their period is like now, are they struggling with other things in school. It’s really more of like getting to know them as a person, particularly if they’re doing well.

I think a big part of gynecology, especially for younger women is trust. Because you’re talking to somebody about periods when you get older. You might be talking to us about sex, about contraception. And those are things that a lot of people really feel like they have to have trust in the person.

And then when you get to 21, you have a Pap smear, and it’s super nice if you’ve seen us, even if it’s only every year, every other year, you kind of like know our face. You’ve talked to us a few times and by the time we’re actually doing some of those more invasive exams, people feel like they already know us.

And that’s really kind of the whole point of it is having access to someone who could, they can talk to you about things that maybe they don’t feel comfortable talking to parents about or honestly sometimes parents are like, I don’t really know. You know, and that’s fair, right? We are not always taught these things about our bodies.

But I think it’s really important and empowering for teenagers to know what’s normal and what isn’t and when they should call and talk to us. Because sometimes teenage years can be kind of a scary time, especially those first couple years after your period.

Most of the time parents are there, especially for that first visit. If I get the feeling that maybe the daughter or the teenager has a couple of questions that maybe they feel a little weird about asking, sometimes I’ll kick Mom out or I’ll ask, “Do you want to talk to me by yourself?”

And you know, sometimes if it really doesn’t seem like that then I won’t necessarily talk to her alone until her follow-up appointment. I feel like that’s something that kind of just really depends on the mother-daughter or the mother-parent –

Courtney Collen:

Dynamic.

Dr. Amy Kelley:

Yeah, dynamic. And also, a little bit how comfortable the adolescent might feel talking to me by herself because sometimes, you know, if you’re 10 or 11 and you’ve had your period for like a year and you’re having issues, you might not have ever really talked to the doctor just by yourself before. So it’s kind of intimidating sometimes.

I have everything from girls who are like telling me like what their blood looks like, you know, and all the nitty gritty details to someone who will like, barely even talk to me or like just doesn’t even want to even say the word period and you know, I think that just goes to like the fact that everybody’s individuals and this is a huge age range, you know?

If you’re 9 or 10 and getting your period, that’s a very different conversation. You’re still in elementary school. There’s different ways you look at the world than when you’re 13, 14. I mean there’s a huge amount of growth during that time and so it really can be quite widely different.

Courtney Collen:

Is there anything that a parent or caregiver can do before an appointment to help a teen feel prepared for a conversation with you?

Dr. Amy Kelley:

I think like just at least giving them the heads up of what kind of doctor we are. So like when we come in and start talking about periods, they’re not like, oh my god, what is this?

So I think at least them like knowing what kind of doctor they’re going to is probably a good step. Yes. It is helpful if people are having periods – especially if they’re having period problems with pain or irregular periods or feeling like they’re really heavy and unmanageable – I do think it’s helpful to maybe look and if you’ve been tracking periods or if you kind of have a calendar to look back on that so that you can answer some of those questions when we’re talking about some of that.

I feel like a lot of moms do that, but sometimes people come in with like their guardian, maybe like a sibling that has guardianship or foster parents or even like dad sometimes because that’s just the way it works out. And oftentimes those people maybe don’t have an idea of what that period pattern is. So just kind of either knowing that or making sure your kiddo knows that. Or your adolescent knows that. That’s very helpful.

Courtney Collen:

Even just jotting it down in a phone on a notes app or something.

Dr. Amy Kelley:

Yeah, absolutely.

Courtney Collen:

That makes sense. Can a teen schedule their own appointment?

Dr. Amy Kelley:

Typically, at least not in the state that we’re in (South Dakota) because we do have to have parental consent to see teenagers, to see people until they’re 18.

Courtney Collen:

Got it. How can parents or caregivers navigate normal puberty changes versus something that may need medical attention?

Dr. Amy Kelley:

I think that there is a wide variety of normal, which also throws a little bit of a wrench in it. But I do think that keeping track of periods when they first start to kind of know like what the actual pattern is. Is your teenager having issues with the period? Like, you know, is she bleeding through her clothes or onto her sheets at night? Are you noticing lots of clothes that have blood in them? Are you noticing like big mood changes around a period or that your kiddo is always missing a day of school because they feel like awful during their period or they’re throwing up? Those kind of things.

I think kind of just noticing that and kind of taking inventory of that I think is a good idea. Also being able to talk to them. You know, we’ve talked in the past about communication being really important during the teenage years even though they push you away and this is one of those times where you may have to pursue your kid a little bit, you know, and really make an effort to talk to them about these issues.

Because they may not always be super forthcoming about it. Especially if they’re embarrassed, like if they are kind of leaking into their clothes and things like that. That’s something that a lot of teenage daughters are like, you know, they kind of just don’t want anybody to know about. So sometimes you have to pursue your kids a little bit if you want to kind of know how they’re doing.

Courtney Collen:

Great insight. What should we understand about conditions like PCOS, which is polycystic ovary syndrome, endometriosis, or severe period pain in adolescents?

Dr. Amy Kelley:

Yeah, I think that the biggest thing is that if your kid is acting differently because of their period, like as far as missing school, not doing the things they normally do. You know, if they’re a runner and they never run during their period or if they aren’t going to their sports practice during that time because they don’t feel good. If it’s interfering with their life, it’s really time to talk to somebody about that because I think that sometimes if we had terrible periods as teenagers and nobody really did anything about it and they’re just like suck it up, then sometimes we’re like, oh well that’s normal and it might technically be normal but we can help so much.

And it’s really rough. Like teenagers, if they miss a couple days of school and you’re in high school, you’re behind. You know, it’s really hard to make that up sometimes. And so it can really interfere with their life even if you don’t necessarily always perceive it as being abnormal. If it’s interfering with life, it’s time to just come and see if we can help.

Courtney Collen:

And even if it would be normal and this is just kind of part of the routine, maybe you have some mild cramping but it’s new and it feels overwhelming. It’s still OK to come and say, “Hey, this is what’s going on.” Or a parent saying that, or the teen, and you just reassure them like this is part of this process.

Dr. Amy Kelley:

Absolutely. And I think if you’re not sure if it’s normal or not, then send off a message to your primary care provider if you haven’t seen us yet, you know to your pediatrician or to your family medicine person. They may or may not feel comfortable following up with you on period issues. I think it kind of depends on the person.

But they can, they do know what’s normal and what isn’t and what maybe you should come in for. PCOS is something that regular puberty can look a lot like. PCOS and regular puberty for the first two years after you get your period, there’s a wider variation in what’s normal. You can get it every 20 to 40 days. It can vary from period to period and how long it is and how heavy it is. And so PCOS in itself is not always something we diagnose until people have had their period for years.

And that’s really because some of the normal puberty like beginning of your period things are the symptoms of PCOS too. You know, like a lot of kids get acne and that can be a sign of PCOS but it can also just mean your kid just is going through puberty. So that is something that if you have concerns about, absolutely ask us about. But just know that it’s not something that we’re going to be like your kid has this right away because it isn’t something we typically diagnose in the first couple years after they get their period.

With something like endometriosis, that is something sometimes kids have symptoms right away. Really the thing I always tell people to look out for if you have endometriosis in your family is if right away periods are really painful and have painful or they have lots of GI issues around the time of their period.

Typically for the first couple years teenagers don’t always ovulate. And so actually, usually their periods aren’t painful. So if your kid, very first or second period, is already really complaining, pain, missing school, that’s not necessarily what I would expect. I think sometimes people watch that for a little bit and don’t realize that it, for kind of your typical puberty, it’s going to take two to three years before you have pain. That’s kind of what we expect is you don’t have pain right away. So if you do, that actually is a good reason to contact us.

Courtney Collen:

Could an adolescent gynecologist such as yourself be considered a patient’s primary care provider? Like talk about how you and other adolescent gynecologists might work with primary care providers, physicians?

Dr. Amy Kelley:

For most part, I really recommend that people still stick with their primary care physician, whether that’s a family medicine person or a pediatrician because there are some things that I think is better from them. And I don’t think that we completely can cover everything that a primary care doctor can cover. You know, certainly there’s lots of stuff that we can do. If you’re behind in your vaccines, we’ll catch up.

I think there’s value in still seeing your primary care provider. And that’s particularly true if your kiddo has any medical issues because we don’t really necessarily like take care of asthma. If your kid is sick, I’m not going to see your teenager to do a strep test. And so you still need your primary care doctor.

And both myself and Dr. (Elizabeth) Miller who are the two OB/GYNs here at Sanford who do a lot of pediatric and adolescent gynecology, both of us talk to pediatricians. If family docs have questions about something, we get messages from them all the time, and we will often kind of answer some of their questions. Or if they are wondering if someone should come see us, that’s a communication that’s often happening in the chart.

We are very happy to work with your primary care doctor, especially for kiddos who have like complex medical issues. Which is one of the things that we do a lot of is complex people, teenagers with diabetes, with like Type 1 diabetes or other significant medical issues. Sometimes periods are part of that, or they make it worse, or they need kind of some different kinds of care. And so that’s something that we really work well with primary care providers to make sure that we’re kind of covering the whole person.

Courtney Collen:

Sure. So you would really recommend starting there at your primary care provider, family medicine provider, and then it would essentially be a referral to you?

Dr. Amy Kelley:

Absolutely. You know, occasionally moms see us and they’re like, “Hey, my daughter – this is happening. Is that OK? Can she come see you?” And yes, of course. Like that’s also an OK time to ask. We may not have a lot of time to delve into it because we’re really there to take care of you if it’s your appointment. But many of my colleagues will see teenagers, especially older teenagers and often do when they see like the mom, you know, because then they kind of have that continuity too. And it’s somebody the mom trusts.

Courtney Collen:

Why is it important, Dr. Kelley to have specialized care for this early stage of life?

Dr. Amy Kelley:

I think that this is not always the easiest thing for parents to talk about. And so having someone who’s super comfortable talking about periods, talking about body parts, that is something that is really nice for teenagers to have.

I often tell teenagers, I’m like, if you have embarrassing questions, I’m the girl to ask. Yeah, I don’t get embarrassed. Really. It’s hard to embarrass a gynecologist.

A lot of this stuff is new to both parents and to teenagers. It’s a learning curve kind of to know how to address it as well as sometimes what’s normal. And I think a generation or two ago, like people didn’t talk about periods. You know, we hid when we were going to the bathroom, we were like, you know, did everything we could to hide those tampons. Like nobody should know that we’re having our period.

Courtney Collen:

Keep the wrapper quiet.

Dr. Amy Kelley:

Yes, absolutely. Like even in the stall you’re like, don’t make any noise.

Courtney Collen:

Coughing over the sound.

Dr. Amy Kelley:

Yes. So I think that has changed for the better, you know, for the most part. But it’s still one of those things that sometimes parents aren’t exactly sure how to address certain issues. And some things have changed. Period underwear was not around a generation ago. Like menstrual cups and discs and some of these things like moms are like, I don’t know anything about this. I need some help here. Which is totally fine and we are here to help.

Courtney Collen:

I mean we could go on and on about those products.

Dr. Amy Kelley:

Well yeah and we could go on and on about, you know, all of these things, about sex education and how, and you know, and you and I have talked before that unfortunately I don’t think we always get the greatest reproductive health education. And so, you know, I think that sometimes talking about these things isn’t easy for parents either. And we are here to help them out, but we’re not here to take their place. You know, like it’s still super important that you talk to your kids about these things and have that open communication. But we can help you with that. Especially if you feel a little bit unprepared for it.

Courtney Collen:

Yeah. At least helping lay the foundation and giving you a platform to go from there. And we’ve had so many conversations about how to navigate those conversations which has been super helpful for our audience.

Are there any misconceptions you hear, or I’m sure there are plenty you hear, but help us clear some up. What are some of the things that parents might not be totally clear on when it comes to adolescent gynecologic care?

Dr. Amy Kelley:

Sometimes people come in and they have prepared their teenager to have a speculum exam and to have a pelvic exam, and so one of the big things is we don’t do Pap smears until age 21 unless you’re a transplant patient. But we don’t have a lot of transplant patients in young people.

Courtney Collen:

Do you mean transplant patients?

Dr. Amy Kelley:

If you’ve had an organ transplant. If you’ve had a kidney transplant or a liver transplant, then we start them at 18. But that is a very, very small slice of the pie. Most people don’t need them until age 21.

And that’s a common question I get and sometimes people ask me why and we talk about the fact that most people if they have mildly abnormal Paps as teens, they go away. And that’s why we kind of wait and check at 21.

The other thing that I think there’s a misconception about is that I’m just going to talk to people about birth control and I’m just going to talk to them if they’re having sex and all we’re worried about like is preventing pregnancy, which yes, super important to prevent pregnancy. And there are teenagers having sex and that is a reality parents need to know. But that is not the only reason to come and see us.

Many people have period issues to the point where it is bothering them. It is interfering with their life. Sometimes, if you have other medical problems, it’s interfering with your other medical problems. And so we often do period management or menstrual management for many, many other reasons.

So your teenager can come and see us even if they’re not having sex, even if that’s not even like anywhere near their reality yet. And I think that that’s something that can sometimes like be misconstrued as well.

And then I think like just what the first couple years of having periods is like and how it can be a little bit more irregular than when you’re an adult, and I think a lot of moms don’t always realize that. So I talk to a lot of people about that as well.

Courtney Collen:

Thank you for helping us clear that up. That’s really helpful. How do early positive experiences with reproductive health care shape a teen’s long-term well-being?

Dr. Amy Kelley:

I think it can make a huge difference. You know, if you have a traumatic experience at 21 with a Pap smear with someone you’ve never met before, then how likely is it that you’re going to come back and get a Pap smear the next time you need one?

You know, maybe you won’t because it was super traumatic and weird. Having some comfort with somebody before we’re ever doing some of those things that are a little bit more tricky and it’s not that Pap smears – Pap smears should not be painful. They should not be difficult for people. But I think there’s this idea in culture that like they’re the worst things in the world so people are scared of them.

So it’s so much better if when they’re doing something that they think might be scary, that it’s with somebody that they have seen for a couple years and somebody that they’ve talked to about hard things already. Because if you have good experiences early on, you’re more likely to get routine gynecologic care. You’re more likely to talk to your doctor when something is going on and you’re not sure if it’s normal or not. And those are really important things to talk to your doctor about and to not be embarrassed to ask about.

And I think that the earlier we learn all our body parts, the earlier we learn how to talk to people about these things that can be a little more difficult to talk about, the better off we all are. And hopefully that will lead to your teenager becoming an adult that takes good care of their health, that knows they have somebody they can come to if they’re having these issues. And that they won’t be too embarrassed to ask us when they have issues.

As you know, I’m a huge vaccine advocate. Vaccines are one of the most important medical advances we’ve ever had. And one vaccine in particular that teenagers, or actually you can get it as young as 9, is the HPV vaccine. And I would just encourage parents if they have any questions about it, talk to your primary care provider. If you’re seeing one of the adolescent gynecologists and your kids have not gotten that yet and you have questions, please ask us.

HPV does not just cause cervical cancer. It causes head and neck cancers, it causes rectal cancer and it is transmitted skin-to-skin so you can get it without having penetrative sex. You can get it without having sex at all. And you can get it even when you use condoms consistently. Almost everyone gets exposed to it at some point in their life.

And I think there’s a lot of misconceptions about it and I often am like talking to people about it in their teen years because they didn’t get it when they were younger. And it works the best if you get (HPV vaccine) before age 15. It works, and you only need two shots if you get it before the age of 15. Hopefully soon, maybe we’ll only need one. But as of now we recommend two by the age of 15.

And so I would just really encourage people to talk to their doctor about that. I completely understand everybody wants to do the right thing by their kiddo and it’s OK to have questions. But definitely it’s also OK to ask us so we can tell you what we think and what we know.

The only other thing I would say is there are a couple of vaccines that your kids need before they go to college, their meningitis vaccines. One, which is one of the other reasons why it’s still good to keep in touch with your PCP and still go to annuals until your kiddos are adults. But those vaccines are really important, and you don’t want to be getting a ton of vaccines the summer before you go to college when you can start getting them when you’re 16. So also just remember that there might be some vaccines your kids need at age 16.

Courtney Collen:

Good to take note.

Dr. Kelley, thank you so much. This was such great information and so helpful as always to have your insights on this topic. This was part of the “Her Kind of Healthy” podcast series by Sanford Health. For more, listen wherever you get your podcasts or online at news.sanfordhealth.org.

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A rural-urban residency rotation model

Courtney Collen (announcer):

“Reimagining Rural Health,” a conversation series brought to you by Sanford Health. In this series, Sanford Health leaders and expert guests share insights, innovations and real-world solutions to the toughest challenges in healthcare today. Each episode explores the ideas, tools and partnerships advancing rural healthcare and strengthening care in communities across the country.

Joining us in this episode is Dr. Daniel Hoody, chief medical officer and chief physician at Sanford Health in Northern Minnesota, as well as Dr. Meghan Walsh, chief academic officer and president of the medical staff at Hennepin Healthcare.

Together, they explore how a rural-urban residency rotation model offers an innovative, scalable approach to physician training — one that addresses rural workforce challenges while strengthening the resident experience.

Dr. Dan Hoody (host):

Meghan, welcome. Thanks for joining us. I’ve been really looking forward to this conversation.

You oversee residency programs at a large Level 1 safety net academic medical center, Hennepin Healthcare of Minneapolis. So, when you consider that only 2% of residency training programs occur in rural communities where 20% of the population lives, what does that tell you about how we’re building the physician workforce today?

Dr. Meghan Walsh (guest):

Dan, the reality is that nearly half of the residents who train in a state stay in the state when they’re done training, and nearly two thirds remain in the region where they train. So, it tells me that where we’re training folks is where they’re remaining in the vast majority of training in urban areas. So that’s one of the challenges that we’re facing in graduate medical education is that over 95% of our training programs are in big cities.

Dr. Dan Hoody:

Well, I’ll be honest, I did not fully appreciate that gap until I came back to Bemidji. I grew up here, as you know, and I was always aware of some of the staffing challenges. My dad was in a similar role that I’m in now here. And so, I grew up hearing about how hard it was to get clinicians up into Bemidji. But seeing the data in front of us really brings us into focus.

Dr. Meghan Walsh:

I think what that tells you is that residency and fellowship is one of the most powerful and reliable levers for building a workforce. We have to move residency education and fellowship education into communities where we’re looking to grow a longstanding pipeline for doctors to work in smaller communities. And it does begin with programs like ours.

Dr. Dan Hoody:

Yeah, we can’t really expect physicians to practice in rural communities if they really never trained there and don’t know what it’s about. You know, in the context of the partnership that we’ve developed with Hennepin here at Sanford Bemidji, you know, thinking back to the conversations that the teams had years ago, what was the hope from the Hennepin side on what could be built?

Dr. Meghan Walsh:

You know, our original vision began in emergency medicine.  So, we’ve been training residents and fellows since the late 1800s. We have over 20 programs, over 270 residents and fellows that train here at Hennepin come here to train. And we retain the vast majority. Over 70% remain in the state when they’re done, but they stay in the big cities.

And so emergency medicine came to me saying, I think we need to have some training time in smaller communities. I’m worried about our workforce readiness when we graduate an emergency medicine resident who has only worked in a Level 1 trauma center.

In their department, in our department, probably within three to five minutes, they can get any specialty at the bedside in the emergency department. Neurosurgery, general surgery, psychiatry, OB/GYN, you name it, they can get bedside assistance from other specialists, from other team members, from advanced technology, et cetera.

And then we graduate these trainees and they go out to communities all over the country. And many of them enter their first job not having trained in maybe perhaps lesser resourced areas or where certain subspecialties don’t exist. And frankly, a career is a long time to be afraid.

And so the emergency medicine groups that we really want to have among at minimum opportunity for residents who want to work in smaller communities or outside the metro to be able to train in these spaces. You know, Sanford Bemidji was the perfect partner because there was some core faculty members at Sanford who were also, who trained in big cities, who moved to Bemidji, who really wanted to teach and train in emergency medicine.

I think that the partnership began with a relationship, and the relationship was with faculty and between faculty. And once we started with that relationship, the rest was logistics. So it was a pilot trial, and it was so popular that it moved from one specialty with one resident and now has expanded to, gosh, five specialties. And I mean, I don’t know, I think we’ll have over 20 residents having experienced Sanford Bemidji in a wide array of fields.

Dr. Dan Hoody:

You know, and as I reflect on that approach, what comes to mind is my experience growing up as a rural kid and getting all the rural interventions, going through a rural med school, going through the rural track at the rural med school, and spending a majority of my career in an urban center, while this intervention doesn’t really focus on rural kids.

It’s with the emergency medicine approach that we all took that it takes every single resident, even those that have never had a rural experience at all. And that’s a different fundamental intervention than most of the interventions we’ve had to try to get medical trainees in rural practice.

And so when you think about that in particular, there are lessons learned from the, not just the “I’m interested in rural medicine” (trainees), but we’re going to take all comers from a residency specialty. Are there lessons learned there that we can extrapolate as we move forward?

Dr. Meghan Walsh:

You know, the current state in the United States around rural training is that rural health systems need to build and grow their own training programs. That’s where the federal funding is. That’s where a lot of the expansion criteria exist within accrediting bodies. You know, create either a rural residency program or a rural training program where, you know, one-third of the time or just under half the time is spent at an urban center and the rest is spent in a rural community.

But what hasn’t been, I think, really explored to the degree that we are creating here in Minnesota is a one-month rotation for every single member of a residency. You know, basic back of the napkin math, if you grow an emergency medicine residency program, you want a rural program, it’s going to take you years to build it up. You are going to have to carry all of the infrastructure and the accreditation requirements, which is a lot of work, a lot of personnel, a lot of investment. And you may recruit three, four per class over a three-year program. You will graduate nine ER residents, emergency medicine residents in three years, plus whatever it took to build.

In this model, we send one resident per month. We have 12 per class. So, in three years, you’re having 36 residents experience Sanford Bemidji, the emergency medicine program there, meet the faculty, see other ways of practicing. It’s just a completely different scale with less investment. And I think it’s a great way to try out a new space and make sure that it works for everyone. And I’d be lying if I said I knew that this was going to really grow and that this would be really popular.

But every single resident that has gone up there from emergency medicine to now internal medicine, general surgery just came back from their first month up there, psychiatry is going up there. And I think all of these specialists, these specialties have been really well received, and the residents have come back and they’ve spread frankly the joy and convinced their peers that this is an important experience. So, they moved it farther and faster than you and I could have just kind of telling people it was a good experience.

Dr. Dan Hoody:

You know, I would agree with that. I’ve heard similar feedback on the ground here from our staff. And I think when I think of the outlay and design that you just walked through, I imagine the majority of the residents coming up here sitting at 80% of our medical trainees that have never set foot in a rural facility in their training.

And so what’s exciting to me as I think and reflect on what we’ve accomplished so far is that we really are turning a passive decision about not to practice rural into an active one for so many of the medical trainees that are coming through here, which is exciting.

And I want to pivot a little bit to build on your last comments there. So the resident experience. So you shared that residents and applicants were in interviews, had started to ask, is there a rural experience? Is there any way to get me out of downtown Minneapolis for at least part of my time? That stood out to me both as a rural kid, somebody who’s worked urban and now back in the rural setting.

So what were you and your program directors hearing from residents? How did that interest evolve over time? And what lessons can we learn from that going forward?

Dr. Meghan Walsh:

Well, the current state of either you train in an urban hospital or you go to a rural training program, which by the way doesn’t exist for every specialty. Rural programs are primarily primary care, maybe a sprinkling of general surgery.

There’s one up in Duluth, which isn’t truly rural. And you kind of recruit to the region. And I think what that did is it selected for folks who said, I want to work in a city or I want to work in a small town. And I think that we really decrease the opportunity to really learn differently and maybe open the door to people wanting this future practice.

And so I think this hybrid mix of the two really helped us bring folks in who want to do some real time, but don’t want all of their training there. I mean, I want to be a general surgeon or if I want to be a general surgeon and I come to Hennepin and I want to really have the reps and I am going to get the reps at a Level 1 trauma center. But I think I want my life to be in a smaller community.

There is a lot of fear in a resident’s mind that they aren’t going to have the skills to practice in a rural community. What do I do when I don’t have all these specialists? How do I enter into maybe doing C-sections as a general surgeon when I never did them in a trauma center because I have OB? And so I think that residents started coming to Hennepin saying, wait, I get the moon and the stars. I get to have all the reps in an urban center. And I also get to try out a smaller community.

And in fact, Dan, I just got an email back from our first general surgery resident who was up there last month. I think you met him. He sent this great email about this being a phenomenal rotation. And he mentioned things that I hadn’t thought of. One of them is that he had exposure to techniques that we don’t do at Hennepin. So he said, I got to do all these different procedures that I don’t do at Hennepin because ENT does it or ortho does it. And I got to do it.

But he said also techniques that come from Mayo and Marshfield and UND and other graduating programs. When I tell you that 87% of our faculty trained at Hennepin, we start to generate a culture of this is how you do things. But when you leave our system and you go to yours, they’re starting to see, wait, there’s multiple ways that I can approach this procedure. And he thought that might have been the most valuable part of going up there is just getting all these other skills that he’s never been introduced to. And he’s a fourth-year surgery resident.

Dr. Dan Hoody:

You know, and as we’ve had the good fortune of being able to take some of the residents out for dinners and other activity excursions and they fill us in on the experience they’ve had here so far. And we were just out at a resort on the north side of Lake Bemidji earlier this month.

And one of the emergency medicine residents alluded to that similar thing. There’s the Hennepin way and then there’s a whole bunch of other ways. And this is a great way to learn the other ways. As we’ve reflected on the resident feedback, it’s also been interesting to see the staff feedback here.

When I remember the discussions shortly after I got on the ground and we were talking about the emergency medicine residents to come up, I had heard from staff, not just in the emergency department, but in other specialties that were understanding we may be expanding this at some point, they said, I didn’t come here to teach. And we had a lot of discussions about that.

And as we unpacked things, even before the first resident got on the ground, it was important for people here to understand that we weren’t expecting chalk talks on sodium transporters in the kidney or the Krebs cycle or anything else like that, that our staff were going to teach by just showing residents how they take care of patients in Bemidji versus the Level 1 trauma center and all those apprenticeship learnings that the 200-plus clinicians here have brought from their own training programs, the apprenticeship of medicine.

And so it was exciting on the ground here to see even with that first emergency medicine resident, the flip after two shifts in the ED, where it went from, “hey, I’m not sure I want a resident” to “when does the resident get to work with me?”

And I was actually meeting with all the emergency medicine physicians last night at my house, just reflecting on the last year and planning for the next year. And one of the most exciting things was hearing all the staff around the table highlighting their commitment to and how they wanted to better standardize the resident experience in Bemidji.

They all want the residents and they want to make sure that if somebody else has a cool case, when the resident’s working with another staff, we have a good understanding of how we can make sure they’re getting the best experience that they can.

So, it’s been really exciting, not just to see the staff appreciation and the staff interest and the staff curiosity and the emergency medicine side, but we’ve seen that expand into internal medicine. The surgery experience you just talked about was great. The surgeons here loved it, and they’re excited for the three residents that are going to come up next year.

It’s been really fun to see that powerful effect that the trainees can have on just increasing the curiosity in the clinical care environment here. So it’s been a great big win on our side too. And some myths that didn’t turn into truths, and the truths have been really largely positive.

Dr. Meghan Walsh:

Well, and I think your faculty had largely been working with medical students, which is a very different experience than working with residents who have had a ton of experience in the OR who, you know, open or close semi-autonomously, right, to an ED resident who can grab an ultrasound and diagnose something independently. And I think that that contributes to actually your ability to care for patients, your ability to learn in both directions.

And I think we underestimate how much a training environment or a trainee also teaches me. I work in a clinical environment where I am learning. When did we, you know, I remember when pro-calcitonin started getting ordered and I thought, what, you know, grand rounds did I miss? Everybody’s, you know, ordering pro-calcitonin, telling me the literature, starting to share it. We’re talking about applications and it’s true. And ultrasound – one of the things we worked with your team on is how could we get more ultrasounds on campus through state support?

And in turn, our residents are getting, especially in the emergency department, a ton of ultrasound training. And then they can bring it up to some of your faculty who may not have had that in their own training programs. Then I think it moves everybody to a higher bar because the teachers become the learners and the learners become the teachers.

Dr. Dan Hoody:

Such a great and powerful point. And it’s been exciting to see, I know Casey, the surgery resident we had this last month, gave a grand rounds on, I believe it was frostbite or some other surgical complication that is very common here. And it was a, what I heard it was a full house. So it’s been exciting to see them integrated into our learning environment beyond just the clinical care. Absolutely.

Dr. Meghan Walsh:

Can I ask you a question? Are you finding that by having trainees, it’s affecting your ability to recruit?

Dr. Dan Hoody:

It’s an interesting question. It’s a powerful one. The goal of this is educational right? We want to do our part for educating the future of rural clinicians throughout America and so ultimately on its own if residents leave with a better understanding of what it’s like to practice in rural America, it’s a success for us.

There’s a secondary component that we are hopeful to see if there are some particular residents that really find a resonance with working here that they’d be interested in choosing a career here. And I can say prior to 2024, I think we had zero emergency medicine residents in the previous 10 years interested in a job in Bemidji. And since this started, I believe we’ve discussed employment with six. And I think we have our first two emergency medicine clinicians that will be working here in the fall as staff physicians. So it’s been exciting to see that component.

We obviously hope that we can put on a good experience for the residents and if it’s good enough that they want to come back and join us. This is a great place to work. Rural medicine obviously has a lot of benefits to offer people that even ones that have never lived or practiced in a rural community and so it’s been exciting to see that. We’ve also heard interest from some of the other specialties that we’ve had here as well.

So we expect in the coming years to see ultimately the fruition of whatever pipeline forms from this intervention throughout the different specialties that we’re looking at.

Dr. Meghan Walsh:

That’s great.

Dr. Dan Hoody:

You’ve highlighted, Meghan, a few of the resident feedback components. Are there any others, feedback or reflections that stand out beyond what you’ve already highlighted?

Dr. Meghan Walsh:

Well, I’ve gotten two pieces of feedback about how the environment that they’re staying in, their housing, just how supportive the community has been. Minneapolis has been hard. The hospital has been a hard place to work with a lot of sort of events over the last few years. And it isn’t always this sort of welcomed environment for a physician learner to be in a setting where they feel like there’s a lot of gratitude for being in medicine or taking care of a patient for a whole bunch of different reasons.

But I think the fact that the community really welcomes them and says hi to them and says, are you the resident? I keep hearing stories of like, I feel like I’m part of something. And even in a short period, of, I’m not just the resident over there, but I’m actually kind of been invited into the community.

I have one internal medicine resident went to his first ever hockey game. He could not stop talking about how fun it was. Another resident that went out for dinner or drinks or something. And there was a whole community of faculty who were there.

And I think just seeing, you know, the lived experience of what does it feel like to, I mean, to sort of build that identity formation, because they’re all in training, but they’re trying to figure out what does my life look like? How do I want to live it? Where do I want to work?

You know, are you all loving where you are or not? And I think there’s much more integration of work-life happening in your space than they get at Hennepin. We all go home, we all leave the hospital, and there isn’t a lot of intersection between the faculty world and the resident. And I think that there’s some real value to sharing in that a little bit more.

Dr. Dan Hoody:

That’s great to hear. And it also reminds me of some of the feedback we’ve heard even just recently this week in a primary care meeting of patients attributed to our primary care clinicians that are coming back from visits in the emergency room saying what a wonderful experience they had.

They got two doctors, they got a resident and another doctor. And as we’re talking about expanding into other specialties, we’re hearing more and more from our patients that they also, they like it and they can see the benefit of having trainees in the community.

I did hear there was some disappointment in that we have not fine-tuned the alert for when the Northern Lights are. We’ve had a couple of residents that have had great experiences with the Northern Lights. A couple were disappointed because we had the Northern Lights and apparently nobody told them, so we’re working through that. So there’s still a few you work out, but largely we’re trying to really give them the full experience.

Dr. Meghan Walsh:

You know, I’ve spent a lot of time at the Capitol because Hennepin’s just going through a lot and it has been so powerful to have greater Minnesota legislators recognize that we’re doing this shared work with, you know, in Beltrami County, with Sanford Bemidji, that the fact that patients recognize that a resident doctor, that’s meaningful because that also generates more support for the necessary kind of resources we need as a teaching hospital to stay viable.

So I think more and more of these partnerships, building bridges between the rural and the metro regions, having residents have an experience where when they get a call from a rural community and there is a provider on the other end of the line who is really unable to manage something that they may have the knowledge to manage, but they don’t have the resources or other means to take care of it, there is a lot more empathy in that connection in how do we get you here? How do we support the patient?

Hennepin has always served that state role, but I think that it has built out this whole cohort of resident physicians who are showing up differently when they think outside of these walls of being in an urban hospital. So I think the impact is so much bigger than, right, did I learn how to manage tamponade in the emergency department? But the people they meet, the stories they hear, the connections that they have over, I think, a longer run is going to be valuable for our state through programs like this.

Dr. Dan Hoody:

It’s interesting you say that because I think a quoted fact is that 80% of the physicians in Minnesota trained at Hennepin at some point or somewhere in that ZIP code, is that right?

And I’ve been on the ground here two and a half years and it’s not infrequent that I go into our doctor’s lounge here and there’s a majority of our clinicians have rotated through Hennepin, whether it’s in a med school or residency. And you hear a lot of stories talking about Hennepin and the wonderful staff there and their incredible experiences they had. So it’s been easy to see historically, you know, what a statewide resource Hennepin is.

And I think to your point, this expansion of actually getting trainees on the ground in rural Minnesota, for all the reasons that we’ve highlighted and more, it really brings front and center what a tremendous asset it’s been to us as a rural system, in particular Northwest Minnesota trying to achieve what we’re trying to achieve for not just education, but again, overall workforce goals.

So we’re excited to see where this can go in the future, which is I think a good segue to where we talk about what’s next. So, you know, a lot of learnings, a lot of successes, I’m just curious from your perspective, Meghan, you’ve got a tremendous amount of both experience on the ground in the Twin Cities as well as national experience through ACGME (Accreditation Council for Graduate Medical Education) and other national educational forums.

What do you see as next for this partnership from your perspective, and then how do you see this informing the national conversation about what should the future of the rural component or GME strategy for ensuring that we’re training doctors for all of America, not just the urban centers?

Dr. Meghan Walsh:

Well, it’s a big question. I think absolutely what we are seeing in only a two-year run is that as little as four weeks in another community during residency can change the trajectory of a physician’s practice. They may graduate from an urban center and actually spend the rest of their career in a smaller community.

I’m also seeing that it is more affordable. It is easier to stand up. It translates across multiple specialties. It’s a little bit of a lower investment, not just in the financial, but in the infrastructure needed to sort of have an accredited health system. So that helps smaller, lesser-resourced hospitals and clinics actually take a stab at trying to partner with training programs throughout the state and actually get them into their communities.

So, I think we’ve shown that it works. It’s a win-win for both of us, right? It’s a win for me to recruit amazing talent to my training programs, knowing that they get an opportunity to go to this other system and see it. I think it’s great for you to sort of also have the ability to show the amazing resources and faculty and community that might be a place that that person wants to spend the rest of their career. So that’s been really valuable.

I think the state has seen this. So, I really need to highlight that MDH in Minnesota (Minnesota Department of Health) has helped make our program financially viable for our health system and for yours. So this was a big experiment, and they funded us with a really sizable grant to get the program off the ground. Came back, funded us again for internal medicine, surgery, psychiatry, emergency medicine, internal medicine, combined programs.

And they are thrilled with the results that the residents love it, that many of them want to actually practice in greater Minnesota and that it isn’t requiring you creating an entire, you know, teaching hospital in Sanford Bemidji. And I think this experiment in our state becomes an experiment for the country. I think that CMS (Centers for Medicare and Medicaid Services) has been very rigid in how they fund resident training. It’s only been through sponsoring institutions.

That is why big cities have big hospitals that have the lion’s share of residency training. And if we keep training them in big cities, our graduates are going to keep working in big cities. So how do we help change CMS’s funding model such that CMS starts to say, maybe there is value in a one-month rotation? Maybe we do need to look at exclusive partnerships where every resident goes to this, you know, this other city to train. This is not a common practice throughout the country.

We are one of a few, and I would say we are the only one doing it to this degree. Exclusive partnership, rural, urban, multiple specialties, and frankly, the residents loving it such that they’ve become our PR for the program. I don’t have to force people. I don’t have to ask people. They are building the energy that makes every class after them want to do the program.

And more importantly, it’s actually recruiting medical students who are interested in this combined, I get both big city and small community and I get to sample them both and see what I want to do for the rest of my life.

Dr. Dan Hoody:

It reminds me of in my role of recruiting our staff clinician workforce, more than once in the last year have I had what I would consider very top priority recruits ask, can I teach? When I highlight that the success we’ve had in this program so far, the extrapolation of this program into other medical and surgical specialties, it has made a difference in our ability to hire.

So, we just hired one of our most difficult recruits, we signed them last month. A key component of that was saying, can I take residents? And so it’s really, it’s been exciting to see that component on the end of pipe workforce for our Northern Minnesota needs really come to fruition through this program. And it really, to me, it highlights that urban medical centers, in particular academic medical centers, not only can be part of the solution. I think they need to be for the rural workforce clinician crisis in particular.

And that what I really like about this, being a continuous improvement junkie, this is a relatively small change in training design, and it has the potential to have a really meaningful workforce outcome. And that, to your point about national extrapolation or generalization of what we learned here,  it makes me really excited for what the future holds in both here in Bemidji and with the partnership with Hennepin and other training centers, but also how we can take lessons learned into other portions of America that are really being burdened by the rural crisis.

Dr. Meghan Walsh:

Well, I know I’ve said this a couple of times, but to not underestimate that a single month can completely change a worldview, right? And so the very first resident, we intentionally picked a resident who was going to be our first experiment. He is a high, he was a high performer. He was super upbeat. He was thrilled about going up to Bemidji.

And so we sent him for emergency medicine, wondering how’s this going to land. And he came back after the most thrilling month where he felt that he had autonomy, but he had supervised support, that he could really stretch his wings and be challenged, but also realize his training positioned him to take great care of patients in this community, and that he didn’t need all the Level 1 trauma wraparound services to really provide excellent care.

And it gave him such confidence, and I’ve heard this repeatedly, that he took a job after graduation in a rural community in Utah specifically because of this experience.

Obviously, I’d want to benefit Minnesota, but I even more so want to open hearts and minds to a very satisfying career in a smaller community because you spent one month in that program. And I think that’s going to be – perhaps it’s unmeasured now – but I think we’re going to see more and more of that stemming out of this program in the next year or two.

Dr. Dan Hoody:

And I think, correct me if I’m wrong, I think that resident was the first one to, in Hennepin history to actually hit his case log for a fishhook removal. Yeah, did not know how to remove a fish hook up prior to this rotation and he’s pretty proud of it and actually I believe you got to keep the fishhook so not sure if that’s protocol. I think he kept it. We’ll keep that one off the record. Any final reflections or comments just on the partnership that we’ve had and the future that sits in front of us?

Dr. Meghan Walsh:

I do think that for a program like this to work, there has to be a cultural “choose Hennepin for the mission.” And I think that Sanford Bemidji shows up the same way. There is a population served and a mission to sectors of the population.

You have travel communities in your vicinity. You have eager faculty that are open-minded to take on a trainee. I’m not sure that the model is so perfect that it could be planted anywhere and work.

So there are some things we’ve seen, housing availability, a community that welcomes them, trust in someone you’ve never met coming into a rotation for a month, a high performing team on your end and on my end where we got all the logistics down so that we could get all of the paperwork necessary for accreditation. And so it was a perfect pairing.

And I think if you’re looking to build something like this, really making sure that you have that cultural alignment so that you can really take off. And I think that was part of our secret sauce that in retrospect I think really mattered. And I might not have seen all of these aspects as we entered into this before we got going. So I’m really happy for that.

I think that it was a really terrific fit and I can see us having more of our trainees wanting to head up there.

Dr. Dan Hoody:

When I first got on the ground here, Rod Will, who’s been one of our internists for decades, he told me that Sanford Bemidji is the Hennepin of the North. He trained at Sanford or at Hennepin. And I think that speaks to the cultural alignment.

There’s been so much integration and experience and apprenticeship coming through the Twin Cities and Hennepin, in particular that cultural alignment I would agree is very strong. There’s a very strong community centric orientation to the medical group here. They really take accountability in serving everybody in the community and it shows up to your point in the success of this partnership.

Dr. Meghan Walsh:

Well, and I mean, think of recruiting people who really want to be good doctors. They’re going to do the reps. They want to be clinically excellent. They may not want to be in a research pathway or other things as for a career.

And so I think this idea that a general surgeon comes to Hennepin to operate and then goes to Bemidji where they’re given the opportunity to do that. I think if your future is, I want to do heart transplants, I’m not sure that Bemidji is the place for you.

But it sure as heck is for Casey and his wife, both who came from North Dakota, who came to our program to be really great surgeons, but who want their future to be in a small rural community. And they don’t want to be afraid to be a surgeon in that community because they weren’t trained well enough.

Dr. Dan Hoody:

Such a great point. Thank you so much, Meghan, for joining me today. I appreciate the conversation. More importantly, I appreciate the partnership, your leadership, and your commitment to thinking differently for how we train the next generation of physicians.

I just want to close by saying the work that we’re doing here together has real impact, not just for Hennepin or Sanford Bemidji or Sanford Health as a whole, but for all the communities that we serve. And I’m really excited about what’s ahead.

Dr. Meghan Walsh:

Thank you, Dan. Same with us. It’s really opened the door in ways that gets us out of these four walls in downtown Minneapolis. I think the state is watching. And legislators are thrilled with a lot of the work that’s come out of this shared program. So thank you.

Dr. Dan Hoody:

Thank you. We’ll see you on the lake.

Courtney Collen (announcer):

Thank you for listening to “Reimagining Rural Health,” a conversation series brought to you by Sanford Health.

Hear more episodes in this series or other Sanford Health series on Apple, Spotify, or news.sanfordhealth.org

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Secrets of memory loss, according to a brain specialist

Alan Helgeson (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about Alzheimer’s and dementia, the importance of early recognition, the science behind memory loss, and clarifies some of the common myths around these conditions.

Our guest is Dr. Nicole Norheim, a clinical neuropsychologist with Sanford Health in Bismarck, North Dakota. Our host is Mick Garry with Sanford Health News.

Mick Garry (host):

As it applies to our conversation today, tell us some things about the kind of patients you have, what your job is, and how do you serve in this role?

Dr. Nicole Norheim (guest):

Sure. So I’m a clinical neuropsychologist. I have a doctorate in psychology, but extra training in neuropsychology. So my specialty is assessing testing patients’ cognition with a series of cognitive tests. And so that’s my specialty. I’m actually lifespan, so I see kids to adults, but I know within the North Dakota population we’re really needed more with the older adults and concerns with dementia.

So with that being said, my specialty is going to look at cognition. We’re going to look at, when I say cognition – memory, attention, language, visuals, spatial deficits – and see what those strengths and weaknesses mean. Is it dementia, is it normal aging or is it something else going on? And that’s kind of what we do. We do an interview, testing and then feedback.

Mick Garry:

All right. First question then, could you explain the difference between Alzheimer’s and other forms of dementia?

Dr. Nicole Norheim:

That’s a great question. That is actually my most common question I get, especially during my feedback portions of my evaluation.

So think about it as, actually, I’m going to say thinking is on a line. On the far left side is normal aging. As we get older, we’re not as sharp as we used to be. We process information slower, but that’s typical as we age.

In the middle, we have a mild cognitive impairment. It’s where people have a little more thinking difficulties, memory problems than normal, but they still can drive, manage medications, manage medical, finances, cook, clean, no significant difficulties.

But then on the other end of the spectrum, on the other side, we have people with significant problems with thinking and memory, but now it’s impacting their day-to-day. They’re getting lost while driving. They’re forgetting to take their medicine, forgetting to pay their bills, having more confusion paying their bills, burning things.

And then the broad term is dementia. So dementia is a broad term. And so there’s different types of dementia. Alzheimer’s disease is a type of dementia. There’s frontal temporal dementia, there’s Parkinson’s disease dementia, there’s vascular dementia. There are many different types of dementia.

But the most important thing is that Alzheimer’s disease is a type of dementia where people get kind of confused. They use those words interchangeably a lot, like, oh, so-and-so has dementia, but it’s like, OK, what type of dementia? And they’re, “Oh, I didn’t know there were different types.” So again, dementia is the broad term. Alzheimer’s disease is a type of dementia.

Mick Garry:

Now, understanding the conditions here, what are some early signs? What are the earliest signs that people should look for?

Dr. Nicole Norheim:

Think about it as normal aging. As I said, you know, we’re going to have an occasional forgetting of names and appointments, but people remember them maybe later on, or with help. And then maybe occasional errors with finances or completing complex tasks. Some people need, with normal aging, help with technology or learning something new or occasional word-finding difficulties.

Think about this. These difficulties are occasional with kind of the early symptoms of Alzheimer’s disease. Now the memory problems are happening more frequently and they’re actually disrupting people’s lives. So they’re forgetting, you know, their bills. They are forgetting more common recipes that they had either easier to follow along or else they had previously memorized.

They’re forgetting how to complete daily tasks of driving familiar routes where they’re like, “I have to put in my GPS now, but I used to remember how to get to my daughter’s place,” or they have trouble following conversations. So now think about it as it’s more disrupting the day-to-day living a little more.

Mick Garry:

And how is Alzheimer’s diagnosed as well as other forms of dementia? How do you determine that OK, this is something that as a patient that you’re going to have to expect is coming next?

Dr. Nicole Norheim:

Great question. So I think about it as there’s a lot of pieces to the puzzle.

So we look at cognitive testing, which I do. We look at people’s labs and even neuroimaging like brain scans. Again, every piece is a piece of the puzzle.

So for a patient or a family member, if they’re concerned about memory, they’ll probably bring it up to their primary care doctor or a neurologist. And the primary care doctor either will even do kind of a brief screening test. And most of these screening tests are five to 10 minutes long. And again, it’s really brief cognitive screening. It’s not diagnostic by any means, but it’s kind of, “OK, where are you at? OK, you’re within the normal range, or OK, there are more difficulties so we’re going to refer you to neuropsychology.”

And with neuropsychology we’re going to do a more in-depth testing. So, more paper and pencil testing. I think about it as more like schoolwork. We’re going to ask a lot of questions about how they remember things, but also look at their, you know, as I said, language, name things and see as best they can do things.

And so that can kind of help us decide on, OK, is it normal aging? Because when we do this testing, it’s actually going to compare their scores to other people their same age because I expect a 60-year-old to perform different than a 25-year-old or a 90-year-old. And so then that can help us decipher of, OK, is it normal aging or is there something more going on?

And based on strengths and weaknesses in neuropsych testing, that can tell me what type of dementia maybe we’re working with. So that’s the cognitive testing portion.

I also have people do lab work. So we all run our typical lab work, our metabolic kind of panel, but a lot of those metabolic panels don’t include B12 TSH, which is your thyroid and folate.

So I will always look at people’s lab work to make sure that those additional labs were also done because if they’re low or high, that can really affect our thinking as well. Another lab is looking at the biomarkers.

Recently, the FDA approved a new P tau 217 test, which can measure the abnormal tau proteins in our blood. And that can be associated with Alzheimer’s disease. Unfortunately, it is not covered by insurance, so it’s going to cost $500. But that also can further help you decide if like, “OK, are we really dealing with Alzheimer’s disease?”

Another test that we could do is neuroimaging, so a head CT or a brain MRI. And so that can look at the structure of the brain. Importantly, it’s not a one-to-one ratio just because our head CT or brain MRI comes back normal, or unremarkable.

It doesn’t mean that we’re not going to have cognitive deficits as well. I’ve seen very good MRIs, very bad testing. I’ve seen it the other way around where I’ve seen very bad MRIs, but very good testing. So again, it’s not a one-on-one ratio, but it can help tell us of what’s going on. Again, all these are pieces of the puzzle.

Another last one that people ask about is genetic testing. So whether it be through 23 and Me or Ancestry, you can get genetic testing for the APOE gene. Just because we have that genetic factor does not mean we are going to get Alzheimer’s disease, but it can indicate that there is an increased risk of having it.

So again, cognitive testing, neuroimaging labs and genetic testing are all kind of pieces of the puzzle that can help determine, “Do we have Alzheimer’s disease – or what’s going on cognitively?”

Mick Garry:

This next question – I think back to other diseases like lung cancer – it’s obvious that early detection means a lot there. In this context, what does early detection mean? Why is it important?

Dr. Nicole Norheim:

Yes, there are so many elderly who actually refuse to come and see me or refuse to actually comment about their memory difficulties because there’s like, “There’s nothing we can do about it.” Well, there is. There’s so many things we can do. So the earlier we can catch it, the better outcomes we have.

So it is very helpful for treatment options, care planning, and just long-term quality of life. So, if we can catch it early and kind of get, as I previously said, kind of that mild cognitive stage, it’s kind of like the stage right before we technically meet criteria for dementia.

There are medications that can slow down the progression. Yes, there’s no cure for Alzheimer’s disease, but there are medications that can slow down the progression. We also can look at possible other reasons for why are these people having these memory problems. So we can address comorbid conditions like, “OK, are we dealing with sleep apnea that’s not treated?”

“Are we looking at your medications that can really affect memory? Are we looking at, you know, low vitamin B12 or low vitamin or low folate, low thyroid?”

So if we can detect these cognitive difficulties early, we can address things that are treatable like sleep apnea or medication changes or adding just a supplement like B12.

Also, it’s so important to kind of get it detected earlier because we can make healthier decisions, staying cognitively active, socially active, physically active. I actually see a handful of patients that really decline after they retire because they’re not as active as they once used to be. So if we know we have these cognitive difficulties, then it kind of drives us to stay more active, whether it be cognitively, socially, or even physically.

And then my last is health family planning. So we hope for the best, but we do plan for the worst. So with Alzheimer’s disease, it is progressive and so we want to hope that we can slow down the progression, but we do want to plan, anticipating at some point we won’t be able to make our own decisions. So let’s get the power of attorney in place.

And so we can decide that our daughter or son of a family member is going to help, whether it be current legal decisions when we can’t do it ourselves, financial decisions or even long-term care. There might be a point where assisted living or nursing home might be better. Some people prefer to stay at home.

So if you make those wishes sooner when you’re cognitively cognizant, then that’s made better in the outcome. So early detection is key for, again, treatment options, care planning, and just long-term quality of life.

Mick Garry:

How does Alzheimer’s typically progress over time? I understand that that’s a fairly involved question, but some of the basics on what you can expect – understanding that it probably depends on the individual.

Dr. Nicole Norheim:

That is so true. It is a progressive disease, but it’s different for every person. And so when patients come and see me, I see them for that point in time. I am like, “I don’t know how you were a year ago. I don’t know how you were five years ago. I don’t know how you’re going to be in year or five years.” So when I see them, it’s that point in time.

I highly recommend they usually come back and see me in six to 12 months so we can redo the testing and kind of help inform the trajectory. Do we have only a mild decline? Do we have a moderate decline? And that can help us. However, there are things that can impact progression such as age of onset, the earlier age of onset, the worse prognosis we have, the faster progression it is.

So typically, normal age of Alzheimer’s disease onset is going to be after age 65. If we see it before age 65, it’s going to be considered like early onset compared to the age. And that’s going to be a faster progression.

If we have more onset cognitive difficulties at age 80, it’s going to be a little slower progression versus somebody who was 55, 60. Also, I think about it as people’s cognitive reserve. So it’s kind of like their functioning, their cognition prior to age of onset. If we have somebody who maybe struggled in school, maybe intellectually disabled a little bit, they’re going to have more vulnerability to the cognitive changes. Versus somebody who has high cognitive reserve, whether they have a doctorate or whatnot, they’re going to have that safeguard better for them and they can defer the cognitive changes a little longer than somebody who has lower cognitive reserve.

Other things that affect progression is medical history. If we have medical comorbidities, like any kind of cardiovascular risk factors like heart failure, diabetes, high blood pressure, high cholesterol, and then we get into Parkinson’s disease or sleep apnea, those things can affect our cognition within itself. So it can actually progress the Alzheimer’s disease a little more.

And then also if we’re not active, if we are just watching TV all day every day, not staying socially, cognitively or physically active, that really can impact the progression as research has shown. If we do stay active, that can really deter but also slow down the progression.

Mick Garry:

Without getting too sciencey here, what is going on in the brain when these things are manifesting themselves in your daily lives?

Dr. Nicole Norheim:

So, as we get older, our brain shrinks. That’s why we’re going to have more cognitive difficulties. Think about it as our, even especially our hippocampus, two little parts of the brain that sit in the back and that’s where they store the memory. And so as we get older, they get smaller and smaller and smaller. So that’s why we can’t hold as much information as we as we used to.

But with Alzheimer’s disease, our brain shrinks a lot faster. And so then we’re going to have more difficulties holding that information and eventually it’s going to even affect our whole brain. So we’re going to have more difficulties, not with just memory, but with our language, attention processing speed, and then that’s when we’re going to have more of those difficulties. So it’s just kind of like your brain is shrinking just a little faster than we’d expect.

We’re not going to see that all the time on a brain scan such as an MRI, but sometimes we can. And that’s why it’s so important to have that piece of the puzzle be like, “OK, let’s look at the brain scan. Is it a little smaller – atrophied, we call it – more than somebody else we’d expect their same age?”

Now with the biomarkers, the blood tests and things like that, now we can look at like the tau proteins and things like that. I think that is another good way to kind of look at how the brain changes as we get older and whether it’s Alzheimer’s disease or not. But our kind of go-to one more day-to-day is going to be that brain MRI and the shrinkage of the brain and seeing if we can see that that’s shrinking.

Mick Garry:

How can a loved one distinguish between normal aging and something distinctive?

Dr. Nicole Norheim:

Yes, I would say most of the time it’s going to be loved ones being concerned and saying, “I think your memory’s a little worse than it should be.” And very rarely, but it does happen where patients will think about it as themselves. They’re like, “Hey, I think I’m struggling a little more.”

But again, I’m kind of going to go back to, with normal aging, it’s going to be more of that occasional forgetting. And maybe if you remind them or they can remember things later on, occasional errors, needing some help with technology, you know, some extra help learning something new, occasional word-find difficulties.

But when we are starting realize, “I’m repeating myself a lot to my mom” or “I’m repeating a lot of stuff to my dad or my spouse” – now we’re kind of questioning that. Or, “My wife used to know the recipe and she didn’t have to even remember the recipe. Now she’s having difficulties remembering the recipe or even following the recipes. And we used to be able to drive. She used to be able to drive very easily around Bismarck, but now we’re having more difficulties. And so now we’re having more of these difficulties day to day.”

And that should be a little alarming. And it’s where we do want to bring something up to the primary care doctor, to the neurologist and say, “You know, I’m a little more concerned about the memory. Should we get a little more evaluated?”

Mick Garry:

And we alluded to this a little bit earlier with the importance of early detection, but what are some treatment options out there that are available right now? And what are the types of things that you can realistically accomplish in, being part of these treatments?

Dr. Nicole Norheim:

Yeah, it’s kind of part, as we said, the early detection. So medications, there’s no cure for Alzheimer’s disease, but the medications such as Aricept, Namenda, Exelon, they can slow down the progression. And so they kind of put more of this neurotransmitter – more of this chemical in the brain to hopefully form those memories for people to slow down the progression.

But it’s also just making healthier decisions. You know, staying active is the biggest thing. Staying socially, physically, cognitively active. A lot of people, as Alzheimer’s disease progresses, it affects memory, but it also affects language. So they’re going to have more word-finding difficulties.

And because they’re having more word-finding difficulties and potentially kind of following conversations because they’re having more difficulties remembering conversations, they’re going to start socially withdrawing. And so we really don’t want them to do that because now we’re not going to be using our language, not going to be using our brain as much.

And so we can decline faster and faster and faster. So we really need to stay socially active, but also cognitively active. Sitting in front of the TV, watching rerun after rerun. My older men love “Gunsmoke.” And so I’m like, no, we can’t want keep watching that over and over and over and over again.

We want to do stimulating things. We want to play board games, card games, jigsaw puzzles, watch game shows, “The Price is Right,” “Wheel of Fortune,” “Jeopardy!” That’s all going to be stimulating the brain.

Reading is really helpful. But again, the worst we can do is just sit and watch TV as there’s just no interaction. We’re not using kind of our brain because we’ve seen this episode a million times and we’ll just keep watching it. So we really just have to stay active.

And then also what we can do is, what we call disease-modifying therapies. This is relatively new. Often people hear about Leqembi; it clears amyloid plaques with infusions. I reserve this kind of treatment for people who have, it’s early onset as I’m saying, kind of early before 65 and who have no medical history.

So if we have a medical history of these cardiovascular risk factors like Type 2 diabetes, high blood pressure, high cholesterol, stroke history, then you’re even more likely to have this brain swelling and microbleeds. So the benefits don’t outweigh the cost as of right now, but again, if we catch it super early, early onset, no significant medical history, then it’s also an option.

This is very promising. I think we’re in the right direction and hopefully in the next few years, five, 10 years, that this is going to be even way better as of maybe even a kind of cure, but only time will tell.

And then lastly is just, I talked about being physically, socially, cognitively active, eating healthy and just getting good sleep. There’s a lot of people with sleep apnea, maybe they don’t like their CPAP, but I cannot stress enough how sleep can be so beneficial to our cognition, especially our memory.

So if we have sleep apnea every night, that indicates that we’re stopping breathing at night or we’re snoring and something’s blocking our airway. So we’re not getting enough oxygen to the brain. And if we’re not getting enough oxygen to the brain, it’s going to cause cognitive difficulties, specifically memory. And so we really need to push that CPAP use if we have sleep apnea.

I have seen where people have cognitive difficulties, they didn’t know they had sleep apnea, or didn’t use their CPAP. They come back a year later after using their CPAP, they actually revert back to normal. So it does really impact our cognition, especially our memory.

So things that we can do to kind of help with treatment options are memory medicine, staying physically, socially, cognitively active, eating healthy, getting a good sleep, use your CPAP. And as I said, there is also those disease monitoring therapies that can help for certain populations.

Mick Garry:

And for sure no more “Gunsmoke.”

Dr. Nicole Norheim:

No more “Gunsmoke.” Stop watching “Gunsmoke.” No, I know it’s really great. My dad watches the show and I don’t know how many times I joke with people to stop watching “Gunsmoke.” And they’re like, “But I love it.” And I was like, “Oh, you do. OK.”

But again, watching a show is fine. It’s great. But it’s just when we watch it all day every day, that’s when we have the problems that we need to do something else to keep that brain engaged.

Mick Garry:

You’ve answered a lot of these questions that I have here that I was going to ask that you’ve already answered. But what do you wish more people understood about Alzheimer’s and dementia?

I think that because you’re on the battlefield every day and you see the challenges from your patients, but also the people around them and their challenges. And I think this speaks to the people around them. How should you view this if you have somebody like this in your life?

Dr. Nicole Norheim:

Kind of the takeaways is many people think that as you get older, dementia’s inevitable, like you’re just going to get dementia. And so I get that a lot because I ask people about their family history and they’re like, well she had dementia but she was 102. Well, yep, you’re going to have cognitive difficulties as you get older, but just because you’re older, you’re not going to get dementia.

So yes, the true question is whether the difficulties go above and beyond the normal aging. And sometimes yes, the cognitive screening tests, whether it be like a 30-question item or 30-point evaluation, it just gets in “OK, I’m giving this 30-question, or I should say 30-point questionnaire, cognitive screening test, a 25-year-old, a 90-year-old, a 60-year-old, and you just get this one lump sum with neuropsych testing.” We really look in depth of what is going on, looking at your scores compared to other people your same ages.

Like “OK, yep, your 102-year-old grandma, this is normal aging, this is what we’d expect. You’re going to forget things.” But then the next person that comes in, I’m like, “Oh, this goes above and beyond.” So there are things we can do and we can help decipher if it’s normal aging or dementia. And then that’s how we create these specific recommendations.

The next thing is, “OK, is it Alzheimer’s disease or is it another type of dementia?” And so if we can decipher that as well, the recommendations change as well.

One of the other biggest things that I deal with is caregiver stress. It is so difficult being the caregiver for people who are progressively in the dementia phase. It is hard to be a caregiver. And so when people come in to see me, you know, yes, I’m taking care of the patient, but I also take care of the family.

And so I’ll ask, “OK, how are you doing? Are we still able to take care of, you know, dad at home?” OK, we’re struggling. Do we need help? Do we need home health care? Do we need assisted living? Do we need something more than that?

Then the next thing is, “OK, now we have to talk about like medication, whether it be memory medicine, anxiety medicine, agitation medicine.” While I do not prescribe medicine, I can kind of help people decipher of like what medication would be good. There are options because anxiety, depression, agitation can be common as the disease progresses. Hallucinations, paranoia can also happen.

So we want to manage the symptoms and medication is helpful, but also behavioral techniques for the caregiver. It can be frustrating to be the caregiver. People will say, “I’ve said the same thing 30 times today,” and we lose patience.

That is normal. That is common. And so we just have to remember that we are a person, we are human, so we are going to get frustrated. We are going to snap sometimes or snap back I should say. And so I’m really there for the caregivers on, “OK, there’s support groups for you.”

These are also, we have to remember that this is a brain disease. This is not them being on purpose of asking you the same question to be annoying. So we want to make sure that we don’t argue with them. People with dementia are always right. Do not argue. They’re always right. If their mom who passed away 30 years ago visited them yesterday, you say, “Oh, they did? What you do talk about?”

And so if we argue with them – they believe in their realm of life that their mother visited yesterday – and if you say that did not happen, you’re going to argue with them. And then now you’re getting them agitated and then their cognition even gets worse. So this vicious cycle.

So providing this caregiver support also during my problem is really beneficial. Don’t argue – they’re right. If they’re anxious about something, paranoid about something, we distract. And having all that for the caregiver is very helpful too. So these appointments, not just for the patient but also the caregivers.

Mick Garry:

What can communities do? We’re painting with maybe a little bit broader brush here, but are there things that again, as a community, that you can do to make this a little bit smoother ride?

Dr. Nicole Norheim:

I think just being aware – awareness. We all know about Alzheimer’s disease, but it does look different for every person. Even dementia in general looks different for every person. So sometimes we have this preconceived notion of what Alzheimer’s disease looks like or what dementia looks like, so we might not understand the person in the grocery store. Why are they acting the way they are?

So being just more aware of the different dementias or different ways that Alzheimer’s disease can look, then we have just a better understanding of, “OK, that’s maybe we’re dealing with dementia.” Or we don’t get mad at somebody when they’re maybe not remembering something on the phone or if we see them at the grocery store that they kind of yelled at you like, “OK, maybe they’re dealing something cognitively.”

But also I think Bismarck is doing, and I even think just North Dakota, United States in general is doing a really great job of having more awareness with Alzheimer’s disease, having the support groups. There are support groups everywhere, whether they be online, whether they be in town, whether they be at the senior center. And so there’s tons of support groups. And so I think that’s really helpful for the patients, but even the caregivers.

And I do think that we are getting better and better with just more of the research and being knowledgeable of Alzheimer’s disease in general as a whole. And I think that’s kind of where we’re going is we’re only going to get better, especially with the diagnosis, especially with the treatment.

And I’m really happy with the way we’re looking forward and what kind of support we have. My number one go-to is the Alzheimer’s Disease Association. There’s such a bountiful information. They don’t work with just people with Alzheimer’s disease, but anybody of dementia, they’ll come to your house. I can even put a referral in. Or you can just call people from Alzheimer’s Disease Association.

And what we’ll do is they will come to your house and be like, “OK, what can we help you with? Is it home health care? Is it financial planning? Is it safety? What can we do?” And get you the right resources. And that’s free of charge, which is really great. So I really push the Alzheimer’s Disease Association. They’re a great resource.

Alan Helgeson:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen wherever you hear your favorite podcasts, and on news.sanfordhealth.org.

Get more episodes in this series

Map a smooth route through menopause

Dr. Elizabeth Hultgren (guest):

It certainly doesn’t mean that like this is the end of, you know, good sex. This doesn’t mean that this is the end of me being able to live my life as I want. This doesn’t mean this is the end of me having the body that I want or the functional status that I want. Really, menopause is just the next phase and for some women, this can be really empowering.

Announcer:

Welcome to “Her Kind of Healthy,” an informative and unfiltered podcast series by Sanford Health. We want to start new and honest conversations about age-old topics from fertility to postpartum and so much more with our Sanford Health experts.

Courtney Collen (host):

We are taking a deep dive into menopause during this conversation, specifically focusing on that hormone shift and some of the symptoms we see as a result, including weight gain, a change in vaginal health, and so many more that we’ll talk about here. And I have Dr. Elizabeth Hultgren joining me for this conversation. She is a board-certified OB/GYN at Sanford Health and I am so grateful to have her here, her insights for this podcast. Dr. Hultgren, welcome. Thank you so much for your time.

Dr. Elizabeth Hultgren (guest):

Yeah, thanks for having me here today.

Courtney Collen:

We want to continue educating and better yet normalizing conversations around menopause.

To level set, I do want to start with a brief overview of what is happening in the body during menopause. We have a lot of wonderful content on this topic at Sanford Health, but I do want to start with like what’s happening in the body during this stage of life, what contributes to some of these symptoms, and then we’ll dive deeper into what those symptoms are and how to manage them.

Dr. Elizabeth Hultgren:

Yeah, absolutely. So when we talk about menopause, we are essentially talking about the decrease in estrogen and progesterone from the ovaries that naturally occur as women age. We can see – average age is 51 for women in the United States, but really can be happening as early as kind of like early- to mid-40s all the way into like mid- to upper-50s as the normal age range for this. And women can start to experience symptoms of perimenopause up to five to seven years even before that.

So really these are conversations that we’re having with women as early as you know, late 30s, early 40s, up until symptoms resolve, which can be 50s, 60s and beyond for some women.

Courtney Collen:

What contributes specifically to weight gain and some of those other symptoms during that season of life? I mean, we can talk about what those symptoms are that you see most often in the clinic and why does it feel harder to manage some of those, including our weight during that stage of life?

Dr. Elizabeth Hultgren:

So weight gain is something I hear a lot of women discuss either at their well woman visits or when they’re coming in for a problem specific visit. What they notice is they may be eating exactly how they did a decade ago.

They may be having the same activity level, however they notice that either weight redistribution, so they’re starting to gain more of their weight more kind of in their midsection as opposed to like their breasts and buttocks area.

Or they may have actually weight gain and they’re like, “I haven’t changed anything. I’m doing the exact same thing I was a decade ago, but my clothes fit different. I feel different.” And so having those conversations about what we can do to help with this as well as the why behind it, I think is very important.

Courtney Collen:

What would be something that you would encourage women to do to manage the weight gain?

Dr. Elizabeth Hultgren:

So typically as women age, their estrogen and progesterone levels are dropping. As those estrogen and hormone levels drop, we tend to lose muscle mass, truly. And so when we think about the number one cause of weight gain as we go into like the perimenopausal and menopausal kind of timeframe, it’s typically that loss in muscle mass. That is really one of the true components of why women start to gain weight.

I always talk to my patients, you know, we just tend to lose not only bone density but our muscle mass as we age. And so really addressing how can I not only maintain my muscle mass, but actually build it as I go into this perimenopausal and menopausal timeframe? How can I do that in order to kind of be the most healthy me that I can be?

I’m not a huge fan of like strict counting calories, but really kind of focusing on OK, to build and maintain muscle, what do I need? I need the exercise to actually do that, to put the stress on those muscles, to actually break down those muscle fibers and rebuild them.

So we talk about weightlifting. There’s nothing that makes me happier than I hear a woman that’s lifting weights two to three times a week. Because I know that’s not only going to be great from like a cardiovascular and overall how they view their physical appearance, but they’re also really maintaining their functional health, which is really something that I focus on as women are going into this menopausal transition.

How can you be that grandma that’s able to get up off the floor, play on the monkey bars with their grandchildren in their 60s, 70s, and beyond? So really kind of focusing on that functional aspect. How can you maintain your strength and therefore typically bone density as we age, decrease risk for things like falls, osteoporotic fractures. And so really when I’m talking about you know, weight, those are all things that enter into the conversation as well.

How can we not only upkeep our physical appearance, but how can we maintain our functional health as we go through this transition? So kind of number one thing I talk about with women, what are you doing to not only build that muscle but maintain that muscle? So we really talk about weightlifting and lifting heavy enough to kind of break down those muscle fibers. Two to three times a week we talk about maintaining cardiovascular health, so getting that 150 minutes of exercise each week that’s recommended to maintain, again, that functional health, that cardiovascular status.

And then kind of focusing on the dietary aspect of this as well. We know that as we age, we lose muscle and therefore our metabolism slows down. So while you may say I’m not eating as much as I used to, the answer to that is you probably don’t need to be because you don’t have the same metabolic needs that you had 10, 20, 30 years ago.

And so kind of making that mental mind shift of I’m doing the exact same thing and I’m not seeing any change, making that mind shift of what do I need to do to feel my body at this stage in my life. And so we talk about, and not like strict carb counting or strict calorie counting, but are you getting the protein that your body needs to not only maintain the muscle mass that you have but gain that muscle that you hope to, you know, build in order to maintain that metabolic activity.

So for most women, they really recommend at least 1.2 to 1.5 grams of protein per kilogram. So for most women, we’re talking about like a hundred grams of protein a day is really what they need to be getting. Most women do not get that.

Courtney Collen:

It seems unrealistic to get that much protein. How do we feel about that?

Dr. Elizabeth Hultgren:

So I think you need to be really intentional about it. You know, being intentional of like, what am I putting in my body and how is this fueling what my goals are? Certainly we know that you do need carbohydrates. You need carbohydrates for brain function, you need carbohydrates for just daily metabolic activity, but you also need really good protein intake as well. You want to maintain those muscles. You want to build those muscles. And so having those basic building blocks there that your body can utilize to help you reach those goals is really important.

Courtney Collen:

When somebody asks you like to break down, OK, well, define protein. What type of protein should we be looking into? I know this is not like a nutrition or dietitian-based podcast (laugh), but if somebody asks a question like that – when we look at shooting for potentially a hundred grams of protein per day – I mean is this five protein shakes? Is it red meat? I mean, talk about maybe what that might look like practically speaking.

Dr. Elizabeth Hultgren:

I really like to meet women where they are. No one’s going to make a huge dietary shift and have it be sustainable. So kind of meeting women where they are. Here in the Midwest we’re very much meat and potatoes kind of like people as a whole. And so if that’s what your diet is, let’s look at how we can incorporate some really good lean proteins into your day to day.

I’m a mom of young kids. I work full-time. We’re constantly on the go. How can I really incorporate that into my life? You know, I can grab three hard boiled eggs on my way out the door on my way to work and throw it in my lunchbox that I can, you know, have while I’m finishing charts over my noon hour. I can grab like a protein shake in my morning that I can have like ready to go in my fridge. I have a box of protein bars in my desk at work in case you know, if I’m eating in the middle of a meeting (laugh), that I can certainly kind of incorporate that into my lifestyle.

Now that’s not for everyone. You know, I have patients that come to me say I’m vegetarian; how do I really do this? There’s really good plant-based proteins out there, introducing legumes and other forms of like chickpeas, beans, those type of things into your diet. Even things like adding nutritional yeast on top of your vegetables, nutritional yeast kind of has like this cheesy flavor to it. It really has a lot of umami to it. So it can be a really good way to add in some extra protein without really even noticing.

So you know, adding, how do I add in little things and keep eating the foods that I like to eat and how can I help adapt it to whatever my lifestyle is?

Courtney Collen:

Sure. This is so good. Thank you.

Dr. Elizabeth Hultgren:

And I’m not a nutrition expert by any means. This is just how I try to incorporate it into my day to day.

Courtney Collen:

No, this is so helpful. Even just again, practically speaking, some of the things, I mean I add cottage cheese to my egg bites. I bake in the morning for the week. You know, things like that. I know the extra protein boost is so important.

We talked earlier about strength training. I think one thing that is very trendy right now, a weighted vest for menopausal women, middle of life, working out walking and we know the benefits of walking, at least moving our bodies several times a week. How do we feel about weighted vests and is that something you want to comment on?

Dr. Elizabeth Hultgren:

Sure. If people like weighted vests, go for it. Absolutely. Whatever’s going to like motivate you to take that, those extra steps to make that extra time outside. A hundred percent I’m on board with it. If you love it, go for it. Now if you hate it, don’t do it because you’re not going to continue with it and it’s going to drive you away from being active. But if you think it’s helpful, love it.

Weighted vests can be really helpful, not only because you’re having to work your muscles that much harder to carry that. But you’re also putting that extra impact on your bones, which again, I like to talk about like functionally how do I help you meet your functional goals as we age? And so if putting that extra stress on your bones through the use of a weighted vest is going to help maintain that bone density, help decrease risk for things like osteoporosis and osteopenia and overall decreased risk for osteoporotic fractures as we age, so if it’s something you like? A hundred percent, go for it.

The other thing I’ve kind of found with this weighted vest trend is more people are getting outside more because they’re like, I have this vest, I’m going to use it and I’m going to go for a walk outside with it. There’s really good data that shows just being outside for 30 minutes every day, not only does it boost our natural vitamin D levels but it also improves things like mood. It improves things like energy and can be equally as effective to some of our antidepressants that we have on currently on the market today.

So I’m a huge believer. Get outside 30 minutes every day, whether it’s just sitting on your porch drinking coffee, whether it’s bundling up and getting that weighted vest on in the middle of winter, even when it’s five degrees outside, whatever’s going to cause you to like make that better health decision. Yeah. A hundred percent on board.

Courtney Collen:

So good. Thank you so much.

There’s a lot of gray area around hormone replacement therapy. Can you first clarify what it actually is?

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Dr. Elizabeth Hultgren:

Yes. Typically we want to refer to it as hormone therapy and not necessarily hormone replacement therapy because of the fact that we use hormones really starting from a younger age as far as treatment of several medical conditions.

And so incorporating really hormone therapy into that same category when we’re talking about contraception, when we’re talking about like menstrual management, it’s really along a continuum and we use hormones for the treatment of so many symptoms that we really like to refer to it more as like hormone therapy instead of like hormone replacement therapy because there’s not a level that we’re necessarily trying to replace.

And I think this is when you go to talk to an OB/GYN about your menopausal symptoms, about some of the symptoms of menopause, this is probably where we break away from a lot of the wellness clinics that you’re seeing in and around your community. When we start talking about hormone therapy, we’re truly talking about how could we utilize hormones to help with some of the symptoms that you’re having.

When we talk about hormone therapy, there’s not a level that we’re trying to achieve. And really when we talk about the American College of Obstetrics and Gynecology as well as the Menopause Society – which is truly kind of your mainstays that you should be looking at as far as recommendations – they don’t recommend routine estrogen, progesterone levels because of the fact that we’re not treating to a hormone level. We’re truly treating to symptom management.

And so I think that’s probably one of the biggest differences you’ll see when you’re seeing a physician or even an advanced practice provider and they’re talking about let’s get you feeling better as opposed to let’s order 500 labs, let’s put you on 10 supplements and let’s check these labs all the time because we’re not truly treating towards an actual lab level.

We know that this is a natural part of aging. So there’s not necessarily a level that we’re trying to maintain. What we’re trying to do is really how can we help with symptom management? And I think that’s really kind of the mindset when you go into these appointments is that’s really what I’m shooting for.

Courtney Collen:

Can you break down like the benefits of this type of therapy? Any risks or common myths and what might make somebody a good candidate for this?

Dr. Elizabeth Hultgren:

So when I have a woman that comes into my clinic, we first discuss what symptoms are you having? Is it the hot flashes? Is it drenching through your sheets at night, so night sweats? Is it more brain fog? You know, what is this that we’re really trying to achieve? And then kind of basing our treatment based on whatever symptoms you’re having.

If it’s, “yes I’m having hot flashes, it’s disruptive to my daily activities, they get worse when I’m leading a board meeting, how can I help with this?” Yes. Let’s talk about hormonal options and let’s talk about nonhormonal options. Because there’s really a large variety of treatment options that we have depending on really what your goals are.

Really hormone therapy with estrogen is going to be the gold standard for women that have hot flashes that are disruptive to their daily activities. And that’s kind of what I talked about. We talk about how disruptive are your symptoms to your day-to-day life. If women are like, yeah, I’m going through menopause, every once a week I get a hot flash. Not really disruptive to me. We don’t necessarily need to do anything.

We can acknowledge it, say “yes, my body is changing. I’m having a shift in my hormonal status, but it’s not really disruptive to me.” So we don’t need to really treat it. When we talk about women that are saying I’m having eight hot flashes a day, I’m not able to get through my workday or not able to get through my daily activities, it’s disruptive. Then let’s talk about, let’s treat it.

When we talk about estrogen use, we oftentimes are talking about supplemental estrogen that’s used at about one-tenth the dose that people would normally be seeing from like a birth control pill, which is something I think many women are very comfortable kind of talking about. We talk about that. The risk for things that would maybe take you out of contention for using an estrogen-containing birth control really aren’t always strict factors in which we can’t use hormone therapy after age of menopause.

We talk about starting with a low dose and kind of working our way up until we have symptom allievement. So we don’t necessarily talk about screening numbers because again, we’re not treating towards a number. We’re treating towards symptoms, and we start talking about this as soon as these symptoms start to develop.

So I have women that come to me in their 40s. They’re like, I’m still having periods but I’m starting to get hot flashes. And we can say, “OK, your estrogen levels are probably starting to decline, not enough that you’re not having periods anymore. So let’s talk about what we can do with this.”

Really where I start typically for my hormone therapy is let’s talk about using the least dose in like the least risky fashion, which is typically a transdermal approach. We talk about using estrogen patches. There’s a lot of forms of them out on the market and we talk about that this is typically a patch that you’re going to place once or twice a week and we’re going to dose it until your hot flashes go away – for women that are good candidates for that.

Women that are not a candidate for estrogen replacement therapy or estrogen therapy kind of in general are women that have a history of an estrogen-receptor breast cancer. Women that have a history of a deep vein thrombosis or a blood clot that’s formed in their legs. Women that have a history of pulmonary embolism or blood clots that form in their lungs. Those are individuals that were estrogen therapy is not going to be an option.

We also talk about, you know, the decline in progesterone as kind of that other hormone we oftentimes think of coming from the ovaries. This can certainly affect things like sleep dysfunction and night sweats. And so we talk about, you know, using progesterone therapy typically in the form of prometrium, which is a tablet that most women can take at night can be helpful for alleviation and improvement of sleep. Which is probably the number two thing I hear behind, you know, hot flashes is why symptoms women have as they start to enter menopause. I’m not sleeping as long at night. I’m waking up in the middle of the night. I just am not feeling waking up as rested as I may be used to.

Women that do not have a uterus don’t have to be on progesterone therapy. If they’re simply having the hot flashes during the day, we can simply provide estrogen therapy for them and that can alleviate those symptoms. If you have a uterus in place, unopposed estrogen therapy can lead to what’s called endometrial hyperplasia or uterine cancer. So you have to have progesterone for that protective effect.

Courtney Collen:

Very valuable information. Thank you so much. What are some questions that women could bring to their provider?

Dr. Elizabeth Hultgren:

When women come in, part of the conversation I have is do you want hormones or do you want to try nonhormonal options? We kind of talked a little bit about some of the hormonal options as far as estrogen therapy, progesterone therapy.

Nonhormonal options can be everything from, let’s talk about lifestyle changes. Let’s see how can we help just your day-to-day activities. So we talk about things like weight loss, we talk about things like dressing in layers, having a fan in the bedroom at night. You know, sleeping with like just a sheet and a blanket that you can throw off if you start to notice yourself getting warm. We talk about things like weight loss because central adiposity or central kind of obesity is going to likely increase some of those like feeling hotter than I should type of symptoms.

We also know that as that essentially your body’s ability to regulate the, you know, really hot temperatures and really cold temperatures can be a spur for having a hot flash occur. We also know anytime you’re in a stressful situation or have increased anxiety, you’re going to notice a hot flash flare. And that’s because they originate really in the same area of the brain.

And so when we talk about use of like SSRIs or SNRIs, so things like Effexor, venlafaxine, these medications are really treating anxiety and depression symptoms. But we know that these can be like instigators of a hot flash coming on. So really when we talk about like nonhormonal options, those are typically in the conversation as well. How can we help get anxiety into better control? How can we help depression get under better control? Because these are things that can spur on a hot flash during your day to day.

We also talk about – there’s neurokinin receptor pathway modulators. So you might have heard like VEOZAH is a new one on the market, probably came about two to three years ago. It’s a nonhormonal but it essentially affects that thermal regulation pathway in the brain. So it really helps prevent hot flashes from occurring and can be a really nice option for women that with a history of breast cancer, history of pulmonary embolism who aren’t candidates for estrogen therapy. There still are a lot of options out there regarding that.

So just know that I think first kind of conversation are we looking at hormonal options, nonhormonal options and then kind of breaking it down from there as far as what’s going to be the best option to treat your symptoms that you’re currently having.

Courtney Collen:

There’s a lot of discussion around the black box warning label being removed from hormone replacement therapy in 2025. What does this mean, Dr. Hultgren? What is a black box warning?

Dr. Elizabeth Hultgren:

So a black box warning is going to essentially be a warning that’s going to warn the consumer of a potential life-threatening risk, to try to keep it short and sweet. Estrogen has had a black box warning on it. Really perpetuated probably by the Women’s Health Initiative that occurred, I can’t tell you a year, I don’t remember off the top of my head, by the Women’s Health Initiative and what it was warning women of is the increased risk of stroke, heart attack, breast cancer, dementia that can occur with estrogen use.

What was removed is we’ve kind of taken that black box warning away. We still recommend following with your provider if you would like to utilize this type of therapy. But especially in the form of like vaginal estrogen, which really pretty much anyone’s a candidate for vaginal estrogen. Really has no contraindications really in any patient population. And so I’m really happy to see it taken away from especially our vaginal topical estrogens that we use.

What we have found is that women that initiate estrogen therapy prior to age 60 or within 10 years of menopause don’t see any increased risk with cardiovascular disease. We don’t see that increased risk of dementia and we don’t really see that increased risk of stroke and heart attack. And so I’m really happy to see that those warnings have been taken away.

I think it really opens up the conversation that individuals can have with their providers and really help to form a more meaningful conversation without just seeing this giant like “do not use” sign on it and being really afraid to approach this therapy that can be really helpful for a lot of women.

Courtney Collen:

Yeah, absolutely. And that’s what this conversation is all about too. So thank you for that insight.

Let’s talk about women over 65. Dr. Hultgren, do you typically see symptoms continue for women at this age? Like the hot flashes or other things associated with menopause?

Dr. Elizabeth Hultgren:

So while most women will notice a dissipation of their symptoms, typically three to five years after kind of that menopausal transition, there are women that will continue to have symptoms into their 60s, even 70s in some very rare cases. When women come to me with this, there’s several things I really want them to know.

First of all is we’ve talked a lot about the use of estrogen and progesterone therapies today but unfortunately for women that are coming to me for the first time that they continue to have symptoms, what we know is that the initiation of these therapies after age 60 to 65 or greater than 10 years after menopause really can have some serious adverse effects that come with it. We see increased risk for cardiovascular disease, heart disease, and more importantly increased risk of dementia was starting these medications after this age.

We think that a lot of this has to do with the vascular remodeling that’s happening. So the estrogen levels have left these vascular changes that have occurred and now increasing estrogen dosing after this can come with some of these side effects. So typically hormone therapy is not something we’re going to recommend for this population.

But there’s a lot of other things that we do talk about. We talk about lifestyle, we talk about weight loss, we talk about some of the SSRIs and SNRIs that can be really be helpful with decreasing these symptoms by about 80%. Additionally when women are coming to me and they’re saying I’m all of a sudden having symptoms and it’s maybe many years after menopause, I think you have to be really careful in making sure that you’re ruling out other medical conditions that can cause some of these symptoms.

We talk about are we screening for things like obstructive sleep apnea? Are we checking thyroid levels? Are we screening for things like diabetes? Because all of these can really mimic as the initiation of things like hot flashes or memory difficulties or brain fog that some of these women may come in with. So unfortunately after about 10 years after menopause, after the 60 to 65 age group, hormone therapy is not going to be recommended. But just know that there’s a lot of other options on the market of things that we can do again to help treat these symptoms if they’re impactful for a woman’s life.

Courtney Collen:

Is there a time to stop hormone therapy? Is there a right time to stop hormone therapy?

Dr. Elizabeth Hultgren:

This is I would say is where the art of medicine really comes in. I would say this is definitely a gray area at this point in time. We used to be hard and fast, least amount for the shortest duration possible. We’re going to not have people on it for more than three to five years. And I would say this is an area that we’re constantly seeing developing.

If you start estrogen therapy immediately after menopause, is it maybe somewhat safer to continue beyond this point? Probably. With all my patients I do discuss that there are some risks associated with estrogen therapy, including slight increased risk for things like breast cancer. Beyond that first five to seven years of use, that risk of breast cancer is low. It’s about equivalent to having and enjoying three glasses of wine each week.

But it’s still a slight risk. So these are things that I do want women to know as they’re pursuing some of these therapies as well.

Courtney Collen:

Let’s discuss something that isn’t discussed enough, in my opinion, sexual and vaginal health during menopause. We just touched on that a little bit with some of those topicals. Walk us through some of the changes during this stage of life and why it happens.

Dr. Elizabeth Hultgren:

So we’ve kind of talked about from the very beginning that menopause we see a decrease in our estrogen and progesterone, or the hormones that are produced by our ovaries. With this decrease in estrogen, we can see thinning of the skin of the vagina and the labia. We see decreased blood flow to these tissues as well as decreased collagen production and decreased elasticity.

So as you can imagine, as that skin gets thinner, as we have decreased blood flow to these organs and as we have decreased elasticity of this tissue, things like intercourse, which typically you know, involves the pliability of the vaginal essentially wall pliability of the tissue can become much more uncomfortable. And vaginal estrogen is one of those things that I’m like should be recommended to all women as they age.

We know that 30 to 60% of women do have what’s called disciplinary pain with intercourse, especially as they age. And so how do we help address this? We know that sexual health is a really important part of women’s health in general, but you’re right, it’s not talked about very much. And there’s a lot of reasons behind that. It may be the social construct that they grew up with. It may be discomfort about talking about more of these intimate issues with not only providers but you know, girlfriends or family members or whomever your like confidants are.

And it’s something that’s kind of, I felt like swept under the rug a lot of times. And so I feel as a gynecologist, I talk about this all day every day. But yeah, you know, just in the general public, this is one of those topics in women’s health that I feel is very underrepresented as far as like what our knowledge about it is and what the open conversation is with this. Again, we have many hormonal and nonhormonal options for women that come to me that say my vaginal tissue feels drier than it should. I feel kind of irritated down there. Sex isn’t as enjoyable or as comfortable as it used to be before. And what can I do about this?

For women that are really wanting to stay like nonhormonal, we talk about the use of like vaginal moisturizers. Replens is one that’s on the market available over the counter. I have no obviously like no interest in this company itself, but it’s just one of the examples that you can find in your local pharmacy. You can talk about the use of, are you using good lubrication? Because as that tissue becomes thinner, as you have less elasticity of that tissue and as you have less blood flow to that tissue, your natural self-lubrication decreases as well.

Courtney Collen:

Is there a specific type of lubrication that you would be recommending?

Dr. Elizabeth Hultgren:

Yeah, we typically would recommend – I recommend a lot of silicone-based lubricants for women because it’s going to last a little bit longer during your intercourse session. It’s going to be a little bit more comfortable. And so using a good silicone-based lubricant, make sure it has no colors, no scents, no like anything else to it. Oftentimes you’re going to see a silicone with added vitamin E. But it’s going to last a lot longer for our post-menopausal women. So we talk a lot about silicone-based lubricants.

The other thing that we talk about though is you can’t use a silicone based lubricant with a silicone based either like vibrator or toy of some sort because it’s going to degrade that silicone toy. So if you’re going to be using like a vibrator in the bedroom, make sure you’re using a water-based (lubricant) with that particular toy.

Courtney Collen:

I see. OK. Great.

Dr. Elizabeth Hultgren:

I don’t know if I’m allowed to say that.

Courtney Collen:

That’s fine. I appreciate that insight very much.

Dr. Elizabeth Hultgren:

And then so women that are open to using hormonal based treatment for what we call genitourinary symptoms of menopause or that vaginal dryness, vaginal irritation, pain with intercourse, we highly recommend use of vaginal estrogen for that.

Vaginal estrogen comes in a couple different forms. It comes usually either in like a tablet or a cream. They are forms that are commercially available so you can order them through a pharmacy and they’re typically medication that they’re actually going to place in the vagina two to three times a week. The important thing to realize is the reason I say like vaginal estrogen can be used for anyone is because it doesn’t get taken up systemically.

What we know is that vaginal estrogen is very safe. Even those that are currently undergoing treatment for like an estrogen positive breast cancer. So these genitourinary symptoms of menopause is something that we hear a lot of, especially from our breast cancer survivors. They’ve been without estrogen, it was a really sudden like shift of estrogen being turned off in their body, whether it be through chemotherapy, whether it being through surgical management. And so they went from like a very normal, you know, estrogen level to sometimes it being taken away almost overnight.

And so they can see a really drastic shift in the way that their vulva, labial, vaginal tissue feels. And so for these women, we absolutely recommend use of vaginal estrogen. We’ve worked with our oncologists here at Sanford and they’re very much on board with this as well. And it’s because of the fact that your vaginal estrogen is not taking up systemically. So vaginal estrogen is great for the treatment of what we call those genitourinary symptoms of menopause. Otherwise GSM is how you might hear it abbreviated, but it’s really safe to use in a very large population because it’s not taken up systemically.

So if you’re having any symptoms, please go talk to your provider about it. It can be life changing for a lot of women. There’s natural ways to increase the blood flow and elasticity of your vagina as well. And we talk about using it. So whether it’s the use of like penetrative intercourse, whether it’s the use of you know, dilators or vibrators or whatever that is for you, we know that stimulation of that tissue increases blood flow to that tissue and actually can help make intercourse more comfortable.

Now if you’re coming in with pain with intercourse, please let your provider know. Because there’s a lot of evaluation we’re going to want to do to that. We’re wanting to make sure there’s not some underlying pathology that’s causing it. But if it’s truly due to the decrease in estrogen, secondary menopause, know that these are very much things that we can help with.

Courtney Collen:

Fascinating, thank you for adding that. I’ve got a few common misconceptions around menopause I’d like you to clear up for us. I have three of them. The first one: menopause happens overnight.

Dr. Elizabeth Hultgren:

Not true. Essentially we talked about menopause is those ovaries slowly producing less hormone than they were previously producing during your reproductive years. And so for most women, I say most because there’s obviously outliers to this, but for most women it’s going to be a gradual decrease in their estrogen, progesterone production. With this you start to see what we and is being a lot more talked about is perimenopause. So, and this is why I start having these conversations.

If women are coming to me with some of these symptoms, hot flashes, brain fog, changes in their menstrual cycles as early as, you know, five to seven years actually before the onset of menopause. So this is a gradual process. It’s all on a continuum. I think there used to be this really hard and fast rule that we don’t start hormone therapy until your periods have completely stopped. I think there’s been a huge shift in this even in the past five to 10 years where we are starting to provide estrogen, progesterone therapy for those that are still maybe having periods, but they’re starting to have some of these symptoms start to creep up.

And really we’re looking at again treatment of symptoms not towards a hormone level. And so we’re starting to add in, you know, do we start with a low dose estrogen patch and some progesterone at night as early as you know, early 40s to help them kind of start to transition and they may be good on the same dose for three to five years and then they’re like, my symptoms are starting to come back. And so we increase that dose as needed. Again, really focusing on symptom management and not necessarily what your absolute hormone levels are.

Courtney Collen:

OK, number two: weight gain is inevitable and uncontrollable.

Dr. Elizabeth Hultgren:

Absolutely false. Again, we kind of talked about some of the reasons for that. I think as we go into this menopausal transition, it’s helpful to be more mindful and more cognizant of these changes that are happening.

But as we kind of talked about earlier, there’s a lot we can do really focusing on are we giving our body the building blocks that it needs in order to maintain our muscle mass? Are we building muscle mass? So we talked about weightlifting two to three times a week.

Are we maintaining our cardiovascular health and our functional health by getting that 150 minutes of exercise each week? And then knowing that yes, as your estrogen levels decrease, you might have a change in distribution of like where our body is choosing to store some of that. But when we talk about overall weight gain, we talk about overall, you know, is this something that there’s nothing I can do about? Absolutely not.

There’s a lot of things we can do about it. Just being more mindful about it, being more intentional about what you’re putting in your body can really be helpful during this transitional phase.

Courtney Collen:

And the last one: symptoms are something you should just suffer through and deal with.

Dr. Elizabeth Hultgren:

100% disagree with this. We talk about a lot about symptom management and again, we’re not treating towards a specific hormonal value. We are treating towards symptom management. And anytime you’re having, you know, gynecologic symptoms, whether it be periods that are really painful for you, periods that are causing you to miss work or school all the way through, I’m having hot flashes or disruptive to me leading a board meeting.

These are all symptoms that we should be addressing in like the purview of gynecology. So please reach out to your local OB/GYN or your local family practice provider that maybe have some really good helpful suggestions, treatment options if you’re having any of these symptoms.

Courtney Collen:

Dr. Hultgren, what is one thing that you wish every woman understood about menopause?

Dr. Elizabeth Hultgren:

The one thing I would say is that menopause is a natural form of the life cycle. It can have some symptoms that come along with it. There’s a lot of things that we can do to treat these symptoms, but it certainly doesn’t mean that like this is the end of, you know, good sex. This doesn’t mean that this is the end of me being able to live my life as I want. This doesn’t mean this is the end of me having the body that I want or the functional status that I want.

Really, menopause is just the next phase and for some women, this can be really empowering. And so kind of being able to take this knowledge, know that if you’re having symptoms, there’s certainly things that we can do to help treat this. And really embracing this next phase of life and really embracing all that it actually has to offer as well.

Courtney Collen:

Is there anything else that we didn’t touch on here that you wanted to include in our conversation today on this topic?

Dr. Elizabeth Hultgren:

Yeah, what I would say is just, there’s a lot of information out there and so making sure you’re getting your good, your information from a good reputable source. The American College of Obstetrics and Gynecology (ACOG) has a lot of really patient friendly information on this. The Menopause Society, previously known as the North American Menopause Society.

If you just go to the Menopause Society, they have a lot of really good patient information under what’s called Meno Notes. And it’s just one- to two-page leaflets that really describe what is the function of hormonal therapies, what is the function of nonhormonal therapies, what is considered normal during this transition, what can I do about it? What are lifestyle changes I can make? And so really make sure you’re getting your information from a good reputable source.

And if ever you’re uncomfortable with a treatment regimen that’s maybe been prescribed or you don’t feel like you have enough information on it, please reach out to your local OB/GYN, family practice, internal medicine provider. There’s a lot of really good providers in the community that are really knowledgeable about this and I would say if they’re not, they’re going to let you know, and they’re going to help you get to someone that is.

And so there’s a lot of people that are really passionate about helping women age gracefully and age empowered and have knowledge about what’s going on with their body during this timeframe. And so make sure that you’re reaching out to get to one of those providers.

Courtney Collen:

How would you encourage patients or women listening to get the right kind of guidance?

Dr. Elizabeth Hultgren:

In our communities, we’ve seen kind of this uprise in “wellness clinics,” and while some of them I think go into it being very well-intentioned and wanting to help women, I think having the background of just physiology, pathology, what the causes of this are, are really important.

So talking to someone that’s board-certified in their area, talking to a physician that has specialty, essentially knowledge or education in the basis of menopausal therapy – so oftentimes this is going to be your local OB/GYN – can be really important as far as understanding the “why” behind this.

I also want people to be really encouraged to ask questions and make sure that you’re not seeing people that have a lot of financial gain to be gained by you seeing them. As an OB/GYN, I love taking care of women throughout all stages of life. Everything from my young adolescent patients through menopause. And so really being able to empower women to make really good choices for their life and whether that’s talking about lifestyle modifications, medications, or just realizing what’s normal at whatever stage of life they’re in, is really important.

Courtney Collen:

Such a valuable conversation. We really appreciate this insight, Dr. Hultgren, and all that you do to care for women in our communities. We appreciate you.

Dr. Elizabeth Hultgren:

Yeah, thank you.

Courtney Collen:

Thank you. Thank you so much.

Announcer:

This was part of the “Her Kind of Healthy” podcast series by Sanford Health. For more by Sanford Health, visit Apple, Spotify and news.sanfordhealth.org.

Get more episodes in this series

Cancer myths vs. truths – and what truly matters

Dr. Dan Almquist:

The best thing to do is get information, ask questions, bring it to the table, have a conversation about anything. If it’s your fears, if it’s your anxieties, if it’s medicines, if it’s supplements, bring it to the table. Our job as physicians is to actually educate you and teach you and help you navigate these really tough things in life.

Courtney Collen (host):

This is the “Health and Wellness” podcast brought to you by Sanford Health. In this episode, we’re unpacking some of the most common myths and misconceptions around cancer from diagnosis to treatment. Whether you’re a patient, a caregiver, or someone who just wants to be informed, this conversation is for you.

Our guest is Dr. Daniel Almquist, a board-certified specialist in hematology and oncology at the Sanford Roger Maris Cancer Center in Fargo, North Dakota. Our host is Courtney Collen with Sanford Health News.

Dr. Almquist, thank you so much for joining me for this conversation. Nice to have you.

Dr. Dan Almquist:

Hey, thanks for having me.

Courtney Collen:

Cancer is one of those heavy topics where everyone seems to have some advice or guidance, like add superfoods, cut sugar, eliminate plastics, less processed foods, more red wine. Like if you do everything right, you’ll be safe. We hear so much about doing this or that to prevent cancer, and it is kind of overwhelming. That’s why I’m really looking forward to digging into some of these things, like what you hear in your clinic and what you want our listeners to know.

So, to start us off, Dr. Almquist, why do you think cancer myths are so persistent, even with so much information available today? Or is too much information the problem?

Dr. Dan Almquist:

Oh, that’s a great question. That I think that’s one of the ultimate questions actually. You know, I always, I guess I always go back to like information or knowledge is power, right? So the more information you can have, the better decision making you can have.

But when it comes to like scientific evidence, this is where it gets really tricky because even in the papers and research that we use, there’s different scales of validity. You know, like how is it powered? Is it the correct patient? Are you actually trying to study these things?

And so even when studies get done it gets complicated. Because sometimes people, if they’re reading it on their own and they don’t have a background in scientific evidence, or even statistics, let’s say, it gets complicated. Because to be able to interpret this, you kind of have to have a background on that.

So sometimes I think people, this paper will come out or the study will come out, it hits the media in the news and people run with it and they don’t really know what it actually means. It’s like when someone asks me like, “Hey, can you fix a car?” It’s like, actually I can’t, like I don’t have that ability. I can read a paper, but like, you want me to take a part of the engine? I can try to read about it and do it, but I just don’t really know how to do it, actually. I kind of get that we all, before this we talked a little bit.

I think we all have these different roles in life and one of it is this where my job is to examine the data and proclaim it forward and kind of say, hey, this is real benefit. This isn’t benefit, this is a negative study, a positive study. At the end of the day, I think information’s important. Asking questions about that information is super important. So I’m glad it’s out there. Because then people can bring it to you and ask questions, which I think is so good.

At the end of the day, why do these continue to go forward? It’s probably because we have this sense of hope, right? Like, we all have this in us where we’re like, “Man, this is going to help me, or this is going to change my life, or this is going to improve the way I feel.” So I think there’s just longing in us to just make things better all around. And I think that’s why these can perpetuate and continue.

Courtney Collen:

Yeah. Thanks for the insight. I want to jump into lifestyle and diet. We hear a lot that certain superfoods can prevent or cure cancer. Is there any truth to that, Dr. Almquist? And if so, what foods are generally more helpful? And maybe on the flip side, what foods should we be avoiding?

Dr. Dan Almquist:

Great question. You’re talking about somebody who’s very, I kind of practice what I preach. So it’s one of those things where if I’m going to tell a patient like, you shouldn’t be doing this, then I shouldn’t be doing it myself. Or if you should be doing this. I’m going to start with the back end of that question.

What should we be avoiding? That is probably easier said than done in all realities. So a couple weeks ago actually, or earlier this year I should say, the World Health Organization came out and said, deli ham, right? Deli ham is a class one carcinogen, which means it has a similar impact on cancer and health as smoking, which is like what? Like how is processed ham as bad as smoking? So if you eat it regularly, the preservatives, the nitrates, those kind of things that are in it are super detrimental to us.

Increased risk of colon cancer. So it’s one of those things where processed foods, ultra-processed foods, there’s more and more evidence that are saying, hey, we should probably stay away from these. And so that would be kind of my first step is like, what can we avoid? And what can we, like for longevity and risk reduction in cancer, what can we stay away from? And that’s the first step. I would say processed foods, ultra-processed foods. There’s more and more evidence mounting against them saying that they’re bad for us.

The flip side of that: What should we be doing? You know, superfoods I would honestly, I wouldn’t classify as superfoods. I would say, hey, fruits and vegetables are super important and it’s honestly, the world has gotten so complicated in just terms of convenience and access and these kind of things.

You know, if we went back 400 years, 200 years and we’re like working on a farm and you’re butchering your own food, you’re planting your own garden, you’re harvesting your own things, that’s probably the best approach in terms of health. Just in general, right? So you’re eating fresh fruits and vegetables, you’re eating unprocessed meats, you’re just eating what was on the farm. In all reality, that’s probably the best thing.

And so, for me, the data has been mounting more and more that fresh fruits and vegetables, not canned per se, but whole vegetables are going to be beneficial on multiple reasons. So one is that just the vegetation itself is good for us. You talk about fibers and those kinds of things which are good for our gut health, but on these unprocessed foods, you’re going to have bacteria and microbes.

And we know more and more that these, this, these microbes on the fresh fruits and vegetables that help sustain gut flora actually reduce inflammation, promote good byproducts, and reduce the risk of colon cancers and those things. So for me, fresh fruits and vegetables, you know, fresh meats, unprocessed foods is kind of where we should go for lifestyle.

And then the two big things we always talk about is smoking and alcohol, right? Stay away from those things. Smoking is the number one risk factor. It’s going to cause you harm no matter what disease you’re talking about.

And then alcohol, there’s different kind of levels with this. The general consensus is abstinence is probably the best approach with that, but fresh fruits and vegetables, you know, they just redid the pyramid. Yeah, and I actually kind of agree with that. You know, when I look through it, I haven’t studied the recommendations in depth, but when I’ve glanced at it, proteins are good, fresh fruits and vegetables are good, whole fruits and vegetables – it’s like those are going to be the mainstay and should be our mainstay for everybody.

Courtney Collen:

Good to know. Thank you so much for the insight. Does sugar, speaking of foods, does sugar feed cancer?

Dr. Dan Almquist:

That’s actually one of the most common things. Besides supplements, like can you take supplements? The next is always sugar and what to do with it. I think that myth started with the scans that we use, right? So there’s a special scan that we use to kind of find cancer and it’s called the PET scan. And we use sugar moieties with that to kind of find where high metabolism is at, which then helps identify cancer.

So, I think that’s kind of where it came because we inject people with this moiety, they sit for an hour, they go through a scanner and we see this glucose uptake and it’s one of those things, or sugar uptake. And it’s one of those things where I think they, they think, oh man, this thing’s living off of sugar. So, the thing I always tell patients about that is like, cancer’s super evil.

If you’re not putting sugar in your mouth, it’s going to find a way to make sugar. So, if it breaks down your fat going after your liver, going after muscle, it’s going to find some way to find sugar. So if you’re not eating it, not only are you going to be starving the healthy parts of your body, so your muscles, your organs, you’re also just allowing cancer to destroy more of your body.

So for me, it doesn’t, it’s not a matter of sugar; it’s a matter of metabolism. So when there’s active cancer, there is just going to consume calories and sugar faster than the rest of your body. And so the worst thing we can do, which is really common in cancer and chemotherapy, is a term called sarcopenia or muscle loss. The muscle loss happens a lot with chemotherapies. And so if you’re not eating, if you think about a bodybuilder, right?

Like they consume a ton of calories and a ton of protein and a ton of sugar just to build muscle. So if you’re not putting that in your body, you’re going to lose muscle faster. And it’s like, man, if you want to stay walking, you want to be moving, you want to be up and down stairs. Like it’s so important to get calories and nutrition in.

I’m not afraid of sugar in these things. So those kind of things. There is some data like intermittent fasting, you know, reduced sugar, ketos, ketosis, which there’s valid data. So scientifically it’s been shown, like it improves processes. And what I usually tell people is, save it for before you have cancer or after you’ve done treating cancer, not during. Sugar’s our friend. We need energy. We need strength.

Courtney Collen:

Yeah. Thanks for clearing that up. As a medical oncologist, I can imagine you’ve seen a variety of lifestyle factors, and we’ve talked about that become common with different cancer diagnoses. If there’s one thing we should stop doing Dr. Almquist or stop consuming to reduce our risk of potentially developing cancer, what would that one thing be? Even if we’ve already talked about it.

Dr. Dan Almquist:

The number one thing’s going to be smoking. You know, in terms of just across the board, if you look at a modifiable risk factor, smoking is the number one thing. If people stopped smoking and they put me out of a job, I would be happy. I would go find something else to do. Like I love what I do, but I would gladly to go serve someplace else in the world and do something else with my life.

Courtney Collen:

But smoking – is it our knowing that people are maybe healthier, a little bit healthier, and taking care of their bodies a little bit more by just cutting that one thing?

Dr. Dan Almquist:

Yeah. So, in nonsmokers, we go back to the nutrition piece. Exercise and nutrition, you know, those are the three things and studies keep showing over and over again, exercise and nutrition. I mean, there, it’s such a simple thing. If you ask a question like eating healthy, it’s like, oh yeah, but it’s so hard to do.

Same thing with exercise, it’s like, oh yeah, that makes sense. But it’s so hard to actually do. So like in terms of just health and life in cancer reduction, it’s like if we could literally as a society nail down healthy foods and 30 minutes of exercise a day we would drastically change how much cancer we’re probably seeing.

Courtney Collen:

Let’s talk family history and risk. I may think if I have cancer in my family, it’s if inevitable for me, or if I don’t have any family history of cancer, then I’m not at risk. Can you help us clear the air with that?

Dr. Dan Almquist:

Yeah. That’s a tough one because – and there’s some blood disorders that, where we see just because you have like this genetic predisposition, it doesn’t always mean you’re going to get the disease. And so it’s one of those things where it’s hard to always to talk about just like family history because there’s so much that goes into it.

You know, was your family all smokers? Like, were they all drinkers? Were they exposed to radiation or whatever else in the environment? So a lot of times, there’s multiple things that stimulate cancer to develop. So the immune system surveillance misses it. There’s something in our environment that triggers it. But for sure family history does weigh in on that.

So there’s definitely some genetic, and we have these syndromes that run in families that predispose you to cancer. And if it’s caught in those families, then we change the way we screen and we follow and we check to make sure we’re not missing cancers earlier in life. But it doesn’t mean it’s going to happen. It’s not a hundred percent guaranteed just because your family’s had it that you’re going to get it.

And the caveat of that too is sometimes there’s cancers that run in families and we actually don’t know the genetic reason for it. We haven’t identified these genes as of yet because this is an evolving area, right? This is still ongoing research about what drives cancer and what doesn’t and what we can modify and what we can’t.

But it does not mean if you had every family member have cancer, it doesn’t mean you’re going to get it. The opposite is a hundred percent true too. Like if there’s no family history, you still can develop cancer. You know, I just, this last couple weeks I had a number of patients, they’re like, there’s zero. We have a lot of heart disease, we have diabetes, no cancer, but why did I get cancer?

And it’s like, well, you ask questions and you realize they maybe weren’t doing their routine screening. You know, the things that we’ve recommended as a medical society saying, “Hey, you should do X, Y, and Z just to make sure it doesn’t happen to you.” And you come to find out like, oh, you never did that. That’s, you know, a reason why we recommend it is to prevent these things from developing.

Courtney Collen:

Yeah. OK. Here’s another myth. I want to dive into if I feel healthy, I don’t need to worry about cancer, or I can skip a screening. A lot of people may assume no symptoms means no cancer. Why is this such a dangerous misconception?

Dr. Dan Almquist:

Oh, this is. It’s always so hard. And I always get heartbroken when I see a patient who skipped their screening. A lot of times people fear colonoscopy and it’s either from the prep or from the procedure itself. But it’s like, one of the big reasons why we do that screening and at even a younger age now, is to prevent cancer from forming.

There are certain polyps and certain family histories that will predispose you to colon cancer. And it’s like, man, if you would’ve at 50 years old or 45 years old gotten that colonoscopy and we found that you had a ton of these premalignant things, we could have followed you closely for a number of years and this would’ve never happened.

So for me, screening is so important. It doesn’t matter how healthy you are. You could be one of the most healthy people. You could live in a bubble and check all the boxes. Like, I ate right, I drank water, I didn’t smoke, I exercised. I did all those things. But there’s still so much more to cancer development than just that. So for me, screening is so important just in terms of cancer prevention, you know?

We can catch a lot of these things if we do them earlier. But you always talk to those people and you’re so heartbroken because it’s like, man, this was preventable if we would’ve just done the colonoscopy.

Courtney Collen:

Yeah. Yeah. I appreciate the insight. Beyond the screening, let’s talk about a biopsy or surgery. Here’s another myth. Can a biopsy or surgery spread cancer?

Dr. Dan Almquist:

That’s actually a tough conversation. The answer is, you know, I guess I always get this question like, oh, when the tumor’s open to air, it will spread. And it’s like, no, that’s a myth. That’s not true.

Now, there are some certain circumstances where when you do a biopsy you can develop what they call a drop met. So a metastasis next to the tumor that when, like they pulled the needle out or they did the procedure, it contaminated that tissue and then it dropped a few of those cells there. They started growing. But it is not one of those things where you go do a biopsy and then all of a sudden the cancer’s everywhere. That does not happen. So that part is just, they have aggressive cancer.

Let’s say you do a biopsy, you had one tumor, and then six weeks later you do a scan. They just had really aggressive cancer. But there is this scenario, and I think this is where that myth comes from, is that when someone got a biopsy, when they pulled the needle out, it brought a couple of those cells and put it right next, or just outside that tumor. So really that happens locally. It doesn’t spread it throughout the body. It just can move it to a local area.

And sometimes you’ll see it where they do a biopsy and then they’ll get the skin nodule and it’s like, oh, that’s a tumor in the skin. But a lot of times if we’re treating it, we can take care of it and just treat both of those at the same time.

So again, it doesn’t risk spreading it all over the place, but there’s this chance, this drop that could develop locally. If I’m honest, in the last few years, I’ve only seen that I can honestly (count on) one hand, like a couple of times. You don’t see that very often.

Our surgeons are really good in the techniques they use this day and age. Very rare that that shows up. But it does happen. But again, it’s local, not everywhere. It doesn’t spread everywhere.

Courtney Collen:

Sure. Is cancer contagious?

Dr. Dan Almquist:

No, the answer’s no. Like flat out, if my mom had breast cancer and my mom kissed me, I’m not going to get breast cancer. And so that part is a no.

But there are, you know, we know like HPV mediated infections, right? So there you could have HPV, you could pass on HPV to a partner and all of a sudden you are spreading HPV to each other, which then can subsequently, you know, oral pharyngeal cancers and other cancers related to a viral infection like that. But cancer, in of itself, you’re not going to get from another person.

Courtney Collen:

Can a patient work and live normally during their cancer treatment?

Dr. Dan Almquist:

Oh, for sure. There’s some people, honestly, every person’s different. So I always tell people that. So I do a lot of head and neck cancer, and when you’re doing chemo radiation, it is super tough, like debilitating, really morbid. There are some people, like, they go to work full-time, they live a normal life. And you’re like, man, that is amazing.

And then there’s some people that that it hits them harder. They have more side effects. And we had the management more so they back off a little bit. But I can promise you there’s probably people you know who are going through cancer treatment and you don’t even know it. They’re just living their life as normal and they’re just out in the community. They’re walking around and you would never guess like, oh, they’re getting cancer treatment right now. It’s really person-dependent.

But yeah, you can definitely, especially if your doc’s good at managing your side effects, you can live a full life. And that’s the whole goal of cancer treatment, right? Is to reduce cancer-related morbidity, give you a good quality of life, prolong your life. So if you’re getting the right treatment and the right care, you should live a full life.

Courtney Collen:

Yeah, absolutely. What have we missed? You care for cancer patients. What are some of the myths or things that aren’t necessarily true that you hear most often that you want to share with our listeners that maybe we haven’t touched on yet?

Dr. Dan Almquist:

Oh man. Well, supplements are a big thing. So that’s the big one. And it’s not necessarily a cancer myth, but there’s just so much online, you know, about ivermectin and vitamins and all these things. And the reality is we just don’t know a lot of this stuff, so in terms of cancer treatment and in terms of how we approach patients, we really just stay with what we know.

So we have scientific evidence that says that. And when you look in these trials, you know, we don’t know if you’re getting high-dose vitamin C, does it influence this chemotherapy or not? Does it influence your immune system? And so it’s really hard. So we get asked a lot about these different supplements.

At the end of the day, a lot of them were preclinical, which means they were studied in a lab and not necessarily in humans or big studies. So when you get a chemo from a doctor, they’ve been studied for lots and lots of people, big, big studies. These supplements may have been studied in a lab and there’s a dish and they run and say, hey, look, this may treat cancer really well, but the problem is maybe they’re really early in their studies, so they haven’t done full human studies.

Does it metabolize appropriately? Does it actually do anything in the human body? You know, just because it worked in a mouse doesn’t mean it’s going to work in us. So that part, we’re just different, right? We’re different animals than those mice. So the reality is, a lot of those things, when we hear about them, it’s kind of like, we just don’t know. Is it good? Maybe. Is it bad? It could be really bad. I don’t know.

So a lot of times those are the questions we face and some supplement that we hear about, and it’s just like, you know, the answer is really, we just don’t know. And so I try to stay away from those things that I don’t know. I know what treatments work. I know what meds can help with symptoms. But then when we start getting into the weeds, a little bit of these, you know, these different supplements, we just don’t have enough data to say yes or no to it.

And it’s a hard conversation because some people are just adamant that these things are going to work, and maybe they will. I don’t know. But at the end of the day, I always try to bring it back to like, this is what I know. This is the care I can provide. Right? And this is where I’m comfortable in helping you.

But there’s, again, there’s a little bit of this, like people believe it. So sometimes it’s hard to argue logic with belief because they believe in it, you know? And that’s their prerogative that they can do that. It just makes it a little bit more complicated for us.

Courtney Collen:

You’ve got to be your own advocate at the end of the day, right? But how important is it to address concerns, questions, things that you’re hearing that you want to clarify with your primary care provider, physician, oncologist? Like how important is that communication with your care team?

Dr. Dan Almquist:

Oh, that’s, so again, like I said earlier, knowledge is power. So, the more you can know, the better decision making you can make, especially under stress and that processes. So for me, I always tell patients the squeaky wheel gets the grease, right?

So you know, it’s one of those things where if you’re making noise, you’re asking questions, you know, I’m going to do my best either to answer them with the knowledge I know or go help find information for you. And so I think, especially at our cancer center, I know that’s kind of the mentality here.

Truly we want to do what’s best for the person in front of us. We want help them the most. If they have questions about the things, we want to discuss them. I’d rather know about it, talk about it. If the patient decides to do something that I don’t necessarily agree with, that again, that’s up to them and that’s their life, and I’ll talk about it with them. But I think talking through things and discussing kind of the risk-benefits and those things regarding anything, you know.

Like, “Can I go to Mexico this weekend?” It’s like, well, you know, “Yes, but we’ve got to do this.” So it’s always good to have conversations about everything. So for me, squeaky wheel gets the grease. If you have something that you desire or a question you desire, bring it forward. We’ll talk about it. And I think most docs truly, they go into this to help you and provide the best care possible. And part of that is just that communication piece.

Courtney Collen:

Dr. Almquist, if a listener has a loved one, maybe, or a friend who has been recently diagnosed with cancer, how would you encourage showing support? I’m sure patients come in, they’ve got a support person, whoever it may be, their questions maybe revolve around, how can I show support? What can I do? Because I’m sure it’s so hard to not be able to do anything to physically take the cancer away. Right? Or the symptoms around treatment, make someone feel better. What can we do to support a loved one or a friend who is going through cancer?

Dr. Dan Almquist:

Oh, that’s a great question. Obviously being there to just talk. For me, the cancer just affects you physically, mentally, emotionally, spiritually. So being present, being open to conversation is number one. At the end of the day, this is something I’ve learned over the last few years which was, so for me, when someone pieced it together for me, it was so insightful for me.

One of the big struggles is when you get diagnosed with cancer, you feel this loss of control. It’s like your body’s doing something you don’t want it to do. These doctors are telling you this stuff. You have to do medicines you don’t want to do. And so you lose a lot of control in your life, which I always think, you know, we have this illusion that we control everything, even though we can’t predict tomorrow. But we, we lose control.

So one of the biggest things I think family members can do is allow a patient to make decisions and control some aspects of their life. You know? And it’s hard when you’re passionate about something, you love something, someone so much, and you’re just like, you’ve got to do this, you’ve got to do that. But at the end of the day, giving some control back to that person, I think is hugely beneficial for them.

It gives them kind of a solid point to stand on. Like, I’m still in control of these aspects in my life. And I think that’s one of the hardest things about cancer is that you just feel like you lose control. So giving that back to them, allowing them to get some control in their life I think brings some peace during the journey.

Courtney Collen:

Dr. Almquist, is there anything else that we didn’t touch on that you would like to add here today as we wrap up?

Dr. Dan Almquist:

I think these questions are great. They truly are things that we face as oncologists or hematologists-oncologists every day. And they’re that process of talking through it, that journey is hard. And like, even as an oncologist, like I try to give the patient as much control as I can, right? I kind of just say I’m here to teach you, educate you. Your job is to decide on what you want to do with this.

And I would say if you’re going to make some crazy decision, I’ll try to try to redirect you a little bit. But at the end of the day, I think it’s a hard, hard journey for patients to go through and families. It’s so devastating and you hear in the news, like if you watch the news, you see people pass away from cancer all the time. It affects literally everybody. It doesn’t have wealth or position or anything. It affects everybody.

So again, I think the best thing to do is get information, ask questions, bring it to the table, have a conversation about anything. If it’s your fears, if it’s your anxieties, if it’s medicines, if it’s supplements, bring it to the table. Our job as physicians is to actually educate you and teach you and help you navigate these really tough things in life.

Courtney Collen:

Well, that’s why we are so grateful for your expertise, your insights here. I really, really appreciate this valuable conversation. It’s not always an easy one to have, but we really do appreciate your insight and all that you had to offer on this topic. Thank you so much for your time.

Dr. Dan Almquist:

I thank you. I appreciate being here.

Courtney Collen:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen wherever you hear your favorite podcast and on news.sanfordhealth.org.

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What every woman should know about uterine fibroids

Dr. Jennifer Enman:

Women, in general, downplay their symptoms. Everybody thinks that it’s normal, but quite frankly a lot of us aren’t ever taught what is normal and what isn’t normal.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” an informative and unfiltered podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. I’m so glad you’re here. We’re starting new and honest conversations about age-old topics from fertility to postpartum and so much more with our Sanford Health experts.

In this episode, we are talking about uterine fibroids, something that affects so many women, probably more than you think. If you’ve ever had painful periods, heavy periods, pelvic pressure or felt like something just isn’t quite right, this conversation’s for you.

Uterine fibroids are very common, but there’s a lot of gray area. So to help us break it down in a way that makes sense, and answer those common questions from symptoms to diagnosis to treatment and also how they affect fertility, I have Dr. Jennifer Enman joining me.

She is a board-certified OB/GYN at the Sanford Aberdeen Clinic in Aberdeen, South Dakota. And the perfect person to join me for this conversation. Dr. Enman, thank you so much for your time. Welcome.

Dr. Jennifer Enman (guest):

Thank you for having me.

Courtney Collen:

I have so many questions. So let’s start simple with this: What exactly are uterine fibroids and how common are they?

Dr. Jennifer Enman:

That’s a great question. So I think we should start with first, what is your uterus? Your uterus is the muscle where a baby would grow when you’re pregnant. It’s also the muscle that contracts to help push menstrual products out. So it’s a muscle, and fibroids are usually benign or non-cancerous muscle growths on or in your uterus.

Courtney Collen:

Who are they affecting? Are some women more prone to these than others?

Dr. Jennifer Enman:

So the literature suggests about 70% of women will be affected by fibroids by the time they go through menopause. However, we don’t know the accuracy because many women can have fibroids and not have any symptoms at all.

Courtney Collen:

Is it hormones, genetics, lifestyle?

Dr. Jennifer Enman:

We don’t think that it’s lifestyle. There’s definitely a genetic component. We see women between 30 and 40 (years old) and sometimes after 40 most affected by fibroids. There is some data to suggest that Black women may be at increased risk for fibroids.

But again, it’s difficult to know because some women have fibroids and aren’t aware of it. Or on the contrary, some women have had fibroids for so long and their periods have been so painful and so heavy they don’t know that it’s abnormal. So we don’t ultimately find out that they have fibroids.

Courtney Collen:

I feel like a lot of women will normalize the symptoms. So tell us what are the signs or symptoms that it could be fibroids versus just a normally painful period?

Dr. Jennifer Enman:

Unfortunately you can have a variety of symptoms, but the most common ones will be a change in your period. They can be a little bit longer, they can be more heavy or they can actually happen more frequently than previous.

So on average, we say every 28 days is considered normal, but I will say there’s variants from female to female in that. But when you have fibroids, they tend to have more frequent periods and the periods are a lot heavier.

You can also have more pain with your periods, and sometimes, depending on the size and the location of a fibroid, you can actually have pain with intercourse. Some women who have very, very large fibroids will actually have constant pelvic pressure, urinary frequency and actually in severe cases cannot fit into their clothing anymore.

Courtney Collen:

What determines how severe the symptoms are?

Dr. Jennifer Enman:

So usually it’s based on the size of the fibroid and the location in general. Fibroids that are very large are going to cause more severe symptoms, bleeding, pain, while very small fibroids – and we’re talking one to two centimeters – most women aren’t going to know that they have those. Now that’s not true for everybody, but in general that’s a good, good way to think about it.

Courtney Collen:

Are there different types of fibroids, and do they affect women differently?

Dr. Jennifer Enman:

We differentiate fibroids based on their location. So some can be within that uterine wall. Some can be within the outside layer of the uterine wall. Sometimes they can be inside the uterine layer, so that’s when we see them affecting pregnancy. Or people with fertility issues. And sometimes they can completely be on the outside and actually attach by a little stem.

And again, depending on the size and the location, that’s when we see the biggest variance in the symptoms that somebody might have. In general, lifestyle doesn’t necessarily affect the fibroids, but someone who has a really big fibroid and is experiencing really heavy bleeding and pain might not be able to participate in the things that they love to do, exercise, et cetera.

Courtney Collen:

Let’s move on to diagnosis. Dr. Enman, how do you diagnose uterine fibroids and why is it difficult in some cases to diagnose these in women?

Dr. Jennifer Enman:

The best way to diagnose uterine fibroids is usually based on imaging. Now when a patient comes in and they’re complaining of different symptoms that they’re having around their menstrual cycle, I want to preface that it can be a variety of things.

Sometimes it definitely can be fibroids, but there’s a lot of other things. So if you came into the office and said, I’m having really heavy periods, they’re super long I’m having a lot of pain, then the first thing we would do would be a physical exam.

And depending on what you had tried – hormones, NSAIDs – then the next step would usually be an ultrasound. In general, that ultrasound can be transabdominal or on the top of your belly. But sometimes we do have to do what’s called transvaginal, which is where you have a probe inside the vagina, which allows us to better measure the size and determine the location of the fibroids.

Some additional ways that we can diagnose fibroids include hysteroscopy, which is a device that has a camera and we insert it through the vagina, through the cervix up into the uterus. This helps us to see fibroids that might be within that uterine cavity.

We can also do a test called a hysterosalpingogram, which is an X-ray that allows us to see abnormalities within and around the uterus. Finally, you can do a sonohysterogram, which is when we actually put fluid into the uterus through the cervix and then we use an ultrasound to show the inside of the uterus to see if there’s any intracavitary fibroids.

And then there’s surgical diagnosis, which usually occurs through laparoscopy, which is when you have small incisions on your belly and we go in with a camera and take a peek at your uterus. If we think you need advanced imaging, sometimes we will do an MRI, which just allows us to better see where the fibroids are and how big they are. But usually we use that for surgical planning purposes.

Courtney Collen:

When we talk about treatment, how would a uterine fibroid be treated? And let’s just walk through some of the options that patients have at Sanford.

Dr. Jennifer Enman:

Sure. It really depends on the severity of symptoms. So if we have someone who has painful periods, also known as dysmenorrhea, and heavy bleeding, but that bleeding isn’t heavy enough where it’s causing anemia – which is when you bleed so much you have low blood count – it’s just kind of annoying, then we might start with some form of hormonal treatment, whether that’s birth control pills or a Mirena IUD.

And again, it really depends where those fibroids are, what treatment we’re going to best utilize. But if we have small fibroids, a little bit of pain and a little bit of annoying heavy bleeding, we might start with hormonal options.

NSAIDs like Motrin is going to be helpful with the cramping. If we have somebody that has more severe symptoms, then we can utilize something called gonadotropin-releasing hormones. And these medications are kind of big-game medications that stop the menstrual cycle and can shrink fibroids. Usually we use these when we’re trying to shrink fibroids prior to surgery to just better prepare for surgery.

As I said, an IUD is a good option. There’s another medication called tranexamic acid, and that just reduces heavy bleeding and blood loss during periods. And then there’s surgical management. So depending on what we’re trying to treat – and right now we’ll just say it’s heavy bleeding and pain – if we’ve gone through all of the noninvasive options without success, then we can move on to a hysterectomy, which is when we remove the uterus. And in doing so, remove those fibroids.

Now in someone who plans to have babies in the future, this would not be a viable option. So there’s another surgical option called myomectomy, and that’s when we actually go in and remove the fibroid itself while leaving the uterus in place. And this gets pretty complex depending on location and size but if you want to preserve fertility, that would be an option.

Courtney Collen:

Can you tell us about any new or emerging therapies that we should know about?

Dr. Jennifer Enman:

So some newer options are radiofrequency ablation, and what this does is it uses energy and heat to shrink the size of fibroids. And usually this is done by a laparoscopy, which is the small incisions on your belly again, or there’s another option called uterine artery embolization. And in this procedure we block the major blood vessels to the uterus, and this helps to prevent blood from getting to that fibroid and feeding it and allowing it to grow. So oftentimes we see that this can reduce the size of the fibroid.

Courtney Collen:

A lot of options it sounds like. So that’s good news.

Dr. Jennifer Enman:

Yep.

Courtney Collen:

A big concern for a lot of women, especially those of childbearing years in our 30s, how might fibroids and treatment affect the ability for a woman to get pregnant and stay pregnant to carry full-term?

Dr. Jennifer Enman:

Yeah, that’s a good question. So again, it goes back to the location of the fibroids. Sometimes if you have a fibroid that’s within the uterine cavity. If a pregnancy embeds over where that fibroid is, there can actually be decreased blood supply to that pregnancy, which can increase the risk of miscarriage. Now this is not for all, but it is a risk.

People who have really big fibroids are also at increased risk of preterm delivery. So usually we will monitor pregnant women with fibroids a little closer. Those kiddos are actually at risk of something called IUGR. If the fibroid is within the uterine cavity, IUGR is intrauterine growth restriction, which is just a really big word for baby is growing smaller than we would expect for that gestational age.

And in some cases a baby can be breech because of the location of the fibroid and we are unable to turn the baby to allow for a vaginal delivery because that fibroid is so big.

Courtney Collen:

OK, thank you. Are there any lifestyle changes that can help manage symptoms or anything we can do to prevent uterine fibroids?

Dr. Jennifer Enman:

So exercise is known to decrease a patient’s pain symptoms with periods. So having a regular exercise routine can help decrease pain.

Yeah, unfortunately there’s nothing we can do to prevent getting fibroids. You know, there’s no medication we can take or no lifestyle changes that we can make. It’s just something that happens. So the biggest thing is raising awareness about what fibroids are, the symptoms they can cause, and encouraging women to see their OB/GYNs or primary care docs if they have concerns.

Courtney Collen:

Could eating less sugar or perhaps taking supplements help at all?

Dr. Jennifer Enman:

No, I am not aware of any studies that suggest that to be the case.

Courtney Collen:

1. Well thanks for making it clear and easy to understand (laugh).

What questions, Dr. Enman, should patients be asking their doctors if they might suspect uterine fibroids in their body? And how would you encourage them to advocate for themselves when they are seeking care?

Dr. Jennifer Enman:

Sure. I think the biggest thing is to bring your symptoms with you. I really encourage patients to have a menstrual diary to say, you know, I started my period on the 11th and I kept bleeding until the 22nd. That’s not normal.

When you have evidence of the length of bleeding time and also the severity. So if you come to me and say, well, I used one tampon during the day and a pad at night, that sounds like very normal bleeding to me. However, if you say, well, I soak through my super tampon and I have to wear a super pad, and that happens two or three times a day, that is too much bleeding and not enough.

So more so than questions, it’s bring those symptoms to me and more than likely your provider will say, “hey, maybe we should look into this.” And if not, just say, do you think I could have fibroids? It’s also always great to know if you had family members, moms, sisters, aunts who may have also suffered from heavy bleeding and pain and if they had fibroids or not.

Courtney Collen:

Good to know, especially on that risk or family history piece, too. We talk about periods a lot and that being such an indicator of potential fibroids if periods are painful or if they’re heavier than normal. Is there a decreased risk for uterine fibroids after, say, menopause and postmenopause? Like are women beyond, you know, mid-40, mid-50s?

Dr. Jennifer Enman:

Yeah, I would say that’s a correct assumption. Fibroids are increased in size usually because of estrogen. Once we reach premenopause or perimenopause, excuse me, and menopause, we don’t have as much estrogen. And once we’re through menopause, we have a lot less estrogen. So therefore the growth of those fibroids should slow. And in most cases, in postmenopausal women fibroids actually decrease in size.

Courtney Collen:

Sure. OK. Thanks for clarifying, Dr. Enman. If someone listening right now is thinking, this sounds like me, what is their first step?

Dr. Jennifer Enman:

I think the first step is to write down your symptoms and the very next step is to get in to see your primary care doc or your OB/GYN and discuss your symptoms and your concerns.

Courtney Collen:

Yeah. How important is it to avoid normalizing the suffering? We like to normalize a lot of conversations, especially when it comes to women’s health, and talk about them. But when it comes to like having that painful period or bleeding longer during your period, you know, how important is it to raise those concerns and not just live with them?

Dr. Jennifer Enman:

I would say incredibly important. You know, women in general downplay their symptoms. Everybody thinks that it’s normal, but quite frankly, a lot of us aren’t ever taught what is normal and what isn’t normal. So first educating yourself on what’s normal, and we can include some things at the end of the podcast for people to refer to. And also questioning when you go in to see your provider, “Hey, is this normal? What should I do about it?”

One thing that fibroids can cause is pain with intercourse, and as the fibroid grows, you can have more pain within intercourse. So if you have gradual increase in pain with intercourse, it’s not improved by position, that would be something I think you should go in and talk to your provider about. And hopefully we’d get an ultrasound or by physical exam could determine if something was going on.

Now there are other things that can cause pain with intercourse like ovarian cysts, but when sex becomes painful, there could be something additional going on. So you should always seek evaluation for that. Especially if it’s something persistent. It wasn’t just a one-off.

There is one type of fibroid that usually we see in older women, oftentimes postmenopausal. It’s very fast growing and it is a cancerous fibroid, but again, it’s in older women. It’s very, very, very rare. So if you’re listening to this and you know someone or personally have severe pelvic pain, feel like your abdominal girth has increased, have a heaviness that’s constant, it would be worth going in to get checked out. But just wanting to say, it’s very, very rare for this to occur, but it can happen.

Courtney Collen:

Yeah. Well, thank you for bringing that up. Again, it’s all about, you know, normalizing the conversation. We don’t want to normalize the suffering. We want women to recognize these symptoms, to note these symptoms and then bring them to their provider. Because the only way that things can get better is if they, you know, seek care and explore options, which there are options.

Dr. Enman, this has been so insightful. As a woman myself, it’s incredibly helpful to dive a little deeper into this topic in a way that feels empowering instead of scary. So thank you for that. Thank you so much for your time and for all that you do to care for women in our communities.

Dr. Jennifer Enman:

Thanks so much for having me.

Courtney Collen:

You are listening to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. A reminder you can find any of our Sanford Health podcast series wherever you listen and anytime at news.sanfordhealth.org. I’m Courtney Collen. Thanks so much for being here.

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Homing in on your breast health

Dr. Jill Klemin:

The main thing is just how common breast cancer is and we hear that statistic: One in eight women develop breast cancer. One in a thousand men develop breast cancer. So it’s not to exclude them, but I do think about 375,000 women in the United States will be diagnosed. It’s a huge number.

Courtney Collen (announcer):

Welcome to “Her Kind of Healthy,” an informative and unfiltered podcast series by Sanford Health. We want to start new and honest conversations about age-old topics, from fertility to postpartum, and so much more with our Sanford Health experts.

In this episode, we’ll hear from Dr. Jill Klemin who is a family medicine physician managing Sanford’s breast specialty clinic in Bismarck, North Dakota. We recorded her speaking during a Sanford Women’s event on Oct. 23, 2025 in Bismarck. It was called the Women’s Social where Dr. Klemin joined other Sanford Health providers on stage to discuss popular women’s health topics.

Here’s Dr. Klemin on breast health.

Dr. Jill Klemin:

Essentially, breast clinic is for anybody and everybody if you have any kind of breast concerns at all. So lumps or bumps, rashes, nipple discharge, pain, any kind of concern, anybody can come to breast clinic for a full evaluation. You can self-refer or have your physician refer if you have any questions.

Oftentimes I see patients certainly with concerns, symptoms, but also I see patients that have a family history of breast cancer, just wanting to know what’s their risk and what should we do about that. I see patients that have genetic mutations, which is so common since starting this work. I’m actually shocked at how common that is, that we have all these genetic mutations in our community as well.

And then what we do is take everything into consideration about that particular woman: density, family history, everything that could apply to a risk factor for her and we make a personalized risk assessment, just me and that patient and talk about what does that then mean? What does it mean once we find out that you’re at higher risk than we anticipated for breast cancer? What does that mean?

And so we do this together and what it usually propagates is a plan which includes imaging. So we work very closely with Dr. (Christina Tello-)Skjerseth and getting patients in for mammograms, extra screening, which could be an MRI ultrasound. We use all kinds of different modalities depending on the patient’s case.

I work very closely with our genetic counselors. They’re some of my favorite people. They do a great job with patients and can help us uncovering genetic mutations that they might have in their family. I work closely with the surgeons and anybody that needs general surgery, plastic surgery.

And then another thing that we do at breast clinic is there’s certain abnormalities or certain findings that we have in women that might require a medication, anti-estrogen medication, and we use that in the appropriate patient as well.

I work with oncology a little bit in that I see all the non-cancer patients and try to do what we can to prevent, to do what we can to work anything up quickly and efficiently. But if there is a diagnosis of cancer, then work very closely with our oncology team to get the patient handed over there as well.

So what I do a lot of times when I have patients, as I’m sure my friends up here do, is just a ton of education. And so just wanted to go over some of the topics that come up in breast clinic every day.

The main thing is just how common breast cancer is and we hear that statistic: One in eight women develop breast cancer. One in a thousand men develop breast cancer. So it’s not to exclude them, but I do think about 375,000 women in the United States – can’t really wrap my brain around that. But there’s a new diagnosis every couple minutes. So as I’ve been sitting here tonight and we spend these hours together, I was just thinking how many women in the U.S. you know, would be diagnosed in that time. It is that common.

And I dare say that everybody knows somebody or has been touched by breast cancer in their family in this room as well. So it’s something that is on a lot of people’s mind and they really feel better when they come into breast clinic and we can evaluate their personal risk and then we make their plan based on that risk following national guidelines. We follow all of the national guidelines, NCCN (National Comprehensive Cancer Network), American College of Radiology, we try to use evidence-based medicine to design it and then typically insurance follows those guidelines.

So then we make sure that we have the financial piece covered for patients too. So, we talk to patients about the education, about how common it is, why it needs to be on our radar at all times. And then we talk about risk factors.

I always break this down into two simple ways of thinking about it. One is modifiable. Like what is controllable in our world? And a lot of that falls under the things we learned earlier tonight about self-care. Then there’s the other silo that’s the non-modifiable. So I’ll start with ideas there.

One would be gender obviously. So women are much more likely to develop breast cancer. Nothing we can do about being ladies. Secondly is race plays into it as well. Certainly genetics. We all know there’s things that run in our family that we can’t escape. And so knowing all of those things about our family history is really important. But again, not modifiable at all.

One of the things as I sit next to a gynecologist, one of the things that does play into a risk factor for breast cancer is age that you get your first period and age that you transition to menopause. And I always think about that makes complete sense because if you get your period and the studies really say that age of 12 years old, if you get your period before 12 years old or if you don’t transition through menopause until 55 or later, it makes complete sense that we’re exposed to those higher levels of estrogen for longer. So those women would then be at higher risk for breast cancer.

The other thing that’s a hot topic, and I love talking about it, Christina loves talking about it too, is breast density. We can’t do much about it. Maybe a few things changed. You know, weight gain, weight loss can change our density a little bit. But a lot of it is genetics that play into it. And there’s so many studies, hot topic being looked at, that density seems to play into the risk of breast cancer development. We can’t do much about what our density is.

And then one of the things that I see in breast clinic are certain breast biopsy results. So when it comes to breast biopsy, benign or cancerous are kind of the two options. But there’s this middle ground that is a benign biopsy. It’s not cancerous, but having those cells in your breast tissue will increase your risk in the future for developing breast cancer in either breast. So again, I consider that under non-modifiable risk factor because it is what it is and we deal with it and we make a plan based on that.

And then I really love listening to all of the self-care and how important that is when it comes to health care and putting ourself first sometimes. And the modifiable risk factors of course are going to be nutrition and it’s been studied very carefully like what certain diet, what should we avoid, what should we eat? And it really is simple for those of us that practice family medicine or primary care and that it’s the Mediterranean diet, which is easy for me as a family practice doc because I can lean into that for cardiovascular health too. So the lean proteins, tons of veggies and fruits. Really just taking the healthy fats, taking good care of your nutrition with self-care and that planning ahead a little bit, prioritizing what’s right for your body and not just like the chicken nuggets that the kids will eat. Like all of that plays into this.

And risk modification. Smoking obviously is always a risk factor I think for probably every cancer. When I talk about breast health, it’s actually alcohol use even more than smoking that I talk about which surprises most women. Like why are you asking me about how much I drink when we’re talking about my breast?

But we know that alcohol definitely impacts breast cancer risk. So having three drinks a week on average increases your risk by 15% and alcohol’s like an exponential graph. So the more that you drink, the higher the risk. And so these are things we see in textbooks all the time. But actually the more that I’ve done with breast clinic, I see it play out with my patients too. So it’s something that everything in moderation, but it’s something that I wanted to mention is a risk factor that most people don’t really realize when it comes to breast health.

And then exercise. So the data really shows right at about 40 to 45 minutes on a regular basis, more days than not, does decrease your risk of breast cancer as well. So there’s things that are in our power that if we pay attention to and practice our self-care and put ourselves first, really can change your risk of breast cancer.

And then there are things that we can’t change. So that’s what we’re here for. So when I have patients with me, we talk about screening. Mammogram is the only modality shown to save lives and it truly, truly does. The whole idea behind screening is to try to find something before we can feel it because then the prognosis is so much better and the treatment is much more limited in a lot of cases. So the idea of screening is to find it before we can feel it. And I always emphasize that I have a lot of patients that are like, “I don’t think I need my mammogram. Everything feels fine.” Like, oh that’s why we need our mammogram. So that is really important.

And then the whole idea too about finding out your personal risk is because sometimes it’s not just about the mammogram alone, that there’s supplemental or extra screening that we can do. So we never substitute for the mammogram because that’s our favorite. But there’s modalities we can do in conjunction with like MRI, ultrasound, things like that. So that’s really important too. So screening with a mammogram is really important. It does save lives.

Density – we talked about hot topic – about half of women have dense breast tissue. 10% of us are like the top tier and what we know about that top tier of density is that our risk is higher than we ever really realized before. It’s really important. And so there’s just something about that density, about the connective tissue in the breast, that does innately increase our risk.

Density also looks white on mammogram, and breast cancer oftentimes looks white on mammograms, so it’s also harder to see on mammogram. I tell my patients we’re looking for a snowflake in a snowstorm. And over time we’ve gotten better at finding that snowflake by having 3D modalities where the radiologist can scroll through that density a little bit better and they can find that snowflake in the snowstorm. So density is something too I wanted to talk about.

It’s not the way your breasts feel. So almost every day I have a patient come in and say, I have such dense breasts. Like they are so lumpy, bumpy and density is actually a radiology term. And so it’s how white your breasts look on mammogram, mammograms or X-rays. So how much connective, fibrous tissue is in your breast compared to how much fat is in your breast. And really only after having that first mammogram will you be able to kind of know your category. So that’s really important too.

And then just my last thing I wanted to wrap up with is patients always say, should I see genetics? Should I get genetics done? And I will never tell a patient no because you can’t always see a genetic counselor. You can have genetic testing done and the cost has come way down over time to have genetics done. But it’s really important for those we have guidelines to tell us who’s more likely to have genetic mutations. This would be somebody that has two relatives on the same side of your family. So like maternal side or paternal side, two relatives. One being young, at least one being young, like before menopause. That would be somebody that should be having genetics.

If you know about a genetic mutation in the family, like cousin so-and-so said they might have a check two mutation. That would be something to pay attention to and either a closer relative to that relative or you should be tested for that mutation itself. Certain cultural heritage that we do test because there’s more genetic predisposition in certain races or cultural heritage.

So it really is important to know your family history. I always tell my patients the holidays are coming up, there’ll be family gatherings, why don’t you like gently broach the subject? Because sometimes it’s taboo. It’s important to know your family history. That’s what I think. I know, that’s what I know. It’s important to know and sometimes different generations or just different family members don’t talk about it, so carefully enter that conversation.

Courtney Collen:

This was part of the “Her Kind of Healthy” podcast series by Sanford Health. For more by Sanford Health, visit Apple, Spotify and news.sanfordhealth.org.

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Colon cancer sets a new course for family life

Denise DePaolo (guest):

I’m still mad about it. I think that not having a colonoscopy ever, I think that it was selfish. I think that he knew that he should have. I think that by not having a colonoscopy, he was operating from a place of fear. I think he was afraid of what he might find out if he went in.

So, I think that there’s probably something inside of him that knew that, if he looked too closely, that you’d probably find something wrong. And that was hard to see him not deal with.

Matt Holsen (announcer):

This is “Family Portraits,” a podcast series by Sanford Health. And now, Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

OK, so when was the last time you stopped and just stared into the distance? You let your mind bounce, not thinking of that next work email, the things you need for dinner because you left that grocery list on the counter, or trying to come up with another good reason because you know, you’ve got to face that unrelenting teenager in that battle for the next latest, greatest iPhone. No, we don’t do it much. If we did.

And if I gave you a simple prompt of what was something that happened in your life that was a major change for you? We can likely all point to something that caused us to take us from a place we maybe wandered a lot to a place of focus. For example, in high school, I began a part-time job at a local radio station. Something that these many years later has provided me with a passion for working with a microphone. Kind of like what I’m doing right now.

Now for others that change may have happened for love, education, financial or health reasons.

Denise DePaolo:

My name is Denise DePaolo, and we’re here to talk about the importance of colorectal screenings and how colon cancer can affect a family and set a new course for people’s lives.

Alan Helgeson:

Denise has a pretty personal reason about why she talks about it.

Denise DePaolo:

Colon cancer was a cataclysmic event in my family. Colorectal health is a topic that people get uncomfortable around because it has to do with butts and people don’t want to talk about their butt. They don’t want to talk about what’s up inside their butt and I don’t want to talk about that. But it’s important that we talk about these things and we normalize them so that it’s not a scary topic and it’s something that people have the expectation that they’re going to do once they’re into their 40s.

Alan Helgeson:

We were early in our conversation and sitting at their kitchen table were Denise, her mother, Jan, and Denise’s daughter, Mia. And there were some giggles at the table as she tried to hold them in because she heard the word –

Denise DePaolo:

Butts.

Alan Helgeson:

At that point I stopped and said, let’s talk about it directly as it happens with so many people.

Denise DePaolo:

Right. Yeah. I mean, talking about butts, farts, things like that. Yes. It’s funny always. And, but it’s also, you know, it’s a serious topic. Talking about your colon and what’s happening inside of it.

Alan Helgeson:

We’re gonna talk about that in a bit, but more about Denise and how she got to this point and how she made it through the ‘90s.

Denise DePaolo:

Well, I wasn’t too into boy bands. Yeah. I was more into like punk rock and, you know, hanging out with my friends, and I played sports a little bit. But by the time we moved here I just wanted to watch bands and have a bad attitude and revel in that.

I’ve always really loved animals. I enjoyed playing tennis and softball and I’ve always enjoyed art. And then got into writing as I got a little bit older and then went to college for English at USD.

Alan Helgeson:

And then off to work.

Denise DePaolo:

I work in PR and marketing. So after graduating from college, I worked in television for several years as a producer and then moved on to be the managing editor of a statewide magazine. And then I was in corporate comms for five years, and then I got my job at the zoo.

Alan Helgeson:

Hmm. I wonder if I should have her look over my notes?

Denise DePaolo:

I probably could. (Laugh) you probably don’t want me to. (Laugh)

Alan Helgeson:

This time all around the table. Denise, her mom, Jan and her daughter Mia. The only one missing is her husband Tony, who’s out for a guys’ night. The four of them make three generations together, all under one roof.

Denise DePaolo:

We haven’t always lived together. When my husband and I met, we both lived in Gainesville, Florida, and then when my dad was diagnosed with colon cancer, we’d just gotten engaged and we’d already been talking about perhaps leaving Gainesville and moving to the Midwest.

Alan Helgeson:

That part earlier where I mentioned something about something big happening in your life that causes you to make a big change?

Denise DePaolo:

I just wanted to be close enough that within a day I could get here and be able to come on weekends and help take care of my dad or be near him while he was sick. And my husband, almost without hesitation, said he wanted to move to Sioux Falls.

Alan Helgeson:

Denise’s dad, John, was diagnosed with Stage 4 colon cancer.

Denise DePaolo:

It was a, it was a scary time. It was a hard time. Being away from home, you know, suddenly that really kind of crystallizes what’s important. And being around my parents, being with my dad for as long as he still had and being here to be with my mom was really important to me.

I’d just gotten engaged. So of course I was thinking about, you know, where do we wanna put down roots? Where do we actually want to live for the foreseeable future and potentially have children? And Sioux Falls was where we decided was the best place to be, and I think it was a really good choice.

Alan Helgeson:

Being here and being able to take on some caregiver responsibilities at this time was a big thing.

Denise DePaolo:

Yep. I mean, my mom, she’s of course the spouse and really took on the majority of the labor of being the caregiver. She was also caring for aging parents at that time who were in a nursing home here in town. And so between my dad and my grandparents, my mom had a lot on her plate. I helped as much as I could.

Of course looking back, you always wish you could do more, but I was also just, you know, graduating college and starting my career at that point too. And, you know, for those who work in media, especially news, it’s very easy to feel like you cannot take time away for personal things. It feels very much like you have to be as engaged as possible with your work if you have any hope of succeeding in that work.

Alan Helgeson:

For Denise’s mom, Jan, there was a lot that she had to take care of.

Jan Orton:

It was hard. It was hard. I can remember there were a few times after we would have an appointment – I would meet him at the appointment. We rarely drove together because I drove from work and pulling into Terrace Park parking lot and having a good cry before I went back to work. It just felt heavy. And I think Tony and Denise tried to help as much as they could, but again, they weren’t living there and so yeah, it was tough.

Alan Helgeson:

As Jan tells us, there’s a certain kind of strength and resilience that powers people through, not a lot of special instructions needed.

Jan Orton:

Yeah. Well, you know, and I grew up with a mom that just, you just did what you had to do. And that’s kind of the attitude. I just, this is what I, this is what’s going on and you just do it.

Alan Helgeson:

When John was diagnosed with colon cancer, Denise and Jan were thrust into a whirlpool of medical information that they really didn’t ask for, but now needed to learn and quickly. Like most people, until it becomes close to us, how much do we really know at great depth about some of these complex medical things like colon cancer?

Denise DePaolo:

Colonoscopies were the preventative, you know, procedure ahead of that. And that’s typically where people discovered they had colon cancer. But that was really all I knew prior to my dad’s diagnosis.

Jan Orton:

Pretty much the same. Didn’t know much. I think I had a colonoscopy or two before he was diagnosed and I kept trying to get him to go get a colonoscopy. “I don’t need a colonoscopy. I’m fine.” You know, guy, tough guy type thing.

And then he, I guess I’m going off the question (laugh), but then he had rotator cuff surgery and our out of pocket was taken care of, even though a colonoscopy doesn’t, you know, you don’t have to pay for that. And so finally he’s like, fine, I’ll go have a colonoscopy.

And yeah, came back that it was cancerous and I remember the doctor saying, well, you have to have surgery, have this out. And it was hunting season and he was like, “Well, we’re not going to have the surgery right now because I have to go goose hunting one last time and I want to feel good when I go goose hunting.” So he went one more goose hunting and I think it was maybe two weeks later he had surgery. And it was just killing me. Because I’m like, you’ve got cancer growing in you. Just get it out.

Alan Helgeson:

Like so many family members after their loved one gets that diagnosis.

Jan Orton:

Go get your colonoscopy. Because John never had symptoms. He had none of the symptoms beforehand.

Alan Helgeson:

John was 59 when he was diagnosed.

Denise DePaolo:

You know, he didn’t drink alcohol much, but he definitely wasn’t focused on eating healthy. He wasn’t big into exercising. There was just habits that could have helped, but that just wasn’t his way.

Jan Orton:

So he, you know, right ahead, right away, had surgery and then had chemo and then he was under the understanding after the key round of chemo that he was cured. He was good. And you know, I think it was like six months later he went in for a PET scan and now it’s back.

Alan Helgeson:

While this is going on, Denise is trying to balance how to help mom and dad while working. It was tough. So Denise and Tony thought maybe living together might be the best way to help.

Denise DePaolo:

We actually did live together one other time. So there was the time when we first moved back and we lived at your house. Yeah. And then when they were building this house, the house on the east side that they lived in sold really quickly. And so then they lived with us for six months while my dad was sick. And so we got to be with him firsthand.

And on one hand I think it was good. Of course it’s never easy to have that many people in the house at that time. Our basement wasn’t finished. We kind of, you know, they finished a bedroom and a bathroom enough to be functional in that basement. And so they were able to live there with us while this house was being built.

But it was also a really good opportunity for my dad to get to know Tony, my husband, and for my husband to get to experience having a stable, like a father figure around my dad. My husband didn’t grow up with his dad.

Alan Helgeson:

Listening to Denise and Jan talk about their dad and husband John, you can tell how much they miss him.

Denise DePaolo:

I don’t know. I think my dad was, he was a complicated guy. I think that he was – I don’t know. He was just an interesting person. He was really well-read, but he didn’t take it too seriously. Like, he was always reading a book but wasn’t like an intellectual, you know?

But he still was highly knowledgeable about a lot of topics. I don’t know. I think he was just the kind of person who really contained multitudes. And I think that that’s the kind of person that I like to be.

Jan Orton:

He was going to live his life to the fullest and do as much as he could. But yeah, just – that was him. He was going to do by God what he wanted to do and that’s how he lived his life the whole time.

(folk guitar music with man singing)

“That’s how it goes. After the storm, the sunlight will guide you.”

Alan Helgeson:

It can be hard not to have strong emotions when a loved one dies. It can be even harder when you believe you could have done something to prevent or delay it.

Denise DePaolo:

I’m still mad about it. I think that not having a colonoscopy ever, I think that it was selfish. I think that he knew that he should have. I think that by not having a colonoscopy, he was operating from a place of fear. I think he was afraid of what he might find out if he went in.

Alan Helgeson:

Fear of what they might find. Sadly a common feeling that might be keeping people back. Another is just not having the facts or understanding colorectal cancers.

Jan Orton:

I remember we were at his class reunion, and he told some of the people we were sitting with that he had colon cancer. “Well, that’s something that you can get over so easily. You’ll be just fine.” And he was terminal at the time and they were very –

Denise DePaolo:

Dismissive.

Jan Orton:

“Yeah, yeah. You’re just fine.” And he got up to go to the bathroom or some. He left the table. And I remember just looking at them going, “He’s dying. He’s terminal. You just can’t just be flippant about it.” I was so mad.

It was like, “Colon cancer is no big deal. You know, that’s very curable. You’ll be just fine.”

Denise DePaolo:

Because if you catch it early enough, it is.

Jan Orton:

And right. And that’s exactly it. And so they weren’t wrong, but they were wrong about his case.

Alan Helgeson:

Even through those dark times, there were other times when his Sanford cancer team could make John smile.

Denise DePaolo:

I mean, I remember him laughing with his doctors and really enjoying his care team. And obviously the appointments were hard stuff, but the people, the care, that was never the tough part.

Jan Orton:

Right. Yeah. I, as he said, he really liked his doctor and he had a favorite nurse with his doctor. And I can remember he turned, oh, I remember he turned 60 and he had a chemo on his 60th birthday and the nurse gave him one of those buttons. Oh, those red buttons that you push. I can’t remember what it said.

Denise DePaolo:

It said BS.

Jan Orton:

Oh yeah. Yes. Yes.

Denise DePaolo:

And he thought that was hilarious.

Alan Helgeson:

The sun is shining on this day. Denise is at work, her office, well –

Denise DePaolo:

Corky’s down here. I don’t know if he’s out or not. And this is Oscar. He’s the oldest animal at our zoo. He’s in his like upper 40s. This is Tiger. She’s the most dramatic parrot at our zoo. This is Shooter. Who’s the best boy? And then Chester, who’s a whole lot of – a lot. And he’s right there. Hi you! They’re all very quiet right now, you guys.

Alan Helgeson:

Denise works at the Great Plains Zoo. The kind of job that I would guess you might want to pinch yourself to wake up from a dream to realize you get to work at the zoo. You have to pinch yourself knowing that you work AT THE ZOO!

Denise DePaolo:

Sometimes. But yeah, I wouldn’t want to go anywhere else.

Alan Helgeson:

While strolling the wide-open spaces at the zoo, talking about her, her family and health care, Denise had an amazing way to connect what she does every day at the zoo in an example of how we age and the care we need.

Denise DePaolo:

You always think of zoo babies and you know, fresh, bright, new roly-poly animals at zoos. But this is a place where we give whole-life care. And so we have those animals like the baby snow leopard who’s going to make her debut and it’s going to be wonderful.

But then we also have those older animals like Callie who’s on medication for her arthritis. And she’s, you know, having maybe not the easiest time walking that she did when she was in her prime, but that’s all of us as we age.

And so I think that it can help us empathize with the animals more that, you know, we are really not so different. We all age and it’s just the natural cycle of life.

Alan Helgeson:

With John losing his courageous battle with colon cancer, the family is strong and, together, Denise, her husband Tony, daughter Mia, and mother Jan, three generations making life work.

Denise DePaolo:

You know, not being alone in the house, I think that it keeps you engaged and active and you know, like a part of something. Right? And I think, I think that that’s been really good for Mia being able to go to, you know, play sports and go to camps and do all these wonderful things, like having that third adult able to like get her to the places and do pickups and all of that. I think that’s been like good.

And I think that being with our family, like all of us together, I think that it’s been beneficial. You know, I could see you being lonely if we hadn’t moved in. Right. And from like a mental health perspective, you know, being with family I think has been really good.

Jan Orton:

You know, and I think, you know, being around Mia, being around a young child has kept me active. Yeah. And so, which is good for me.

Alan Helgeson:

Living through painful memories and loss of a loved one really changes how you look at things. Health history is an important thing now for Denise and her family in their daily living.

Denise DePaolo:

I would say that because of the increased risk of colon cancer and other health issues, my husband’s family has a pretty significant history of heart disease and cancers. And so, he does a vast majority of our cooking and makes a very big effort to cook healthy meals, you know, diverse and fun meals, but really like low meat, lean meat, no meat meals. That’s been, I think, great.

You know, we also, we’re a family that takes lots of walks. We like to stay active and that’s really important to us. You know, something I look back at too is, you know, my dad, while yes, he loved to hunt and fish, he wasn’t necessarily a guy who was out playing sports with me when I was doing that. Like, he’d had some injuries in high school playing football, and I remember there was a few times where he was out playing catch with me, but not much by the time I got to that age.

Jan Orton:

I would say the only thing is, is, you know, and I would say that Tony and Denise push it more is trying to eat healthier. But I was already getting a colonoscopy and so if the doctor recommended it or recommends something, I do it. I do the heart screenings and everything. I’m not going to die of colon cancer because I didn’t take care of myself.

Denise DePaolo:

I would say that we’ve had overwhelmingly positive experiences with our doctors and care teams at Sanford. You know, me personally, we’ve had my husband, daughter and I have had the same primary care physician since we moved from Florida, so, long before my daughter was born. We started going to him and he’s been great. And I like that he has that history with us.

Alan Helgeson:

A history and knowing that there is colon cancer in the family. It was very important for Denise to be aware and take screening seriously.

Denise DePaolo:

I had my first colonoscopy when my daughter was just a few months old and that was, you know, my body was still healing. I’d had a C-section. I remember there was just some interesting things going on with my bowel movements. And I brought that up to my doctor and I think maybe there’d been a little bit of blood or something and they’re like, you know what? Let’s just see what’s going on.

And I really, really appreciated that they took that seriously and that they got in there and checked it out. At that time, having an infant, the thing I remember the most about the colonoscopy, yes, doing the prep was a bummer, but I also, it was like the first like guilt-free nap I’d had in months and, you know, just being like, no, I have to sleep it off. I’ve had anesthesia (laugh).

Alan Helgeson:

So for Denise, there are a couple of big reasons why she is making this a health priority and such an advocate for people to get screened, right?

Denise DePaolo:

Yeah. When taking my family history into consideration, and also you’re hearing more and more people, younger and younger being diagnosed with colon cancer, that’s scary. Especially when you’re someone at high risk.

Alan Helgeson:

Reflecting back on her dad and was there something they could have said or done that may have changed things.

Denise DePaolo:

I know that my mom got after him to go and he wouldn’t do it. If he wasn’t going to listen to her, he probably wasn’t going listen to me. And maybe he would’ve, but I also believed very much that he was an adult, that he had all of the resources at his disposal and he chose to not use those resources.

And so while I hate what happened to him, I am devastated that he’s missing his granddaughter growing up. I’m sad that he doesn’t get to come visit me at the zoo and do rhino feeding for my mom’s birthday, and like all of these wonderful things that we’re getting to do as a result of this.

It’s also, his health was his responsibility. And while yes, we can do everything we can to push our loved ones to care for themselves and encourage them to care for themselves, ultimately it’s on each of us to make sure that we’re having those screenings done.

Alan Helgeson:

Denise and Jan did all the things. They asked John to get screened for colorectal cancer. And they kept asking. Today the family knows how important preventive health screenings are. Specifically, Sanford Health recommends that adults start screening for colorectal cancer at age 45. For women and men under the age of 45 with signs, symptoms of colon cancer or have had a family history of colon cancer, to talk to your Primary care physician.

Visiting their home, it doesn’t take long to see that this home is filled with love and charm. The walls are filled with frames of family photos, photos that capture serious portraits, school pictures, and purposely silly photos in many of them. John is a constant reminder of his presence and his importance in their memories. Asking the family, if you could say anything to John today about his health, what would it be?

Denise DePaolo:

I wish that you’d been more proactive. I wish you could know your granddaughter because you’d have a lot of fun together. I wish you could see everything that we’ve been up to, because I think that he’d be really proud of where we all are.

(Piano music with woman singing)

“Here today and on through, I see my light in you.”

Jan Orton:

I wish he would’ve gotten that colonoscopy. How many times did I nag you to go get a colonoscopy? And he wouldn’t do it. I would tell him how much he’s missed with Mia. He would’ve loved having a grandchild, and that’s what I would tell him. And that I love him.

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Support the physical needs of your ‘mental load’

Dr. Marie Schaaf (speaker):

The people around us very much influence who we are and how we feel. So knowing which relationships are healthy for us, which relationships are damaging, and how do I manage those in my day-to-day life?

Courtney Collen (announcer):

Welcome to “Her Kind of Healthy,” an informative and unfiltered podcast series by Sanford Health. We want to start new and honest conversations about age-old topics, from fertility to postpartum, and so much more with our Sanford Health experts.

In this episode, we’ll hear from Dr. Marie Schaaf who is a specialist in neuropsychology in Bismarck, North Dakota. We recorded her speaking during a Sanford Women’s event on Oct. 23, 2025 in Bismarck. It was called the Women’s Social where Dr. Schaaf joined other Sanford Health providers on stage to discuss popular women’s health topics.

Here’s Dr. Schaaf on mental health.

Dr. Marie Schaaf:

Our brains are so powerful, they do so much for us, and we don’t realize how much they do for us. They can do really good things for us, and they can also cause us a lot of trouble if we don’t realize what’s happening. So it’s really important to know how our brain works and what it’s doing for us to make it work best for us.

So, you know, on the therapy side of things, I really talk a lot with folks about how our thoughts and our emotions and our behaviors and our relationships and our environments, they all have this complex interaction. We really need to know how all of those pieces work and how all of those pieces are influencing one another because in each one of those spots, we can make a change if something’s not working.

For example, in my notes, one of the very first things I have at the top, I wasn’t even going to say it, but imposter syndrome. I’m sitting up here telling you how you’re supposed to feel, but that’s a judgment on myself, right? I’ve got a little bit of training in mental health, so I can let that judgment go and continue.

But it’s very important to know what our thoughts are doing, what our emotions are doing, how our behaviors are benefiting us. The people around us very much influence who we are and how we feel. So knowing which relationships are healthy for us, which relationships are damaging, and how do I manage those in my day-to-day life, right?

We really want to think about – on the neuropsychology side of things – our brain uses a ton of energy. And how are we giving our brain the energy it needs? The two answers are rest and nutrition. What are we giving our brain for energy, right? We also know that our brain uses a bunch of energy for different things.

So again – jumping back to the therapy side of things – managing our emotions takes a lot of energy. So if we have emotions popping up in different situations or with different people, we can drain our energy fast. And then our thinking skills, like our memory or our attention, coming up with the word we want to use, they’re just not there because we ran out of energy, right? And so, knowing how to take care of our brain process, our emotions, give it the rest and the energy it needs, the nutrition it needs, all of this is so important, and it’s so complex.

To me, it feels like a spider web. You wiggle one spot and the whole thing moves, and it’s like, well, where’s the wiggle coming from? It can be really hard to tease apart sometimes, but with therapy, we can learn strategies that help us to build our stamina. Within the field of neuropsychology, we can practice strategies that help keep our brain efficient so that we can do all of the good thinking skills that we need to do. Being aware mindfulness practice can really be valuable for us as far as noticing when things change.

Because for a lot of us, we talked about that mental load. We’re paying attention to everything else. We may not realize when we have a shift and when we need to make a shift to help ourselves get through situations or persevere in difficult spots. So it’s really important that you know, we know how our brain works, we know how our emotions work, we know how our thoughts work, we know what fills us with energy. We know what drains our energy. And with our presentation previously, we talked about values. Where do I want to put my time and my energy? What’s most important for me to use this energy on? Right?

We know that for women, as far as behavioral health conditions are concerned, depression and anxiety, maybe you’ve heard the phrase, “they’re the common cold of behavioral health.” Almost everyone will experience some of those symptoms at some point in their life. And we all have normal emotions, but when they get in the way of our day-to-day functioning, we really want to make sure we catch those, we treat those, and we have really good treatments for behavioral health conditions.

We have therapy. We have medication. And what we find is the combination of the two actually works really well. The medication helps us to kind of manage those emotions to an extent. And the therapy part teaches us how our brain works and what skills work and how to keep ourselves going and doing better long-term. So the two work really well together. So I just want to make sure that when we’re thinking about mental health, we’re thinking about the whole brain.

The brain does a bunch of stuff for us, and we want to make sure that we are addressing all of those components.

Courtney Collen:

This was part of the “Her Kind of Healthy” podcast series by Sanford Health. For more by Sanford Health, visit Apple, Spotify and news.sanfordhealth.org.

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Sanford Sports helps guide future college football player

Alan Helgeson (announcer): 

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is around how Sanford Sports training yields results for a future Hawkeye. Our guests are Hudson Parliament, Justin Parliament, and coach Kurtiss Riggs, Sanford Sports Academy. Our host is Matt Holsen with Sanford Health News.

Matt Holsen (host):

Thanks to all three of you for joining us today. We appreciate your time. First off, I want to start with Hudson and congratulate you on your back-to-back South Dakota Gatorade Football Player of the Year Awards and on your commitment to the Iowa Hawkeyes. I’m sure that took a ton of hard work. How did those accomplishments make you feel?

Hudson Parliament (guest):

They make me feel great. Knowing that I’ve put in a lot of work the last four years and that it’s paying off big for me.

Matt Holsen:

For those who may not know, you were an impressive offensive lineman at Brandon Valley High School, among many other things. 109 pancake blocks to your name your senior year and I don’t think you’ve let a sack happen for the last two years. So congrats on that too.

You are college bound soon, like we mentioned. Take us back to when you were a bit younger. When did you realize that college football was your goal? What was the moment?

Hudson Parliament:

Seventh or eighth grade, I knew I wanted to play college football.

Matt Holsen:

When did you realize that you needed kind of a more serious training environment?

Hudson Parliament:

Probably been my freshman year when I’d gotten pulled up from freshman football to varsity to play. I knew to be successful at that level, I needed to develop my skills and get better and be able to compete with some better talent and some older kids.

Matt Holsen:

Justin, as Hudson’s dad, what would you add to that and what were you looking for? How did you end up partnering with Sanford Sports Academy?

Justin Parliament (guest):

You know, being pulled up as a freshman to play varsity football, I just remember me and his mom and sister dropping him off at practice and picking him up from practice each day. The kid wasn’t old enough to drive to even get to and from practices and it was a big transition.

It wasn’t something that we necessarily saw or expected by any means, but at that point we knew that the coaches believed in him. And that was a big step there. It was like, OK, now you’re going to be competing against older, stronger, faster, more experienced kids. So what are you wanting to do? Are you wanting to do anything more?

There was some teammates, too, that were doing some off-season work and they invited him in to join them at the Riggs Academy. They were commuting him back and forth and helping him out there. And he came home every time and was like, he was excited every time. And we knew that it was something that he wanted to do. So we fully invested there.

Matt Holsen:

It seemed to work out great. I’ve got a question for coach Kurtis Riggs. What would you say is the biggest benefit Sanford Sports Academy provides to its athletes?

Kurtiss Riggs (guest):

Hudson’s a little different story. Justin hit it pretty spot on. You knew you had something there that was pretty special. Hudson was a very good wrestler. Justin and his wife did a great job with allowing Hudson to get involved with powerlifting. He was exceptional there.

Then they kind of made a choice. So, to move away from wrestling and to focus on that outside training for football, they started to get enough interest, and Hudson had a love and passion for it.

And he came in actually doing some defensive line stuff first and he could play both sides. You saw that longevity-wise and the need at a position was probably greater on the offensive line side. He was willing to play both. And I felt like he was great.

We knew he was great but his junior year in our combine, he took an offensive tackle that’s at South Dakota State now that’s, I mean, he’s 6-foot-5, 325 pounds. Hudson was at defensive line against him and he launched him darn near four or five yards backwards. And that clip was on social media. And I got more calls about that clip and who is this individual and how powerful he is. And things were already moving in the right direction at that point but they really took off after that. You just knew you had a special individual physically but also you’re getting a great person off the field too.

Matt Holsen:

That’ll definitely capture some attention I would assume. Hudson, what was different about day one when it came to Sanford Sports Academy football?

Hudson Parliament:

Coaches there really cared and really wanted to develop you and help you get better. Gave you all the right tools and all the right coaching and just how they truly cared.

Matt Holsen:

I love the story that Coach Riggs just said about the combine. Do you remember that moment? What was going through your head when that happened? When you became kind of a viral moment on social media?

Hudson Parliament:

I do remember that moment. That was awesome. I remember, I kind of surprised myself when I did it. I didn’t really know where it came from but it was awesome. It was cool.

Matt Holsen:

How did it make you feel to be treated like a serious athlete when it came to your work with Sanford Sports?

Hudson Parliament:

It felt awesome. They pushed me harder because they knew I could take it and I needed it and I truly wanted it.

Matt Holsen:

It seems to have worked. I’ll go to Coach Riggs next. What does Sanford Sports do to promote its athletes to college coaches? What kind of a network do you have?

Kurtiss Riggs:

It’s pretty vast. I’ve been able to, over the years, either with me coaching or people I coached with or coached under me have all succeeded in the field. And you just keep those relationships.

And so, when you say you have someone of the stature and power and ability of Hudson, it travels quickly. It travels to all levels and we’re able to reach all levels, which is a huge benefit for someone like Hudson.

And thankfully parents were great about also coming to me and saying we’re not sure about some of these things because the recruiting world is crazy. And Justin can attest to this, Hudson too. I mean you’re getting inundated constantly by people and you’re not sure what you’re supposed to ask or what you can say or can’t say. You just feel honored to be looked at and recruited by these institutions.

And so we were out able to help him have an agent come in and just talk to him, get to schools for camps and then pretty much they had it. Then they knew, and Hudson was strong in his faith of “here’s the school I really loved.” I know when I asked him, “Why Iowa?” he was quick to say it’s the one school when I left that I already started to miss.

I think that a lot of kids can’t do that. A lot of kids, they try to do what they think everyone else thinks they should do. So to be able to know and recognize and feel comfortable is huge.

Matt Holsen:

Justin, can you add to that? What was the recruitment process like for Hudson and how did Coach Riggs and his team help?

Justin Parliament:

We started getting some feedback from like Hudson’s high school coach, Matt Christensen. I think there was some feedback to him from Kurtiss real early on. It wasn’t necessarily told to Hudson or our family but it was kind of secondhand. And that’s when I knew that Kurtiss was talking to, I think in the beginning it was probably FCS (Football Championship Subdivision) schools.

And then as Hudson was doing combines and the training, they were coming in and we were getting more feedback and then that was translating to social media. They started to contact Hudson and inviting him to camps on junior days. And then he went to the SDSU camp after his freshman year and was offered at SDSU.

And that’s kind of what started things. And I know that Coach Riggs was talking to them prior to that. That’s when everything kind of exploded, really. And that evolved to FBS (Football Bowl Subdivision) schools. Kurtiss had given me a little bit of feedback. I don’t think he necessarily gave it to Hudson, which I always respected that. He would talk to us. He didn’t want to, I mean I felt like Coach Riggs was trying to keep him humble, keep him working. Doing what he had done to get him to that point and wanted to continue to see where he would take it himself. It kept Hudson focused on football and doing the things that he had done to get him to that point.

Once other schools started to reach out, then we knew that it’s like, OK, we kind of talked as a family and talked to Hudson. It’s like, OK, is this something that you want to continue to pursue? And he was all in and we started signing him up for camps after his sophomore year.

So where he started to attend more like FBS camps which most all of them resulted in offers. And then it just kind of exploded. Just the way it was handled was really appreciated by our family.

Matt Holsen:

I appreciate that. Hudson, what would you add about the recruitment process? Was it exciting? Are you happy it’s over? What do you remember about that process?

Hudson Parliament:

Now that it’s over? I am happy that it’s over, but during it, it was exciting. It was fun. It was stressful at some points too. I remember a lot of the phone calls. I remember coming home from school a lot of times and being like, OK, I got a phone call at 6:30 and one at 7. And those were exciting, but those were also probably stressful points of it.

Overall, it was a lot of fun. I mean, going to visit all the schools and meeting all the different coaches and just seeing how each place is different.

Matt Holsen:

For other 15, 16, 17-year-olds, if you would have any piece of advice for them or what you would’ve liked to have known during your process, what would you say to other youngsters out there?

Hudson Parliament:

When you’re being recruited, like a coach is either texting or DMing or calling you, treating them with respect and taking their time to respond to them. Look for a place that truly cares. You know, that they are going to develop you and help you with the recruitment process.

Matt Holsen:

Justin, as a parent, what would you like other parents who may be getting into this process in the future, what would you like them to know?

Justin Parliament:

Every recruitment process is different. Not to compare your child to somebody else. Go with your gut feelings, having conversations as a family.

Matt Holsen:

Kurtiss, what would you add to that and how can families or athletes connect with you and your team?

Kurtiss Riggs: 

Just going a little bit back on some of the things that were brought up here, and Justin kind of touched a little on it. Hudson was so humble and I think that humility is what made his teammates so much better.

Because they came with him to work out and they worked to be as good as him. And I think that’s why some of his teammates earned scholarships because of those workouts working with him. Some of the offensive linemen were able to go get scholarships and that’s why they won state this last year.

They had lost in the state title in a great game his junior year and then won it this last year. And I really believe it was those types of things, his leadership and guys following his lead and their quarterback too. But for us, it’s come in and train and we’re going to train you to get better.

And as we recognize, and we’ll be very honest, if we feel like you have the potential to play college, we’ll tell you that. We’ll say, hey, there’s an opportunity here but we’ll also tell you the level of what we think. We’re not going to mislead people as many places do and say, “Oh, you know, he can play quarterback at Oregon,” when there’s probably very little chance. And we’re very honest about the percentages and the opportunities but if it’s there, then we’ll definitely help get more out of it than what’s there.

And so, anyone can go to sanfordsports.com and find your way into the football element. We got all our academies there. There’s a lot. But the football one, we got a great staff. All our coaches are head coaches. They’ve coached at the college level, professionally or a lot of them are local area high school coaches.

Some of the high school coaches had to coach Hudson and then had to worry about going against him too. Which was always funny because they would come to me after and say, what do you think we can do to get him to maybe come to, you know, O’Gorman or whatever? And they were laughing about it. They know that they’re diehard Brandon Valley and that’s what makes them so great.

But it was a pleasure to work with them and a pleasure to get to know the family. I can’t wait to follow him. I think it’s funny though that (former SDSU coach) Jimmy Rogers – Justin talked about this – Jimmy Rogers was Hudson’s biggest fan early on as a freshman. Jimmy Rogers was like, “I would do anything to get Hudson Parliament at South Dakota State.” He said that to me. And now he’s the head coach at Iowa State.

And Hudson’s second biggest fan was Tyler Roehl. He watched Hudson work out with me, and he said, “That kid is going to be a center in the NFL someday. Mark my words.” He was the running backs coach at Iowa State at that time. And he just said, “Man, we’d love to have him here.”

And then he ended up going to the Detroit Lions but is now the offensive coordinator at Iowa State. And so Jimmy and Tyler are going to have to coach against Hudson and they’ll be rooting for him but they’ll also be dreading when they’re going to have to face him I bet.

Matt Holsen:

I think you have a bright future ahead. Hudson, what are you most excited about as you get ready to head to Iowa this spring?

Hudson Parliament: 

I’m ready to get started. Kind of start at the bottom again and work my way back up, developed by the coaches there and learning things from the older guys and earning their respect as I do it.

Matt Holsen:

What would you say to Coach Riggs and Sanford Sports?

Hudson Parliament:

I’d want to thank them for all the things they’ve helped me with, developing my skills on the field and then the recruiting process. Helping me and my family through that and all the support and help they’ve had.

Matt Holsen:

We want to wish you all the best. Justin, anything else you want to add before we end our time here?

Justin Parliament:

Trusting your coaches. I remember, Hudson, his freshman year played defensive line as a starter going into his sophomore year, I think after the Legends camp, his current offensive line coach at Brandon Valley came to him about playing offensive line. I remember Hudson coming home, he was very disappointed and struggled with that. There was a lot of emotion in that.

If you ask Hudson now, he is like, you know, they knew. Believing in your coaches. They’re getting feedback and they’re seeing things too. Kind of to Kurtiss’s point about a position, you see a lot of that in the recruiting and in college football too.

Somebody goes in and thinks that they are something, but a school will see them as something else in a lot of cases. I think the high school coaches at that level see that early on and they have your best interest in mind.

Matt Holsen:

I appreciate you sharing that. As we look ahead here and head into February and the spring, what comes next? What are you excited about, Justin?

Justin Parliament:

I know how excited he is to be surrounded by similar talent. Just like Hudson said too, you know, start over. Like him starting over the same way when he came into high school football. Had no expectations. Earn the respect of coaches and current players. I really feel like he has a great opportunity, especially in the weight room when he gets down there.

That was part of his decision to go early. He can push guys, upperclassmen and in that weight room, start over and be a zero star. Go to work and do what he did to get him to this point and just do it all over again.

Matt Holsen:

I think that’s well said. As we get close to ending here, what would you like to say about your relationship with Sanford Sports? Or what do you think other parents should know if they’re thinking about engaging with the Sanford Sports Academy?

Justin Parliament:

It’s different in the way that it’s just brutally honest. In some cases, that’s what us as parents, we need to have somebody that can evaluate and give good, honest feedback. That is, it’s going to be time well spent for the athlete, the family.

There’s all different divisions, NAIA, Division III, Division II, Division I coaches there, and they evaluate the talent rather quickly and place you. And I think if you look at the placement, it may not always be where somebody wants to be placed, an athlete or a parent. All college football is high level football, you know, and being grateful for all of them opportunities.

Matt Holsen:

I want to wish Hudson and family the best of luck, and I want to thank you all for your time today. We appreciate you.

Alan Helgeson:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen to wherever you hear your favorite podcast and on news.sanfordhealth.org.

Get more episodes in this series

Are TikTok health hacks hurting you?

Dr. Jennifer Schriever (guest):

Electrolytes are all those, you know, sports beverages like Gatorade or Powerade. A lot of the powdered little packets of supplements that will talk about how much they hydrate you. In general, most people don’t need those.

Matt Holsen (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about TikTok nutrition trends, what’s safe versus a scam. Our guest is Dr. Jennifer Schriever, family medicine physician specializing in obesity medicine, Sanford Weight Management Center, Sioux Falls, South Dakota. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Dr. Schriever, thank you for joining us today.

Dr. Jennifer Schriever:

Oh, thank you for having me.

Alan Helgeson:

Dr. Schriever, why don’t you tell us a little bit about your clinic and what your role is at Sanford Health?

Dr. Jennifer Schriever:

Sure. I’ve been a family physician at Sanford for 22 years, but then starting three years ago I helped develop a weight management clinic where I work full-time now. We help take care of patients in a comprehensive fashion and I work with a lot of dieticians and other physicians and advanced practice providers as well as some counselors to help guide people toward a healthier lifestyle, better metabolic health, weight loss, of course, coordinate some care with the gym next door.

Alan Helgeson:

Well, Dr. Schriever, we had the honor of talking with you a little while back, and it doesn’t seem like that long ago, but I was looking here and gosh, it was almost a couple of years ago, we were talking about some of the latest trends on TikTok, and I guarantee you that we’re doing an update on that, that by the time we get done with the podcast and what we’ve set out to talk about, there’ll be new trends. It moves that fast on social media it seems. So as we talk about these nutrition trends, let’s jump right in with both feet and what are people saying about amino acids and BCAAs? So people are drinking amino acids like it’s their morning coffee. What’s the science behind all of this and what are your thoughts?

Dr. Jennifer Schriever:

So amino acids are the building blocks of protein, and we have essential amino acids and non-essential amino acids. So essential amino acids mean you need to get them from your food and the non-essential, really your body can make those up. Essential amino acids can easily be obtained through a balanced nutrition diet. They’re in a lot of protein and dairy products as well as some nuts and plants and that sort of thing, but you really need a balanced diet to get all of them. Our diet in general tends to be deficient in protein. We haven’t had good guidelines of how much protein to get. So essential amino acids can be used to increase the amount of essential amino acids that your body needs for the day. But amino acids are really important for skeletal muscle. So as you break down muscle throughout the day, if your calories are not high enough, you’re gonna break down muscle. If you’re working out, you’re gonna break down muscle. The muscle needs the protein or the amino acids to build that back up. So there’s pretty good evidence to support muscle building from essential amino acids as a supplement if your protein is inadequate. There are some more and more data developing that maybe it helps with brain health cognition. It might help support and prevent dementia. So that’s I think where the big growth is coming there. And there are also benefits in certain populations, but it just really does come down to how efficient is your body at using the protein that you’re getting, how balanced is your nutrition as far as protein content, and then whether or not you’re using that amino acid as a supplement to that. So it could be very useful. You could be also going maybe a little bit over and beyond of what you need for the day when taking a supplement.

Alan Helgeson:

So like anything, I mean there’s a lot of good stuff behind it, but people go a little bit farther. And then with that we’re starting to see some things where people are giving the amino acids and electrolytes to their children. What’s the expert advice on that?

Dr. Jennifer Schriever:

I would really hesitate to give any supplements to children and also just caution in general with supplements. You wanna be sure it’s regulated, it’s third party tested, to be sure it’s safe. In general, we’re gonna do a lot of studies on adults before we ever do any studies on children. So I’d be really cautious about giving a supplement to a child, including amino acids, even though they’re the building blocks to protein, without some direct guidance of a dietician or a doctor who is finding that useful for your child based on your child’s certain situation. And I don’t think that’s gonna be very common that you’re gonna wanna do that to your child.

Alan Helgeson:

Well, let’s talk about some of the differences then, Dr. Schriever. Like the difference between essential amino acids, BCAA’s, EAA’S, who should take what, when and why?

Dr. Jennifer Schriever:

So branch chain amino acids are made up of three of the essential amino acids. If you’re buying a branch chain amino acid, that’s all you’re getting in that supplement. And often those are in flavored powders, so you can use them to flavor your water. Essential amino acids also just for short, are called EAAs. So that’s the same thing. It’s just a matter of what is on the label. In general, EAAs is probably gonna be what’s in big type, but then somewhere else on the label you’re gonna find that it’s an essential amino acid. So branch chain amino acids may have been out first or were really popular for a while, especially around a workout, where they could be found to be pretty beneficial, but so are essential amino acids. So I’m seeing less and less branch chains available just because they’re not providing the complete picture, of those essential amino acids are not found to be as valuable. That’s the main difference there is just the difference branch chains are just three of the essential amino acids.

Alan Helgeson:

As we’re working through all these different trends. And like I said, they keep updating and updating, new ones coming along all the time. Now this next one, we’ve heard about this for a long time. Let’s talk about colostrum. Claims around immune support and gut health. Is there legitimate research around this to back it up? Do you recommend people take this and if so, who should and why? I know I threw a lot of questions at you, so gotta start wherever you want to jump in on that Dr. Schriever.

Dr. Jennifer Schriever:

Colostrum. You know, there isn’t good definitive evidence for benefit in any case for sure. Certainly there are lots of studies showing that it may help like diarrhea in HIV patients or in another specific situation like that. The studied doses of colostrum aren’t even what is available over the counter. So then what is the benefit of taking something less? People are hoping it will help immune support and the only studies that are more convincing are in very high intense athletes because they’re so physically active in their sport or events that they might have less immune system, that it might support and help that sort of person. But in general, most people there is not definitive evidence that it is supportive. So the science is based on the benefit of colostrum for newborns, but obviously we aren’t going to get a lot of colostrum from that source, and these are coming from cows. So anyone who has any sort of allergy to dairy or you can have a specific allergy to cows, really should avoid any of these supplements. Certainly wouldn’t gear them again towards children. I wouldn’t use them for treatment of that. Are they being studied, certain populations? Absolutely. Because it’s interesting to see. But you’d want that in a very controlled, safe environment with people that really understand what they’re doing.

Alan Helgeson:

Well I think you talked about some of the side effects and risks with that. Are there even things beyond what you may have mentioned there, Dr. Schriever?

Dr. Jennifer Schriever:

When producing the colostrum, you know each cow is probably going to produce different amounts of immune support or whatever else we’re going for in their growth hormone, and that sort of thing. So you can’t even count on stability from, probably, dose to dose or supply to supply. You’d also worry about any contaminants. So you’d wanna a reliable source or some third party testing of those supplements. Side effects could probably still be G.I., especially if you have any lactose intolerance or other things that might make you more reactive to something that comes from a dairy product. But in general, there doesn’t appear to be still a lot of evidence supporting benefit.

Alan Helgeson:

Well, we’ve been talking about colostrum. We’ll make the jump now to raw milk, and as somebody that grew up on a dairy farm, it wasn’t uncommon to hear about consuming raw milk, but that is showing up now as a trend, and wanting you to address that. What are the risks of consuming raw milk?

Dr. Jennifer Schriever:

The biggest risk of raw milk is the bacterial contamination and the significant gastrointestinal illnesses that can come from those bacteria. Some of them are just, you know, gonna cause severe G.I. distress, but sometimes that becomes a much more serious condition. Just like with any diarrhea or illness you can have, you know, shut down of your kidneys. And listeria is a particular bacteria that could be present that could be very harmful to a pregnant woman, cause a miscarriage or even death of that baby. So those are various serious conditions, and we certainly don’t want to expose any child under five to something that is not pasteurized, including raw milk. The pasteurization process kills all those bacteria and doesn’t change the nutritional value of the milk.

Alan Helgeson:

Are there any nutritional advantages to raw milk over the pasteurized milk? Because there must be something that somebody grabbed onto something to make this a thing and a trend, right?

Dr. Jennifer Schriever:

I think the thought is that people may have thought that raw milk would cure lactose intolerance. There’s no evidence to support any advantage of that sort of thing. Or might they become less allergic to milk or not have an allergy if it’s not pasteurized? And there’s no evidence to support anything like that.

Alan Helgeson:

Dr. Schriever, let’s talk about what parents might need to know about giving raw milk to their children.

Dr. Jennifer Schriever:

Parents should really know that there’s a high risk of a bacterial infection with raw milk that can make a child very seriously ill. They are at more risk just to their developing body and organs than an adult who’s more developed and maybe more stable. So a child would be at higher risk for very severe illness, end up in an ICU from a diarrhea illness, and even hemolytic uremic syndrome is one thing that’s really specific and related to that, that can cause severe harm to the kidneys. So we want to really avoid anything not pasteurized in young children for sure under age five.

Alan Helgeson:

Alright, that’s raw milk and we’ve talked about that one as a trend. One of those things that’s bubbling up right now on social media. Let’s move on to daily electrolytes. You can’t pick up a bottle of water in the convenience store that doesn’t say something about electrolytes. And people are giving these with aminos and electrolytes to their kids now too. So expert advice on electrolytes and aminos to kids.

Dr. Jennifer Schriever:

Sure. So electrolytes are all those, you know, sports beverages like Gatorade or Powerade. A lot of the powdered little packets of supplements that will talk about how much they hydrate you. In general, most people don’t need those. If you have balanced nutrition from your food and you aren’t out there in really hot weather exercising or sweating a lot, your body is going to manage its electrolytes just fine. Most kids in sports, just typical soccer games and that sort of thing, are gonna do fine with water rehydration. You really want to not necessarily give them these electrolyte products that can be very high in sodium, which can be detrimental to one’s health, and you just don’t need the added sugar or other ingredients that may come in a lot of those electrolytes. So you just really have to watch that. And some of them are gonna be higher in potassium, which you wanna be sure you’re not getting too high on that. Most people with healthy kidneys are gonna do just fine, but why do something you don’t need? So examples of people, or a situation, that really might need those electrolyte drinks: Really heavy duty exercise or physical activity requiring a lot of sweating; it’s really hot out causing a lot of sweating, a marathon runner, that sort of thing. If one had an unrecognized health condition or were on a medication that affected their sodium levels or their potassium levels, and you really escalated your intake, or just had such a consistent intake of an electrolyte beverage, you could cause too high of levels of sodium or potassium. Or maybe the opposite by having so much of one you lower another. Sodium levels being off can cause significant confusion, or a potassium level being way off could cause a heart arrhythmia or, you know, cause some harm to your kidneys if there was something in there, or a medication you were on, that affected how you metabolize those sort of electrolyte things. Also, some of those are gonna have a lot of sugar in them and you really just don’t need all that added sugar most of the time. So that, of course, in someone who is diabetic or pre-diabetic, at least not make them not feel well after a while depending on how it’s affecting their blood sugar level. You know, most people with more significant conditions like that are gonna be aware and recognize those foods, but if you had someone developing diabetes, then you could really put them into a bad situation.

Alan Helgeson:

Well, thank you, I appreciate you sharing more and offering clarification on daily electrolytes. And as we wind down the update on these trends that we’re seeing on TikTok, Dr. Schriever, we can’t wrap things up without getting to GLP-1s. I know something that is part of your daily work and the people that you get to see and work with each day. And there isn’t a daily newscast that doesn’t include a story about GLP-1s. What we’re seeing a lot now is day-in-the-life videos that are focusing on what people eat while on GLP-1s. So let’s talk a little bit about that. What do you recommend for a day of eating if you can? And I know that’s a lot to unpack in a short amount of time. Is there anything that you maybe want to do to address that in just a short amount of time?

Dr. Jennifer Schriever:

It still remains very important when you’re on a medication that’s gonna suppress your appetite like that, to still eat enough. The amount should still be balanced as far as the content. So it’s really important. We give out a handout, but it’s still important to get enough protein. We still need some carbohydrates and fiber on board. It’s best to fuel your body still throughout the day. Your body will recognize if it’s starving. And if we really are trying to create some long-term maintenance of weight, then we don’t want to disrupt our metabolism, cause lower metabolism. It’s very easy to feel comfortable with lack of hunger because then we know historically in our past, that helped us lose weight. But then that’s not sustainable weight loss if we’re losing a lot of muscle. In that process of weight loss, we’ll lose water fat and muscle. So it’s really important to keep it balanced. And so we’ll tell people “always eat your protein first” and give them a goal of how much to eat. And then your vegetable, so you get your fiber on board. Then a healthy fat. Save your starch for last. And then that will also help maintain that fullness that you’re going for with those products. If your appetite is so suppressed and you’re struggling with that, then we’ll work with patients on, you know, maybe some sort of protein shake or supplement, or how do we increase the density of calories in your food with healthy food choices, not processed food choices, so that you can get enough nutrition in smaller amounts, or maybe smaller frequent meals throughout the day.

Alan Helgeson:

Are there things that you would say people should really work towards avoiding, Dr. Schriever?

Dr. Jennifer Schriever:

Yes, good point. So the GLP-1s, or the injectable medications for weight, or even diabetes, are gonna slow your stomach from emptying. So food is gonna sit in there longer. So if you have a food that is gonna cause heartburn or upset your stomach, it’s sitting in there longer. So you really want to avoid something like that. When you’re on these medications too, then you’re more likely to have side effects. If you’re picking some of those extra foods that you really tend to enjoy once in a while. So something that’s more fatty or higher in sugar, then I’m going to warn you that you’re at higher risk for side effects. You might have more nausea, you might have more heartburn. Instead of constipation, maybe you’re gonna get diarrhea, or just feel really bloated or like a big gas bubble, or that sort of thing. So those are the foods to eat less of. Or if you’re at an occasion where there’s just gonna be something that you want to at least have a small amount, then let’s fill your stomach with some protein and vegetables first to create a good base there, that you slow the digestion of those other foods.

Alan Helgeson:

Well Dr. Schriever, thank you for joining us and giving us the updates on what’s going on. And like we talked about at the beginning of the program, they’re gonna change probably nine times before we meet again, right? So we’ll have you back again real soon. Dr. Jennifer Schriever joining us on this episode of the Health and Wellness podcast series. Thanks, Dr. Schriever.

Dr. Jennifer Schriever:

Thank you.

Matt Holsen:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen wherever you hear your favorite podcasts. And on news.sanfordhealth.org.

Get more episodes in this series

Colon cancer in millennials: What you need to know

Announcer:

This is the “Health and Wellness” podcast brought to you by Sanford Health. This episode is all about colorectal cancer and what you need to know, especially as millennials. We’ll break down the importance of education, prevention, risks or symptoms you shouldn’t ignore, and why screening today isn’t as scary or complicated as people might think.

Our guest is Dr. Kent Peterson, a specialist in colorectal surgery at Sanford Broadway Clinic in Fargo, North Dakota. Our host is Courtney Collen with Sanford Health News.

Courtney Collen (host):

Hey, Dr. Peterson, thank you so much for joining me for this conversation.

Dr. Kent Peterson (guest):

Nice to see you, Courtney. Thanks for having me.

Courtney Collen:

Colon cancer is something that I think a lot of people, especially millennials, may not think applies to them just yet, but that’s changing. I’m learning and we’ll talk more about why.

But today we’ll also discuss why education and awareness and early detection matter so much for this generation, and how having the right information early can make a really, really big difference. And by the way, a millennial is considered a person born between the years 1981 and 1996. So we’ll start with this.

Dr. Peterson, again, we’re so grateful to have you. When I think about colon cancer, it has always seemed like an older adult disease. That mindset seems a bit outdated now. So I’d love to know what has changed. Are we seeing more cases in that millennial generation of people?

Dr. Kent Peterson:

Yeah, this is a really good topic. Thank you for bringing some spotlight to it. I think the good news is that colon cancer is decreasing in older population, which has been for some time. But unfortunately, you’re exactly right. It’s becoming more common in younger adults, particularly we’ve seen over the past 20 years.

People under the age of 40 are twice as likely to get colon cancer and four times as likely to get rectal cancer as the generation before them. And remember, this is people that would not be caught by screening normally. Frankly, this is one of concerning part of my job and one of the reasons why I went into colorectal surgery to try to help figure out why this is happening and treat this problem.

Courtney Collen:

Let’s break down the science. What is happening inside the body when a patient receives a diagnosis of colon cancer? And then we’ll talk about some of those warning signs.

Dr. Kent Peterson:

Yeah, Courtney, we call this the adenoma to carcinoma sequence. You know, something that you’ll read on a science book, but basically a group of cells become abnormal and they grow into what we call a polyp. We call this precancer stage in adenoma.

Over time, typically years, these abnormal cells develop more mutations and are able to invade deeper into the colon wall and even travel to lymph nodes or even other parts of the body. This is when we consider it colon cancer or carcinoma. And depending on what stage it is at the time we find it really varies what treatment options we can offer.

Courtney Collen:

What are some of the warning signs that millennials should not ignore?

Dr. Kent Peterson:

This is also a really good question. The typical story I will see as a colorectal surgeon is someone that’s had bleeding for years. Maybe they’ve seen their PCP, maybe they didn’t have a good experience with health care, kind of went away, ignored it. Maybe they get frustrated and say it’s just normal, or they were told it’s just hemorrhoids. It’s just how it’s going to be.

And those are typically the people that I wish would’ve gotten a colonoscopy years earlier before seeing me and would’ve had much better options that we could discuss. But there’s other reasons too – change in bowel habits, particularly those that are unexplained or persistent. We’ll talk a little bit about family history, I think.

Courtney Collen:

Yeah. I’d love to jump into risk and family history for a moment. How much of colon cancer risk is lifestyle related? And first, what are some healthy habits or realistic prevention steps that young people can take right now regarding their colon health?

Dr. Kent Peterson:

Yeah, this is, it’s a tough question to answer. There’s clearly some mutations we know about that are passed from parent to daughter or son that puts you at risk for colon cancer. Not everyone knows that they have them. Some people do, and that would change it.

But there’s clearly a large amount that are lifestyle related. Myself and others in the field think that clearly there’s a diet component to this. This is something that’s really been hard to research. I myself have done research looking at mostly people in the Midwest, and it did seem that obesity seemed to be tied with colon cancer, but the majority of the people that actually got colorectal cancer were not obese.

So the thought is maybe the increase in processed foods have some sort of increased risk over time that can kind of speed that process up of changing from a precancerous to cancerous lesion.

Courtney Collen:

So let’s jump back and talk about knowing your family history. How important is that piece to this? And if we don’t know about our family history in this space, what should we do if we don’t know our risk?

Dr. Kent Peterson:

Yeah, I think it’s an important discussion to have, usually with your primary care doctor, to better understand your risk. So people with a first-degree relative, a brother, parent (with colorectal cancer), so they would typically start screening earlier than the average person, typically at 40, or 10 years before your relative’s age at diagnosis.

There’s also another, a number of other genetic syndromes that can predispose to cancer. But one particular thing that comes to mind, within the last six months, there was a 30-year-old that had done a random genetic screen that they offered and found that they had Lynch syndrome. And this is one of the most common predisposing syndromes to colon cancer. She ended up getting a colonoscopy because of that test and found a colon cancer, which otherwise she really didn’t have any symptoms for.

And because of this, we were able to resect at an early stage of disease. So clearly it’s important to know your family history. If not, ask about it with your parents, with your primary care doctor and they can get you an answer of if you should be screened earlier.

Courtney Collen:

Yeah. Such good information. Thank you for that insight. How does a cancer diagnosis hit differently for someone in their 30s or 40s compared to an older patient?

Dr. Kent Peterson:

I think these, you can probably tell, these are some of the patients that stick with me because I remember them very vividly. You know, it’s not something you expect to have when you’re young. You expect to live forever, and particularly because it’s a cancer that’s very treatable if found early. I think it’s especially hard when you wish you could have found this a little earlier and treated it earlier.

Courtney Collen:

On the flip side, what does early detection change for younger patients?

Dr. Kent Peterson:

We know that people that are younger present at a later stage of diagnosis. So we’re talking, presenting before it has time to grow before the time this cancer has to spread to other organs. We’re talking about a much higher likelihood that we can offer a cure.

If caught early, 95% of people can have this tumor completely cured either by surgery or a combination of surgery and chemoradiation. But clear if it’s, if we’re unable to do that at a later stage disease the survival significantly goes down over two and five years.

Courtney Collen:

Screening is important. And that leads us into our next part of this conversation. A colonoscopy, Dr. Peterson, as we know, is the gold standard for colorectal cancer screening. Let’s spend a few minutes here. Who needs a screening first? When should that start and how often do we need one?

Dr. Kent Peterson:

Yeah, so for the average person, age 45. This is what we call the average risk: so a patient with no symptoms, no family history, never had a polyp before, start at age 45. And they recently changed this about five years ago to try to account for some of these younger onset cancers. So typically insurance will cover that. It’s not a big issue.

So if that’s normal, then typically it’ll be 10 years after that if nothing’s found. If you have a family history, typically it’ll start at age 40 or 10 years before the last one and usually do it every five years.

Courtney Collen:

Good to know. Walk us through now, what happens during a colonoscopy appointment from start to finish?

Dr. Kent Peterson:

Yeah, I’ll say a lot of people tend to come in very nervous for this, and that’s understandable. I’ve also had a colonoscopy and I’m very nervous for it. But I’ll tell you that the worst part is always leading up to it. Afterwards, everyone ever always says, that was it. Well, that wasn’t so bad. And they say, well, at least I got a day off of work or school. And I had a really great nap.

And now I feel much more relieved that I know I don’t have colon cancer or some polyp that become colon cancer.

Courtney Collen:

Clear the air here for a second because I’ve never had a colonoscopy. What is, what’s so nerve wracking about it? What is, what’s like, what’s the elephant in the room here?

Dr. Kent Peterson:

Yeah, I think people, number one, people are like nervous. They like didn’t do the bowel prep well enough, which is always usually just fine. So that’s not really a stressful thing. And I think maybe just, you know, asking about it and talking about things that related to poop is awkward for people. But again, I’m not the best person to ask because I talk about poop every day and I’m pretty OK with it.

Courtney Collen:

So if someone is nervous or feeling uneasy about their upcoming appointment, what would you tell them?

Dr. Kent Peterson:

People often feel uncomfortable. I said it’s completely normal. It’s completely regular. You don’t have to feel awkward. This is something we do every single day. Again, these things aren’t things that jump up within days or weeks or months. This is years.

So you get screened once. You don’t do it for years again, typically. So if you’re having issues or it’s that time of your life that you need a colonoscopy you should not be stressed about it. I promise you, you will. Afterwards it won’t be a big deal. And if you talk to someone who’s had a colonoscopy, they’ll tell you the same thing.

Courtney Collen:

And just peace of mind, I feel like for understanding your health a little bit more and staying in tune with what’s happening in your body is always a win. After some of those moments of feeling nervous or uneasy.

Dr. Kent Peterson:

Just knowing that if it is just hemorrhoids for example, then it’s just hemorrhoids and you can live with that and not be stressed every time you see a little bit of blood in your stool.

Courtney Collen:

Yeah, absolutely. What’s the biggest myth or misconception about colon cancer or about colonoscopies maybe that you hear often that you’d like to bust right here with me?

Dr. Kent Peterson:

I think one question I get a lot is about – so Cologuard, which is a stool study that kind of people have tried to replace colonoscopy with, but it’s not really a replacement for it. Cologuard will has a great sensitivity for detecting what typically are kind of advanced adenomas or polyps that have grown relatively large compared to the average polyp that we find on a screening colonoscopy.

So typically those people that have a positive Cologuard will then get a colonoscopy and continue to get colonoscopies once they know they have polyps. This is more of a screening test for people that maybe don’t have access to a colonoscopy or for whatever reason, may not be healthy enough to get a colonoscopy. Certainly, it’s a great resource to have and I think it was caught a lot of people that for whatever reason won’t get a colonoscopy.

But it’s just not a replacement. I hear like parents a lot, my parents, my in-laws, they say if I get colon cancer then it’s just my time. So that’s not why I’m going to get colonoscopy. However, I guarantee you that you do not want colon cancer. Like if we catch this early, we can do a minimally invasive, I personally will use the robot surgery, which is has a very short recovery time. Often people are back to life in a matter of weeks.

And that’s if we find a colon cancer, often we find polyps that we can remove before they come colon cancer. But if caught late, often the decision that I have, and I don’t like to have this discussion with anyone is choosing between an ostomy or having this obstruction, which really just is uncomfortable, inability to eat or drink anything. And that’s just a situation I don’t want anyone else to be in. And I don’t personally like being in that either.

Courtney Collen:

So, biggest takeaway, get screened on time or early if there’s a risk or family history piece involved. And the outcome could be good.

Dr. Kent Peterson:

Absolutely. I think care and cancer especially colon rectal cancer has made a lot of progress in the last 20 to 30 years. And now our challenge is just being able to screen for it and treat it. Ideally, in a perfect world, we could have perfect unlimited resources that everyone could get screened when they’re young at appropriate times, and there would be never any colon cancer that you never had to see a colorectal surgeon for.

Unfortunately, obviously there’s only so many people that can do colonoscopies and do these testing. So it is on the rise, but it doesn’t have to be.

Courtney Collen:

What actually does happen? I mean, you do the prep work, you come in and then do you lay on an exam table and then like what technology is looking at what, and then how long until like the follow-up?

Dr. Kent Peterson:

This is my colonoscopy spiel, so I say this a lot. Yeah, logistically it’s pretty easy. You come in the morning of, you’ve done a bowel prep that starts usually the day beforehand where you’ll have to drink clear liquids and then drink the prep material. It’s gotten a lot better than it has in the past. People generally tolerate pretty well.

The morning of or afternoon you’ll come in, you’ll meet your endoscopist, which is here, usually a GI doctor or a colorectal surgeon. They’ll kind of talk about the risk and benefits of the procedure. Again, the benefits being that we can find these polyps, remove them before they become cancer. You know, generally they’re a very low risk procedure. And then you’ll get some sedating medication, whether either an endoscopist gives you medication to make you sleepy, kind of a twilight anesthesia where you don’t really remember anything, or an anesthesiologist will come see you and give you sedation where you’re kind of completely out.

The procedure itself, we’ll use a colonoscopy, which is just a kind of a long tube with a very high definition camera on the end of it to look all the way through the rectum, the colon to where it meets the small bowel. That’s all the area that’s at risk for adenomas or colon cancer.

Once we get there, we’ll slowly come back and if we see any polyps, we’ll take them off. We’ll send them to a pathologist who looks at it on our microscope. That pathologist will generally take up to a week, but usually less than that to let us know if it’s a benign polyp. If it’s a pre-cancerous polyp once in a while, you do find a colon cancer, but generally you have an idea if you’ve, if there’s a colon cancer by the time you leave.

The endoscopist will talk to you if there’s something they find that’s concerning. Afterwards when those results come back, the endoscopist will either give you a call or send you a message on MyChart, letting you know what the results mean and how frequently you should get your colonoscopy.

Courtney Collen:

If someone is looking to get screened but doesn’t know where to start, perhaps they don’t have a primary care provider or they don’t get to the clinic as much as they should, but they want to prioritize this specific screening, how would you suggest that they begin that process?

Dr. Kent Peterson:

I’ll say typically a primary care doctor will either order the colonoscopy themselves or refer them to me as a colorectal surgeon. Say, either they’re concerned for hemorrhoids or they had some sort of bleeding or change in bowel habits. And that’s generally how that’ll work.

Again, I understand that it’s hard to find a primary care doctor, especially one you trust. You know, if you’ve got to ask friends or family, you even make appointments online. But again, this is pretty routine things for most family care doctors, so it’s not something to be nervous about to bring up. Even if they don’t bring it up with you, bring up the idea and I think it’s, even if it’s just for the peace of mind I think it’s worth talking about.

Courtney Collen:

If there’s one message as they wrap up here that you want millennials to hear loud and clear about colon cancer, rectal cancer, colonoscopies, what would it be?

Dr. Kent Peterson:

Yeah, I think the one message is don’t be afraid of colonoscopies. Colon cancer is scary, but we are not. I looked back on my schedule for this last day, and half of the people were under 50. There was a 50-year-old that had 26 polyps that had no history of it before. There was a 46-year-old that I found on a screen just with no symptoms that I found multiple polyps. A 45-year-old that I found polyps on and a 38-year-old I felt polyps on. So everyone under 50 that I did a colonoscopy had polyps.

Again, that’s not completely normal, but it’s not unheard of either. So I think if you’re thinking about it or feel unsure, I would just say don’t be afraid and talk to your doctor about this.

Courtney Collen:

Yeah, I think it just further emphasizes the importance of screening and staying on top of your health, whatever that may look like for you. Is there anything else that I did not ask you that you wanted to share on this topic today?

Dr. Kent Peterson:

Well, Courtney, thank you for having me again. I think this is an important topic again. I think it’s something that just isn’t talked about given the nature of the anatomy.

But I think it’s something very important to talk about and even with friends, family doctors, whatever it may be. And I think hopefully together we can kind of reduce this problem that we have with increasing cancer in these patients under 40 years old. And I think this is one step towards that.

Courtney Collen:

Wonderful. Dr. Peterson, thank you so much for your insights here, this conversation. I learned so much as a millennial myself. I appreciate your time and all that you do at Sanford Health. Thanks so much.

Announcer:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen wherever you hear your favorite podcast and on news.sanfordhealth.org.

Get more episodes in this series

The great protein push: Is more better?

Dr. Jennifer Schriever (guest):

The two most important meals to get adequate protein, if we’re just gonna look at meals separately, would be breakfast and your evening meal.

Matt Holsen (announcer):

This is the Health and Wellness Podcast brought to you by Sanford Health. The conversation today is about the great protein push is more better. Our guest is Dr. Jennifer Schriever, family medicine physician specializing in obesity medicine, Sanford Weight Management Center, Sioux Falls, South Dakota. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

We’re talking with Dr. Jennifer Schriever today joining us for a conversation about protein, because protein is everywhere, in all of the food labels and all the food products. And I just read that Pop-Tarts is coming out with protein-packed Pop-Tarts in a variety of flavors because everybody’s looking for protein in their products. So we’re glad you’re here today, Dr. Schriever. So Dr. Schriever, why don’t you tell us a little bit about what your role is at Sanford Health and what you do so we know a little bit more about you before we start the podcast.

Dr. Jennifer Schriever:

Sure. I have been at Sanford for 22 years, most of the time practicing in family medicine, and in the past three years helped develop the weight management clinic, and now work here full-time to help people improve their health and create a lifelong journey that makes them feel better and have more energy and better metabolic health.

Alan Helgeson:

Well, Dr. Schriever, we’ve had the opportunity to talk with you several times in the past, and grateful to have you come back again and talk about this because it seems to be one of the hot things in the nutrition world these days anyway. And it’s an important topic because everybody needs protein, but we wanna dig into more of what the right amount is, what the right protein is, because there’s a lot there. It’s not all the same for everybody, and hopefully you can give some definition to that. So let’s talk about protein-packed snacks, coffee, protein oatmeal, protein desserts. Is this trend of protein in everything helpful to one’s health? Or is it really just a marketing thing?

Dr. Jennifer Schriever:

I would say that’s a mixed answer. It certainly is a lot of marketing. So often when I talk to patients and you see protein oatmeal on the shelf, how much more protein does your protein oatmeal have? These can be beneficial, but it’s really important to understand what you’re buying and what’s in the label. What is the rest of the content of that protein food? So even you would think a protein yogurt, it’s yogurt, right? It should be great for you. But one protein yogurt isn’t as good as the other. So what you want to look at is the label for the nutritional label and then, you know, the content of what they’ve included. My concern is how much protein is in there? How much sugar is there, especially added sugar? And of course you wanna look at the fat content. And you could look at the ingredients, is it a really long list? So then maybe that has a lot more processing to it. So then it’s probably not a good choice. Now sometimes, you know, depending, like protein bars, we can talk about how to pick a good protein bar versus another. Because those will have a lot of sugar in them, and it’s confusing because one protein bar looks pretty good, but then when you look at the sugar content, it’s really not as good for you compared to the amount of protein in it.

Alan Helgeson:

So you really have to look beyond just that word protein when it comes to labels, right?

Dr. Jennifer Schriever: 

Right. So for instance, with a protein bar, you can look at just two things. How many grams of protein is in it? One simple way is to add a zero or take a times 10, right? So if you have 14 grams of protein in that protein bar, so now we have 140 that we’re thinking about. How does that number 140 compare to the calories in the protein bar? If it’s more or equal to the number of calories in that protein bar, then you’ve got a good protein bar. If your calories are way above that, then you have a bunch of extra ingredients in there that you probably don’t need, and it’s probably not gonna be worth the value of the protein in that protein bar.

Alan Helgeson:

You walk down the aisles of protein bars and it’s just astounding. It’s overwhelming. So I’m gonna raise my hand and say, I’ve looked for the nicest label. Being honest.

Dr. Jennifer Schriever:

Yep. Or what’s gonna taste the best, right?

Alan Helgeson:

Exactly. A lot of ’em just taste the same.

Dr. Jennifer Schriever:

Yeah.

Alan Helgeson:

Let’s talk about the right way to make sure that protein is spaced out throughout the day. Can you be a little specific about the amounts of protein and how we need to do that throughout the day for us?

Dr. Jennifer Schriever:

Sure. You know, nutrition science just keeps getting better and better. So I think we do have better answers about these things. It might not be definitive, but we are getting better information. So as far as meals, the two most important meals to get adequate protein, if we’re just gonna look at meals separately, would be breakfast and your evening meal. The middle of the day isn’t quite as important. You can look at it a different way too, is we really need a certain amount of protein throughout the day to at least maintain muscle health and build it. If you are getting that protein throughout the day, or don’t wanna necessarily get it all at once, but if you are getting enough protein throughout the day and there’s a time of day that you want to work out fasted, that’s probably fine. You’re gonna make up for that protein content the rest of the day. Interestingly, you kind of need a minimal amount at a meal for adults over 25. To really get enough protein at a meal, you want about 30 grams. Under 25, you’re gonna be better at metabolizing everything and you’re probably gonna get by with good protein muscles, muscle protein synthesis or making your muscles back up with less protein at a meal. But in general, as long as you get enough throughout the day, you’ve divided it up a little bit, you’re gonna be okay. But if we have to look at when we wanna get the most to help the breakdown of muscle that may occur overnight of your muscles, if you don’t have enough nutrients on board, then let’s build up some good amount of protein in the morning as well as at the evening meal.

Alan Helgeson:

So talking about grams per body weight, is there a calculation that you really work with when you talk with people?

Dr. Jennifer Schriever:

So that varies a lot too, and the science, again, keeps changing or there’s different evidence depending on how you’re looking at it. In general, I would say the RDA is not enough and that’s 0.8 grams per kilogram. And then that’s a hard thing to think about, because in the United States, most of us don’t think about what we weigh in kilograms. We think about pounds. So there’s some evidence to support that you really need more like 1.2 as a bare minimum grams per kilogram to just maintain muscle mass. So if we think about if there’s 2.2 kilograms per pound, then that would be at least 0.6 grams per pound. That gets so confusing. The caveat might be if you have any sort of condition where we need to monitor your kidney health or something, then we’re gonna not go by this gram per kilogram or pound of body weight as much. So then we need to know those guidelines separately. But in general, we do about a gram per pound of ideal body weight. Not your current weight, but what we estimate your ideal body weight to be. So you can do that by knowing BMI for your height, you know what a BMI around 22 to 23 might be, and what’s the weight of that? And then you get your gram per pound. That being said too, some people naturally have a whole lot more muscle or are active, so then we’re gonna tell that person to get more protein. It’s very individualized.

Alan Helgeson:

So I’m guessing moving to that next question too, about age, also serving size. How does that roll into it too, Dr. Schriever?

Dr. Jennifer Schriever:

As we get older, protein becomes more and more important because again, we’re not as efficient at using that. That being said, you can maintain muscle mass with protein intake, but if you don’t also do some strength training or resistance training or exercise to activate the muscle breakdown/buildup process, then that protein isn’t gonna be as useful. But you need at least a certain amount to help maintain a reasonable amount of muscle mass. So definitely would shoot for at least 30 grams of protein a meal. If you don’t want to necessarily count that for most people, you can look at the palm of your hand and make it the size of your palm, thickness of your palm. If you’re a taller person, maybe we need to go to the first knuckle and that would be a rough way to look at the size of your portion of meat that you could kind of eyeball that if you don’t want to get into more specifics. If you’re really active, then you know a bigger portion might be, active as far as in strenuous work or strenuous exercise, then we might want to increase your protein intake. We can also talk about it as in percentages of the food intake of a day. So if you know your rough calorie goal, if you’re not as active, we might have at least 30% of your calories from protein. If you’re more active, we might go more towards 40% of calories. But we’re gonna take into account the whole picture. How active are you in general and what is your highest level of activities? So some people have a really physical job or their exercise is really intense.

Alan Helgeson:

So you got into the activity level. How about somebody that’s maybe fairly sedentary, not active at all?

Dr. Jennifer Schriever:

So then as part of percentage of calories, we’d still stick to the 30% and still at least 30 grams of protein a meal. But we’re also still gonna look at the size of the person to give that sort of goal because we don’t want to break down muscle. We’re just gonna get weaker and weaker. Also, the more muscle you have, the longer you’re gonna live, the less you’re likely you’re gonna fall, the better you’re gonna survive any disease states that can hit. We know that even for people undergoing cancer treatment, the healthier and stronger they are, the better they’re gonna make it through any disease state. So that’s why that’s so important.

Alan Helgeson:

This next question, talking about types of protein and breaking out a little bit between, are processed protein products as beneficial compared to protein from whole food sources?

Dr. Jennifer Schriever:

Most of the time I would say from a protein gram goal, it’s probably pretty reasonably equal. But if it’s mostly plant-based source, then you’re not gonna have all the essential amino acids that you need throughout the day. Now if that’s just one portion of your intake throughout the day, then that’s probably just fine to have a plant-based source if it doesn’t have the full essential amino acid picture. The benefit of having whole foods over processed foods is everything else that whole food has. So taking a steak versus a whey protein, that steak is gonna take longer to digest. That’s gonna make you feel fuller. Even though the protein gram amount is gonna be equal, it also might have some extra vitamins and minerals that maybe what weren’t included in your whey protein shake. So you know, sometimes I think those whey proteins might have some extra vitamins in them as a supplement, but that steak is definitely gonna have some B vitamins and other things that you need. And so if you are also one that tends to be hungry throughout the day and struggle with fullness, let’s avoid the shakes and get more whole food because you’re gonna feel fuller longer. Even that breakfast meal can make that day go so much better.

Alan Helgeson:

Does the human body actually absorb and utilize the protein in these artificial sources?

Dr. Jennifer Schriever:

I think you’re referring to like these extra marketed protein labeled foods. Yeah, it’s going to use them just fine, and often those are supplemented. Even a whey protein is gonna be used in protein bars or pea protein or an egg white protein. Your body is going to be able to utilize whey proteins more quicker than pea protein than raw eggs for instance. But there’s a lot of benefits to eggs. I’m just not sure we wanna eat raw eggs ’cause of what else we’d be at risk, therefore. So it does, but the disadvantage still is that’s highly processed. What have they used to process it? Have we added extra ingredients, salt, sugar, other things that might even cause inflammation so that we don’t feel as well eating them? What is the sugar substitute? Sometimes I don’t in general think sugar substitutes are necessarily bad in moderation and not in high amounts, but some sugar substitutes are gonna bother people. So then you’re gonna be uncomfortable. But then you’re also lacking probably fiber in some of those supplements or a different form of fiber because they’ll often add them to certain things. But how do you feel when you take those? And if we’re causing inflammation from these extra ingredients, that’s just gonna disrupt metabolism in some way or joint pain or other bodily processes.

Alan Helgeson:

Dr. Schriever, are you able to break down the structure a little bit between these manufactured protein sources versus the whole food protein sources?

Dr. Jennifer Schriever:

What some of the concern is they’re plant-based protein sometimes and then I guess I don’t know for sure, but it seems like there is some evidence that depending on what they’ve used to make those proteins, that you don’t break them down as easily or aren’t able to use them as well as whole food. But it depends on which one you’re talking about and what they use to make it.

Alan Helgeson:

So there’s a trend out there now about a protein shake before bed. Can you talk a little bit about how this may or may not be beneficial to nutrition but also to the quality of sleep?

Dr. Jennifer Schriever:

Sure, and I think this is gonna depend on the person. A protein shake before bed can be useful. Did you reach your protein goal? Did you miss a meal? Is this gonna help supplement what you missed during the day? Or a lot of us have been in that habit throughout our lives, or it’s just the routine to have an evening snack. So is that a better alternative than your typical evening snack? I think evening snacking is partially because we’ve been busy all day working and now we’re more relaxed, have less distraction and unfortunately the kitchen’s really handy. So it can provide a balance or a substitute for a time when you are hungry and if you didn’t eat enough during the day. So then that’s gonna support you sleeping overnight. If you tend to wake up in the night and be more hungry, that shake might help you feel fuller overnight. If you can add even some fat to it a little bit and maybe a little carbohydrates, that’s gonna help balance your sugar better overnight and you can have a more even sleep. That being said too, you might not wanna have that very close to bedtime because you’re gonna be at more risk for having heartburn or having it sit in your stomach longer ’cause you’re sleeping and resting. Then it can disrupt one’s sleep. It’s all gonna depend on how you handle food timing before you go to bed and until you really start to focus and pay attention. I don’t think people notice how that food timing for each individual helps. Some also will have tryptophan in them, which is also in turkey and that’s why you get so tired after turkey dinner. So maybe they’re gonna help with sleep that way.

Alan Helgeson:

If only they were turkey and gravy flavored. Right? Well on this next one, for someone who may be just starting out or overwhelmed by all of the information out there, what are some of those foundational principles that you would say, ‘Hey, just focus on these’?

Dr. Jennifer Schriever:

Really focus on whole foods. It’s back to, you know, shop on the outer aisles of the grocery store and not go in the middle. Buy something that’s not boxed or packaged. One simple way is try to add more vegetables to your day so you add more fiber. Add more fruit. I think vegetables tends to be the biggest challenge for most people. Or reduce the sugar in your nutrition, you could start that way. Try to snack less. But also if you want to, look at specific plates. Like, one good one is myplate.gov or Harvard has a healthy eating plate. So if you like a one pager with some simple, like, this is what my plate should look like, and these are the foods that make up that sort of thing. Fries are not a vegetable <laugh>. Get back to the basics and then have someone maybe visit with a dietician or someone else that can help you move on from there. But you can really do a lot by just doing those things.

Alan Helgeson:

What are some red flags or maybe what should people be skeptical of? Things to look for in various trends that they maybe should go, ‘eh, I gotta watch out for that. That doesn’t look right.’

Dr. Jennifer Schriever:

Anything that just makes a new and amazing claim. You know, just like anything else, if it’s that great and supposedly that innovative, I’d really start to question it. If you don’t see it from more than one resource, if you can find more information on it about something that’s, you know, health system supported or WebMD, and look at a few different ones and see if that information is comparable, that’s what I would definitely worry about. Or does it guarantee a certain amount of weight loss or a certain health benefit that you’ve never heard from before? Also, you kind of wanna look at who’s making money from it, what is their experience, what is their education? Just like you’re gonna be worried about the latest and greatest of anything. It’s the same with supplements and food. All those things.

Alan Helgeson:

What would you recommend as some of those reliable sources people can use for accurate science-backed information?

Dr. Jennifer Schriever:

If it’s an individual, you’d wanna look at their credentials. So you really wanna look for a dietician, not a nutritionist. A dietician with the right education to earn that title is gonna be what you’re looking for versus a nutritionist might not have that level of education. If you’re looking at a website, if it says .org, .edu, that’s gonna be an organization that has spent a lot of time studying and deciphering what is accurate information for you. So if it has .net, if you’re curious, then let’s look for other resources that are more reliable. If it’s biased towards a certain brand, they say is better than another, then I doubt most supplements have enough studies to prove that because it’s just very expensive to study those things. But I would look for at least more than one source and make sure at least a couple of them are reliable and trusted.

Alan Helgeson:

Dr. Jennifer Schriever, always a pleasure to talk to you and always such a great source of information. Thank you again for joining us.

Dr. Jennifer Schriever:

Yeah, thank you.

Matt Holsen:

This episode is part of the Health and Wellness series by Sanford Health. For additional podcast series by Sanford Health, listen wherever you hear your favorite podcasts and on news.sanfordhealth.org

Get more episodes in this series

Managing weight as a chronic medical condition

Dr. Lindsey Henderson:

When we talk about weight, it’s not about the number. I honestly hate the BMI scale. I really wish we could get rid of it. It is not an accurate judgment.

Courtney Collen (announcer):

Welcome to “Her Kind of Healthy,” an informative and unfiltered podcast series by Sanford Health. We want to start new and honest conversations about age-old topics, from fertility to postpartum, and so much more with our Sanford Health experts.

In this episode, we’ll hear from Dr. Lindsey Henderson who specializes in family medicine and weight loss management at Sanford Health in Bismarck, North Dakota. We recorded her speaking during a Sanford Women’s event on Oct. 23, 2025 in Bismarck. It was called the Women’s Social where Dr. Henderson joined other Sanford Health providers on stage to discuss popular women’s health topics.

Here’s Dr. Henderson on weight loss medications.

Dr. Lindsey Henderson:

I think it’s fair to say if we all really thought about it, the majority of us have thought about our weight, probably judged ourself, weighed ourself, or thought about how our clothes fit, at least in the last week, if not in the last day. Weight has a significant impact on us and a lot of times all through our lives. When I talk with patients, I’ll have people tell me, like, “My mom put me on a diet when I was seven.” And those are things that really affect us long-term that we always think about.

So it’s been nice that there’s been more investigation and study into weight, and we now know it’s a chronic medical condition. It’s not a personal failure. Weight is something that we can’t necessarily help. There’s so many factors that influence our weight, our genetics, our metabolism, our hormones, our behavior, our environment.

So, when we think about treating it, it’s important that we look at all those things and not just tell somebody, “Hey, you should eat less and you should exercise more” because that’s not what it is. When we think about weight, I think it’s important to know goals should also be realistic. We are not how we were 20 years ago or 30 years ago or 40 or who we are now. And so meeting ourselves where we maybe could be now and not where we were when we were 22 because we’re not the same.

Our hormones have changed. We’ve had babies. We age. Age is the biggest factor with weight and we tend to get that deposition, the mid abdomen and that’s not something that somebody did. It’s just the way our bodies age. So it’s really important we look at all the different parts. We kind of look at four different pillars is what we call them when we talk about weight and when we’re trying to treat it.

So, behavior and mood is a big, big factor. You know, are we emotional eating? Is our mood controlled? Because that can really affect how we feel. Another one is diet, activity, and then medications are there and they’re great to use when they’re appropriate. But it’s important that we combine all of those things together.

BMI is an inaccurate measurement for many people

The other thing is when we talk about weight, it’s not about the number. I honestly hate the BMI scale. I really wish we could get rid of it. It is not an accurate judgment, and we don’t all fit the same mold. Our bodies are very, very different and it’s OK that they’re different. So somebody may lose five pounds but you know, maybe they’re moving easier and their clothes fit better and their mood is better and their cholesterol came down. That’s a win. It doesn’t matter if you lost 20 or you lost five or you lost a hundred.

Like it’s about how we make ourselves feel and how we feel in general. So I think it’s really important to have those realistic goals when we talk about weight and realize where we are. Medication, I absolutely will talk about medication. Obviously they’re all over right now. I could probably tell you if I got a dollar for every time I saw a TikTok picture, I would be rich because people bring them to me all the time and be like, I want to try this.

So those injection medications have gotten a lot of press because honestly they tend to work pretty well, but they’re not the only thing in our arsenal that we do have to use. Honestly, phentermine, one of the most commonly used medications still has been around since 1959 is still probably the most widely used medication that’s there. So there are oral medications as well as those injections medications that really are appropriate to use.

But it’s important to talk to your provider to make sure they are fits for you because not everyone is OK for every medication. Just to kind of delve into the injections a little bit more because they have gotten so much press, so there’s three on the market right now.

Weight loss involves four pillars: medication is one

The first one that came out actually came out quite a while ago and we really don’t tend to use it. It’s called Saxenda. It was a daily medication and while it can work, it doesn’t work nearly as well as the kind of newer ones that have come out.

Wegovy and then Zepbound are the two main medications that are kind of all over, and they’re good medications. It is incredible to have somebody come back and tell me how they feel on them because it really helps with appetite and fullness. But I think the number one thing people like is it helps with that food noise, that kind of constant, “oh, what am I going to eat next? Where’s my next snack? You know, maybe I should grab this.” It really helps quiet that down.

But as much as these medications are good, I do have a little bit of a love-hate relationship with them. They’re not perfect. They also really need to be used appropriately. And that’s one thing is with weight in general and even as we age, we lose a lot of muscle mass and especially with these medications, we can lose a ton of muscle mass. So it’s really important that when you’re losing weight, whether with an injection or anything else that we’re working to do it in a good way that’s healthy for our bodies.

The other thing with these medications is they aren’t a short-term fix. Studies have come out that really show they are more indicated for long-term. If you stop them quickly, your weight will come back. The longer you’re on them, the better chance you have. But really it is a commitment. So it’s not just a short-term fix with these medications and making sure we use them appropriately is really one of the keys.

And of course cost. I mean we can’t forget the cost. The cost of them is atrocious. Hopefully over time that will eventually improve. But really for right now, the cost is probably one of our biggest factors with using these medications.

Behavior, diet, activity support long-term weight loss

But outside of medication, we do have to look at diet. And I know diet is like a bad term, right? It’s like eat less, starvation. But really the best diet is one you can sustain. Really working on like whole foods, lean meats, I think we talked about lots of vegetables, high fiber, and it really can help maintain our fullness and also help with maintaining our muscle mass as we’re working on a healthy lifestyle in general.

Looking at what we drink each day, you know, our water intake, do we drink a lot of other things? How often do we go out to eat? No one is perfect and no one should be perfect. We all have to have our good days, right? And that’s OK, but we always have to look at a broader picture of that and make sure that we still enjoy life. What we eat should not be something that is the center of our day all the time. It should just be part of what we do each day, but not the center of it.

Activity is usually kind of a dirty word, but really activity is one of the most important things, especially because of that muscle mass. But I think the most important thing is that we need to start with where you’re at, not where you think you should be.

Long-term goals are around 150 minutes a week of an organized activity that includes cardio as well as weight. But that doesn’t mean we need to get there tomorrow. If we are more of a sedentary person, it is OK if two times a week for five minutes. If you do an online video, fantastic, cause at least we’re getting it into our habits and we’re building those and we can progress from there. If you’re more of a cardio person, you know what? Pull out the weights. Maybe we can start with five minutes of weights twice a week.

Weight is considered a chronic medical condition

But it’s those small changes that are really important because then when we build those habits, we can continue those habits. They’re the hardest thing to do. It takes the time and that’s why activity’s usually the hardest because we’re exhausted. Our mental load is huge, but it is worth it to do it for yourself.

And I think that’s one thing is we probably aren’t good at taking time for ourselves, but that doesn’t mean we shouldn’t, and it doesn’t mean we can’t. It’s just trying to learn to do that as we go. So I probably have taken more time than I should, but I think it’s really important to remember that the goals of weight are different for everyone and our successes are different for everyone. But I think it’s important to also support each other in that because it’s not easy and it’s definitely work and it’s always a constant thing and that’s why we treat it as a chronic medical condition – because it is one.

Courtney Collen:

This was part of the “Her Kind of Healthy” podcast series by Sanford Health. For more by Sanford Health, visit Apple, Spotify and news.sanfordhealth.org.

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Clinician well-being is a strategy to keep good doctors

Alan Helgeson (announcer):

“Reimagining Rural Health,” a conversation series brought to you by Sanford Health. In this series, Sanford Health leaders and expert guests share insights, innovations and real-world solutions to the toughest challenges in health care today. Each episode explores the ideas, tools and partnerships advancing rural health care and strength in care in communities across the country.

Joining us in this episode is Dr. Tait Shanafelt, chief wellness officer of Stanford Medicine, alongside Dr. Heather Spies, who is physician director of clinician experience and well-being at Sanford Health. Together they’ll discuss clinician well-being as a strategy, leadership, culture, and the power of listening in rural health care.

Dr. Heather Spies (host):

Dr. Shanafelt, welcome. Thank you for joining us. I’ve been looking forward to having this conversation with you. I’ve had the honor of knowing you for a few years now, since I took your Chief Wellness Officer course in 2021 at Stanford. So just since then, it’s been such a fun journey to see the evolution of clinician well-being being prioritized by more organizations. And so we’re going to talk about that today.

And then to be able to work with you in many different aspects – meet with other leaders across the country, whether it’s an American Medical Association (AMA) meeting or a national meeting conference on physician health, most recently in Boston – it’s been a joy. You have helped elevate clinician well-being from a nice-to-have to a core essential element of organizational performance, culture, and sustainability. First, thank you for elevating that across the country for so many people. You’ve made a big impact.

Dr. Tait Shanafelt (guest):

Thanks, Dr. Spies. It’s great to be with you. I’ve really been looking forward to this, Heather.

Dr. Heather Spies:

Yeah, that was a long intro and a long thank you, and well deserved. So, I also want to thank you because your work has really changed how we do things and/or helped shape it at Sanford. I’ll try to keep Stanford and Sanford straight throughout the podcast, right, with the difference there.

But how we think about clinician well-being at Sanford Health, not just as a commitment that aligns with, you know, our mission and values as an organization, but really as a strategic investment in the future of care delivery, especially in rural communities which we serve a lot of. So, I’m going to dive into a couple questions here for you.

You began conducting your research on well-being over 25 years ago, and really centered around physician well-being, and we’re one of the earliest leaders in this space. You helped define the role of the chief wellness officer. So, I have two questions related to that.

At that time, what convinced you that clinician well-being was not only a human issue, but a leadership and business issue? And as we look ahead, how do you see that role evolving?

Dr. Tait Shanafelt:

Yeah, no, it’s great. Great question. I think in those early days, several decades ago you know, much of our early work was looking at that intersection between clinician well-being and the care we provide patients, both with respect to quality of care, whether the care is compassionate, whether it’s patient centered.

And I think we begin to see in a number of studies that there were these strong links between the clinician experience and clinical care. Subsequent studies also begin to demonstrate links to turnover in health care workers, health care workers cutting back the amount of time they devoted to clinical care.

And so we begin to have all this evidence that the well-being of the health care workforce was really jeopardizing every, all the things we aspire to in the mission of health care organizations. And that’s the foundation really, that begins to shift organizational thinking and to recognize that this, as you said, wasn’t nice to have sort of in a workforce morale kind of line of thinking but as a fundamental necessity for us to be effective as health care organizations.

And as that recognition begins to take hold, organizations begin to appreciate that if they were going to be effective in addressing that opportunity, they were going to need to establish a leader within the organization who would be responsible for it. Just like we have chief quality officers, chief experience officers, chief nursing officers, that we would need someone who was going to both have some expertise related to this domain and the evidence on how to advance it and could help guide the organization’s strategy, evaluation process, and implementation.

Dr. Heather Spies:

Yeah. Thank you for that. And I know without someone kind of at the helm, and even just sitting around the table sometimes just as a visual reminder is what I learned, right? That hey, are we keeping the well-being of our physicians and our clinicians in mind and, you know, kind of at the heart of the center of all the decisions we make. Because there we have so many difficult decisions in health care all the time every day, right? So that leads perfectly into the Stanford model of occupational well-being. I wanted to bring that up because we’ve really shaped our strategy at Sanford around that. Can you speak to that model a little bit? Kind of how it started, how it evolved also?

Dr. Tait Shanafelt:

Absolutely. The Stanford model is intended to be both holistic but simple. And one of the centerpieces of it is that we’re trying to do something more aspirational than just mitigate distress or occupational distress. We’re trying to foster meaning and purpose and professional fulfillment in people’s work experience.

And we view that as really a three-legged stool. That there are these individual factors and things that we can do to take care of ourselves and promote our own professional well-being. But that, in addition to that, there are the organizational characteristics and then the efficiency and daily experience in the work environment that are also very critical to fostering that outcome. And that, when we think about the organizational characteristics that really drive a great workplace, much of it centers on dimensions like the behavior of leaders.

What does good leadership mean at Sanford? Do we have that well-defined? Do we select leaders with those qualities? Do we help our leaders develop those skills? Do we measure them? Do we give them feedback? Do we foster an environment where people have an opportunity for voice and input into decisions? Do they have some flexibility? Is there a sense of connection and community within the team? Are we fostering these things?

And, and obviously to the extent we do, it can really change the experience for the workers. And then when we think about efficiency, we often think about that topic from the vantage point of being able to serve a higher volume of patients or delivering a greater volume of care.

But we can expand that thinking to consider how simple or burdensome it is for a nurse to provide for their patient what they need. And are we creating a lot of friction for that process? Or are we removing unnecessary steps or the things that get in the way of that so that it can be you know, a well-oiled machine, and for the worker and they can devote their time and energy and attention to the parts of care that are most critical?

Dr. Heather Spies:

Yeah. Thank you for that. I agree. It’s such a balancing act and such a commitment from all people involved, right? Not just the individual, but from the organization. And that’s where we like to focus too, at Sanford, is saying, what are we doing as an organization to help support our people?

And burnout’s a big component of that, right? We hear burnout a lot more, I think, especially since COVID. But you know, as a practicing OB/GYN, and you know, as our physician director of clinician experience and well-being, we’ve really focused on burnout because we know it affects the quality of care for our patients.

And it’s taken years, but with some intentional strategies, we’ve seen an improvement in burnout in our physicians. You know, as you’ve watched this field closely over decades, what have you observed most recently specific to burnout and kind of focusing on the organizational kind of responsibility that is there for that?

Dr. Tait Shanafelt:

It’s a great question, and I think a really important one as well because it’s easy for us to look at our current organizations, our current daily experiences and still recognize that we have a long way to go, but we sometimes add to that. And nothing has been done, or nothing has changed. And that last bit is just a profoundly inaccurate statement.

And when we look back to 25 years ago, and the state of things at that point in time, to a large extent, organizations just ignored this whole domain. About 15 years ago, it begins to be well appreciated that there was an issue. It was having consequences for organizations that mattered. And we sort of shifted to this era where organizations started to recognize the importance.

In many cases, they did start to assess both burnout, engagement, clinician well-being, teamwork, other characteristics that influence our work experiences. But to a large degree, there was not a well-structured process to follow through on what we learned. And that organizations largely responded by resilience training and stress reduction approaches, you know, sort of generic ways of trying to boost morale that weren’t really addressing root cause.

And I think it’s really been here in the last seven or eight years that organizations have begun to approach this in a more robust way that begins to think about addressing the root cause contributors that create unnecessary work burden or that create friction between teams or that begin to reimagine team-based models of care delivery that better meet the work as we’re doing it today.

And so I think that is where most of us recognize the need for much more action. But we have come a long way from sort of a time when there was largely either ignorance or neglect of this domain to a time where there was awareness, but the ways we were intervening were largely individual focused to now a more sustained organizational attention and beginning to think about developing structures and processes to redesign the work itself and make us more effective in it.

Dr. Heather Spies:

Absolutely. And that’s perfect. I was going to talk about one of those ways. And, you know, in your course years ago, one of the things I took away from that and really learned from was tools to use as one of the leaders trying to lead this work forward. And the listening session was one of those things that was just extremely helpful to me.

So you have kind of a listening model, and it’s developed over time. But it’s really been, I think, a cornerstone for a lot of organizations to be able to help create that culture of well-being. So as you’ve seen this implemented across organizations, can you share some insights about that and how that’s kind of changed leadership assumptions or kind of revealed some blind spots maybe?

Dr. Tait Shanafelt:

Yeah, it’s a really great question. And I think we first started down this road, I guess it was 16 or 17 years ago. I was at Mayo Clinic at the time, and we had very robust organization-wide survey data. And that information was pointing us toward which units and teams, divisions were struggling and even gave us some insight into maybe some of the challenges.

But what we felt and found was that that survey data, while really important and helpful to identifying where the opportunities were, was sort of generic. And that when you looked across maybe 25 units that were being identified as needing additional time and attention we didn’t really understand what the unique challenges were in those units and what the opportunity was. And it was really out of recognition that we said we need to go down and just ask a lot of questions and listen and better understand the challenges.

And so the listening sessions are structured really to provide qualitative insights that give us much greater understanding of, if we’re talking about inefficiency or if we’re talking about suboptimal teamwork, we’re talking about a work structure that makes work-life integration – we really have to understand what are the characteristics of the structure that are making that a challenge? How is that affecting you in your day to day? What opportunities do you see for a different way of doing the work?

And the people in the team or in the unit are those who have the best insights on those fronts. And so it was really out of a desire to try and do something meaningful for 25 different diverse units and recognizing we really didn’t have the data we needed to be able to do that.

Well, that led us to the listening sessions. And then I think what is the key is that many organizations have created channels for feedback. And that’s important. But that listening session is really one component of a multi-step process to take that input and try to translate it into effective interventions to address the concerns that then make that unit function more optimally.

And so I think that the listening sessions are a critical first step, but it’s really building out the rest of that apparatus to help translate what is learned into meaningful action. That is the key.

Dr. Heather Spies:

Yeah. And then closing that loop, right? So listening, but then taking away the things that are maybe those top priorities for a particular department. Because they’re going to be different, like you said, for different ones. And then, coming back, you know, committing to a time to come back.

This is what’s being done. This is just what can’t be done right now, and this is why. And those kind of things.

So, you know, after learning about these certain type of listening sessions at your course, of course you get to network and develop relationships with fellow alumni from the group. And so, Dr. Sarah Richards, from University of Nebraska Medical Center, and I ended up at another conference soon after. And so she was kind of moving them forward in her organization. So we partner together and use them. So that’s the thing I love about our work Dr. Shanafelt, is that we can share with each other and lift each other up. And it’s less of a competitive area of medicine. It’s a place where we all want to lift each other up together. So that’s been really rewarding for me. So, just wanted to share that.

Dr. Tait Shanafelt:

It’s so well said. And I think one of the best qualities of getting to do work in this field is that there are really passionate colleagues who care a great deal about addressing this issue, and it tends to be a very generous group of people. As you said, these aren’t state secrets.

It’s sort of, you know, much like the quality improvement movement that we all just believe that this is the heart of the work we do, and if one of us has insights to create higher quality and better outcomes for patients, we should be generously sharing that across organizations. And I think this domain is very much the same, and it’s still a very nascent field as well. There’s still so much to learn that doing it together and encouraging each other and sharing what we learned is critical to accelerating progress.

Dr. Heather Spies:

Yeah. Yeah. I agree. And ultimately, it does affect the patient care, like we’ve said, and we’re getting to see more and more evidence of that, which is helpful for us data-driven folks. Right. So one of the things I wanted to kind of lead up to next was, you know, when we started implementing these listening sessions I then shared the structure of this session with our physician executive leaders and then one of the groups took it as a project, shared it, and it really started to spread system-wide.

So I think it’s such a great example of how you can take one structure and find ways to scale it. And so that’s been something fun to see. So turning that insight into improvement, how do we scale it? I think that’s one of the biggest things I hear across other health systems is how do we start and then how do we scale it?

So I just wanted to share the three questions we asked because back to what you said earlier about engagement surveys and things like that. This group that did the project, they did the survey. They looked at their survey data before the listening sessions, then they did the listening sessions, and they just asked the three questions: What’s going well for your department? What are the top three things affecting your daily practice? Which issues can we act on now and which are outside our control? And then they had that discussion, right?

They had that hour set aside to go through those things, really address them together as a department. And then they came back after they went through the process of figuring out what they could do and then came back and did survey data a few months later and found a significant improvement in engagement and well-being, decreased burnout. So I would love to just hear, you know, if you’ve heard that what type of similar things you’ve seen and done across the country.

Dr. Tait Shanafelt:

I love you describing it because there’s so many important ingredients that you described Dr. Spies that I think are easy to miss. You know, then, one of the first pieces that there’s a strong evidence for from leadership walk round is starting with appreciative inquiry.

You hinted at what’s working well in this unit that other units could learn from. And there’s actually evidence that beginning on that type of a note actually is really important. Before we focus on the things that aren’t working to acknowledge that there probably are good things in this unit. Let’s celebrate them. We want to build on those strengths and so I love the way you’ve incorporated that.

And then I also really like the way that the third question you articulated of which of these things are most actionable now, or are things that we control locally and can change the fastest, even as we maybe identify the things that we’re going to have to work on for a longer period of time, or maybe just now isn’t the right time?

And I think it’s easy for us to sit around point to all the things we don’t control, you know, payment models for health care in the United States. I mean, we’re not going to fix that in three months. And yet there are many other actionable things that we can do to make this unit a better place to practice.

And so helping the team identify the things in that second category and saying, “let’s advance those even as we wait to work on these other things” is important. And then also to think about being transparent when now is not going to be the time to do something, even if it is under organization control or local control, it just isn’t the right time because we have a different initiative, there’s a different priority this year, budgets are held flat.

And that we are just very transparent with. That is another evidence informed component of this, that if we don’t close the loop on that, there’s a common outcome where people feel like they’ve given us feedback and then they assume that we’re going to follow through. And if we come back and we haven’t followed through, they assume we ignored the feedback. And that can breed cynicism because you asked me for my input, and yet you didn’t do anything.

And so that’s why closing the loop of we heard you. We went and explored that. Turns out right now, we’re not able to act on that. We’ve still got it captured for when the time is right. Keep the ideas coming because we want to identify those we can act on now. But that one isn’t going to move forward at this time. That, again, helps people feel that the feedback that they’re providing is being taken seriously.

Dr. Heather Spies:

Yeah. I think that’s so important. What do you find is the most important? I know we’re talking about ways to get things started, some of these tools to use, I think a lot of leaders that are listening to this are probably measuring burnout. They’re starting to implement some things and have strategies in place.

What do you think is the biggest, the most important mindset or capabilities shift that you would think about to just help organizations sustain that future movement or that forward movement is what I should say of progress?

Dr. Tait Shanafelt:

Yeah, it’s a great question. I think the first suggestion would be to make sure you’re seeing the intersection between clinician well-being and quality access, cost of care delivered, you know, most of these other outcomes because it can create opportunities for us to advance two things at once.

And that within a quality improvement project, by slightly expanding the scope and thinking about, let’s also then think about how does this affect the team doing the work? And if we were not only going to create a better outcome for patients, but simultaneously make the work easier or better for the people doing it, we can often do two things at once.

Some people wonder, does that just happen naturally in a quality improvement project? And I would say, no, it does not. It can, but it is often by chance. If we aren’t very deliberately asking some of those questions, we might only get 10% of the benefit where we could get a much greater amount.

But that also brings the wellness improvement work into the quality improvement work, or the effort to expand access or to deliver more care. And so instead of being one more thing when all our leaders have limited bandwidth, we’re incorporating it into those other projects. I think that’s one important element. And I think it can also break the zero-sum-game thinking.

It goes without saying that these are challenging times in health care. You know, reimbursement, there’s pressure on reimbursement. We’re trying to cut costs as health care organizations, we’re trying to expand access and it’s tempting to say, I really wish I had the opportunity to work on some initiatives to improve well-being in the department or in the clinic or in the hospital. But because we have these other priorities right now, we just can’t.

And I think that – or even worse to say that there’s a mindset that advancing well-being would undermine our ability to simultaneously expand access or to advance quality. And that, again, is that zero-sum-game line of thinking. And to recognize that you probably won’t be able to effectively achieve your access goals if you aren’t also attending to thinking about the well-being of the workforce.

Because you might in the short term, but we have just robust evidence that turnover goes up, people cut back, and so thinking about these things together as a non-zero-sum-game problem is also really important for leaders because there’s just so much attention right now on some of these other priorities that rather than viewing well-being as antithetical to them, seeing that they interdigitate and need to be advanced together.

Dr. Heather Spies:

Yeah, I’ve seen that come so far, even just in a handful of years. Right. You know, from that MA calculator for the cost of burnout and how many physicians are going to turn over and what that’s going to cost in our organization. And the ROI, I remember, of course, learning those elevator speeches about that.

But now I feel like there’s – people are looking at that with an open mind and saying, yes, we definitely see the connection between reduced work hours or earlier retirement. I mean, that is going to affect the access to care that we have and the quality of care that we can provide.

And especially for us here in Sanford, in the middle of the country with our rural areas, it’s extremely important that we’re paying attention to taking care of our clinicians so that we continue to be able to provide care.

I’m going to connect it back a little bit to leadership. We talked about that at the beginning. You know, why does physician leadership development have such an outsized impact, do you think, on how we do with our engagement and the well-being of our clinicians? Because we’ve really invested in it at Sanford, and I feel like we’ve seen some good returns on it. So just would love to get your perspective on that.

Dr. Tait Shanafelt:

Yeah, it’s such a great question and I think it is in part because so much of the experience within a team is shaped by the leader and we have many studies that have found that the behavior of leaders is one of the strongest drivers of professional fulfillment. And I think there are multiple reasons.

We have sort of proposed this construct of wellness centered leadership that says that, well, there’s an element that is caring about people, always recognizing that they have different interests, different career aspirations they want to develop in different ways. And so recognizing that as the leader and sort of investing in the growth and development of the individual people reporting to, to you as a leader is important related to that theme.

But I think some of the sort of magnified effects are that leaders also have a lot of effect on how teams work together. Just is there a sense of connection within the team? Are people working together in a way that’s supporting one another? Does the team have a shared sense of vision? So even though each of us might have individual career aspirations and developmental goals, we’re also a part of a team that has a job to do, and the leader can often help that team have that shared sense of vision and then also help advance change in the areas where it’s possible.

And so some of these outgrowths of the listening sessions we were talking about, if we identify a way we’re scheduling, a way we’re cross-covering, a way the workflow is happening that makes it more burdensome, if the leader isn’t empowering the team to say, well, why don’t we explore a different way we could do it? And to, with the right guardrails, bring a team together to think about how we could try it differently and then pilot it and see if it worked. And iterate that those types of changes won’t go forward without the support of the leader.

And so I think there’s so many ways in which leaders help individuals feel seen and validated and developed. Help teams have a shared sense of purpose and support one another in very emotionally demanding work. And then also have this belief that they can have input. They can help identify better ways of doing things. And even though we can’t do everything, we will take that feedback, we’ll prioritize across the team what we want to, where we want to start, and then there’ll be a path for us to try to effect change.

And, you know, those characteristics are just so critical in whether individuals feel like they are working in a maybe imperfect environment, but one that is supportive and is receptive to feedback and is changing for the better incrementally over time. Or they’re just in that unit where things aren’t optimal and nothing’s ever going to change. And that experience, even though they might be starting in the same place, can be very different. And much of that is determined by that local work unit leader.

Dr. Heather Spies:

Yeah. We see that so much. Thank you for that. And I think that gives so many good ideas in there of how leaders can just sometimes pause and focus on what can I do to encourage my team, make sure they know I care? And then some real actionable things in there too that you mentioned. So thank you for all of those.

I could talk all day. There’s so many different things we need to start wrapping it up. So I’m going to just kind of go into the finale here. We’ve covered a lot of ground today from listening and action to leadership, culture, and well-being.

What I’d like to focus on, just to kind of leave our listeners today, is kind of what matters most looking ahead. So, if you could offer one piece of guidance to health care leaders to improve clinician well-being and organizational performance, what would you suggest?

Dr. Tait Shanafelt:

Yeah. I think change is possible. That would be the first thing. I mean, we have to believe that, or otherwise it’s just a problem we care about but are unable to solve. So I think that, you know, just have that sense of belief that we can do better. And so I think that’s the most important because nothing moves forward without that.

But you know, then if there were some simple add-ons, I would say, you know, use a system approach. We’ve been talking about some components of that, and what you’ve described and how you’re using listening sessions at Sanford and across Sanford is an example of that. So use a system approach, recognize those interconnections with the other priorities so that you can advance them together. Don’t take on that zero-sum-game thinking but recognize how they work together and then focus on what’s possible now.

And, you know, even though that might be some incremental wins, those do start to really add up and over time, and even beyond the incremental gains themselves, that spirit of, we are a team that is taking ideas and identifying those we can advance now and moving them forward. That sort of spirit is therapeutic, independent of what the specific thing we’re trying to improve is. And so, I think those would be some of the points of reflection for leaders who are in the midst of this work.

Dr. Heather Spies:

I love that. So well said. Every part of that is going to be so helpful to our listeners I think today. Thank you so much for being here with us today, Dr. Shanafelt, and I know people can dive in further if they’re interested in some of your work and your course and all the different things that are out there. Looking forward to continue to work alongside you in lots of different ways in the future. I agree. I think the future is bright and I think we have seen change and we’re going to continue to see change.

Thank you so much for being here.

Dr. Tait Shanafelt:

Thanks Dr. Spies, great to be with you.

Alan Helgeson:

Thank you for listening to “Reimagining Rural Health,” a conversation series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, or news.sanfordhealth.org

Get more episodes in this series