Hormones, Menopause, and the Life of a OBGYN with Dr. Heidi Flagg

We are 20 years behind in researching women's health and specifically the physiology of a woman.

Hi, everybody, and welcome to our podcast. This is Generations md. My name is Stephanie Davis, and I'm here joined by my colleague Sarah Davis, also my mother. Welcome to the podcast, everybody. We're excited about this week. We're gonna start a new series. We have our first ever guest coming.

First guest.

Yes.

Yes. So you want to talk about a little bit what we're going to be talking about today and just the series, what we're thinking.

So when you're in your third year of medical school, you rotate through the different specialties, you learn about them, and you try to decide what type of doctor you want to be. You rotate through surgery, medicine, psychiatry, all the different things. But the problem is you do three months at most three months, sometimes one month of a rotation, and you're trying to decide what you're going to be doing for the rest of your life. And it's just really not enough information. The other problem is that most med schools are in academic institutions, and the type of cases that they see, the type of things that those doctors are doing, are not necessarily representative of what a doctor in private practice might be doing. So my intention of this was to try to bring on some guests of people who have been in these various careers for quite a long time, decades really. That just happens to correspond with my age and my friends who are going to be most of the guests. But they also have a lot of experience, and the idea is just to have them come on and say what they love about their specialty, how their specialty is different from maybe what they thought they were going to be doing when they chose that as a third year med student and any insights that they would have for other med students or people who might pick this specialty and just again, so people sort of understand what this pathway is we're talking about. I mean, once you choose your specialty, the residency is anywhere from three to five years minimum. Then there can be fellowships after that and other things. And so it's not like you can just do a residency in radiology and then say, oh, never mind, I want to go back, and B&OB gone. I mean, you just spent five years of your life working like a dog for very little pay to learn this thing in and out. You just really, it's. It's nearly impossible to go back. Although once in a while I see people that go back and did do another specialty. But that, that seems kind of crazy to me. Do you have some updates, Stephanie?

Yeah, I would like to say that last week we were talking about choosing a medical school and whatever, and now I can finally say that I've gotten into two.

Two.

So now I do technically have a choice, so. Nice. But I also just got denied from one. So denial letters are still coming in. So are acceptance letters and even interviews. So if you still haven't gotten an interview, I actually just got one today. It's December 5th. Anyways, so excited to start this new series and so excited to welcome our first guest.

So exciting. This is our first guest on Generations md. She is a very successful OB GYN in New York City. She's also my friend and I just found out by looking at her website that she's actually a fourth generation physician. So she's the perfect guest for generations MD. Let me introduce Dr. Heidi Flagg.

You guys are awesome. I'm honored to be here. Thank you for including me. This is wonderful.

Have you had a long day today? Were you in clinic?

No, I was not. Actually. This is my day that I work remotely and do things, clean out my inbox and do some management stuff. But I happen to have a Christmas luncheon today, so that was kind of nice. Or holiday lunch.

Yeah.

So we just kind of want to hear your journey and how you got to where you are right now.

So just take it away. That's amazing. All right, well, again, thank you for having me. This is wonderful. And Stephanie, I love that you're doing this because I think it's. It's just. There's just not enough information out there for people to kind of figure out their path. Right. And it's. It can be. It's not always that easy to make these decisions as we go through. But how did I get to. I became an OB gyn. I come from, as Sarah said, fourth generation physician. I happen to be the first woman in my family. Come from a long line of surgeons, actually. So growing up as a kid, I would, you know, go into the ER with my dad, into the OR in small town Kansas. Winfield, Kansas is where I grew up. So had a lot of chance to go in and see what he did, which is pretty unique and was really wonderful, actually. So when I got into medical, I certainly loved the surgical specialty just because I had exposure to that. But when I got to medical school, I really left an open mind. I wasn't clear what I wanted to do. And when I got to the OBGYN residency, there really is nothing like delivering a baby. That moment of delivering a healthy baby and having a healthy mother and Babies on mom's chest. There's just that moment in time that's so incredible and it's hard to even describe, quite frankly, but that really drew me in. And also taking care of women, and taking care of women throughout the life cycle, the one thing, and I reflected on this actually, when Stephanie, when your mom and I were together with all our buddies from medical school, we calculated how long we've been friends and it's 31, 32 years, something like that. And I had that recent moment where I looked back to, to kind of think about how long I have some of these relationships I've had with my patients and when they're over 20 years that I've taken care of them, that's just really kind of incredible. And I took a moment to really think about that. Having that much involvement in somebody's life on such an incredibly personal level throughout all these different stages is really something else. And I'm incredibly grateful for it. It's an incredible privilege. So I really, I try to focus a lot on that day to day. But you know, many of, many of the specialties, anesthesia surgery, whatever, patients come to you, they get the problem fixed and then you don't see them again. Right. There's no long term follow up. So I would say that's one of the kind of more incredible parts of my career, that long term relationship, my journey. Yeah. So I fell in love with OBGYN and then went and did a residency. And I don't know how much more you want to hear. There's a lot to talk about here, but ended up, you know, I'm in a private practice, as you know, Stephanie, you got to shadow me that one day, which was a lot of fun.

Well, I guess my, my question just on that is what, what surprised you when you got in as a practicing ob GYN in private practice? What, what came along that you did not expect? I mean, you knew you were going to work hard. A lot of that stuff, you know, you kind of knew about. But what was something that you wish you could have told your younger self when you were making that decision to go?

And so there's no question that the lifestyle of an obstetrician gynecologist is probably one of the worst in terms of lack of sleep and stress level and even responsibility. You're taking care of not one patient, but two patients at a time. And of course, I knew that I was going to be sleep deprived. I knew that there were going to be tough moments and all of that. What I wasn't entirely prepared for. You get through medical school, you get through residency and you kind of think, all right, I'm an attending now. Life, you know, like the lifestyle, the balance is going to be better. And I think it's really important if you go into OB gyn, I'm hoping, Stephanie, actually for your generation, it's better. This, this is going to be more addressed. But I think what I wasn't prepared for was the long slog of trying to balance work and life, kids, family, all of that. That it's a day to day, it's a constant challenge and that the way that our medical system is set up, it doesn't support that. With insurance based practice having to churn through a lot of patients to even make ends meet, the liability. You could talk about a lot of things, the barriers that are in the way for creating that balance. The lack of autonomy, I think was kind of shocking to me. Such a profession, you know, you're so trained. Right. We come out of this out of four years of medical school and then four years of residency in my case, and you're so highly trained at something. And then ultimately in our current system, you have a sort of shocking lack of autonomy on some levels now, you know, and that's not to say that there shouldn't be safety nets and things like that keeping an eye on the system. Right. I totally agree with all that. But it is. So I think that and the constant challenge that I had personally, balancing family and work.

Yeah. Going off of just work, life balance. Like how were you able to have a family and still be a practicing OB gyn?

Oh, boy, Sarah, how do I. I got that one. Okay. I look back sometimes, I have no idea how I made it through. Sometime, you know, when you kind of put your head up and look back for one thing. I mean, I was incredibly fortunate. Out of some misfortune, I was able to start my own practice. But that ended up being a really incredible thing. You know, out of something bad that happens there. There are several silver linings and good things that happen from that. And this was a great example. I was able to start my own practice and had to work incredibly hard to build it. But once I got to a certain point, I then was able to manage my schedule, have more freedom. When I built the practice up and had more people on the call schedule and more support, then I could do things on my, you know, get more freedom in my schedule and have more flexibility. I think your generation is going to work more for bigger hospital systems and things like that it's going to be less opportunity to build up a private practice. Your mom has done it beautifully. Right. But in a certain way. Right. And the, the other thing I will say is we, we talk a lot more about burnout these days. I probably could write the book on that or at least a chapter on what that feels like. Right. What it feels like. I wasn't entirely sure what was happening at the time and why I was feeling the way I was, but I got to, and this, this was the beauty of having my own practice. I got to a point I, I, I was textbook burnt out about nine years ago and was able to come off the call schedule and not do the all nighters. I was doing every other, every third, every fourth. It was constantly changing because there were coverage issues and there was never any control of the schedule. It always seemed to change and I would have to pick up more call. And that uncertainty and not being able to plan certain things really, really got so difficult. And obviously the lack of sleep was just a massive issue. I think all of these things are being addressed now, thankfully for physicians. And you know, there's some things that have been done, like guidelines that have been put into place so that you don't go 36 hours without sleeping and things like that. At least I hope. Yeah. I don't know. I was really lucky because I got to a point where I was burnt out and I was able to, to, to change things. But what I will say is that what I wish I had at the time was a little more support in the system. Because if only I could have tweaked my schedule a little bit, I felt like I could have gone longer and kept delivering babies. It was one of the most difficult decisions of my life, quite frankly, to stop delivering babies because I, I really, it, it felt like it took a piece of me when I had to quit. That was your drive. Exactly. That's what pulled me into the profession. Right. So that was a very difficult thing to give up. I wish there' support in the system to just make it a little lighter call schedule, you know, a little more flexibility to do more stuff during the day and not at night, that kind of thing. Whatever it was, you know, I probably could have come up with something. And also, not for nothing, but actually this is really important, the cost of our malpractice premium. This is a real negative here. You know, it's so exorbitant. Right. We pay one of the most costly malpractice premiums as OB GYNs right up there. With neurosurgery and anesthesia. And, you know, to cover that cost, you have to deliver X number of babies before you make even one penny or can pay any other employee or your rent or whatever. Right. It's part of your overhead. And in my case, my practice pays well over $1 million a year just to cover our doctors. And, you know, so you have to deliver a lot of babies before you cover that cost.

I think that's a really important point and something that, you know, I want to talk to as we. As I talk to all the different specialists. You know, I feel like in. For me, growing up or going through med school, it was like. I felt like talking about money was kind of like something people didn't want to talk about. Like, it just seemed sort of gauche or something to say that. But the financial aspects of running a practice are so super important and have everything to do with. Tied into your lifestyle and so many different things. And I think that, you know, overhead of the practice is really important because if your overhead is so high, there's no way to work part time or have some of those other more flexible options because you've just, you've got to. You got to work enough days to pay all the staff for the equipment, for the malpractice insurance, all that. So that's just going to be something that will, that will keep coming up. And I think it's just important for medical students to think about that. But one question I have for you is, you know, I know there is a little bit more of a trend now of using these laborists. So people that just deliver babies like a hospitalist is. Do you see that as something that.

Is helpful to your specialty or do people are just. Are people still in the mindset of I want my ob GYN to deliver my baby?

You know, that's really interesting, both of you, right? So I've thought about this long and hard, and I. It just felt to me like we were, we were, we were going. We were at an intersection at some point in my career, and we were on opposing pathways. We were going in opposite directions where people were hoping and wanting, understandably, more personalized care. But the system was going away from that. And the labor setup is an example of that, right. Where we're going away from that more personalized care where you really have a relationship with your provider. So that's. I wouldn't say that it helps or hurts. I mean, let's, let's just be positive here and say that it, it helps. I think Because I think we have a shortage of OB GYNs and I think it's only going to get worse actually, unfortunately. But so I would say in that regard, it helps in that, you know, it gives somebody, it gives some, it gives new, newly minted OBGYNs an option. Right. And if they really want to, if, if, if they want to, if they want to prioritize lifestyle and life work, work life balance, a laborist is actually a really good position for them. Right. I mean, you can still have an amazing experience. You can, you obviously still have to interact with a person and their labor and you do get to know people in these situations, right? I mean, I, I talked about the long term relationship that was, that's been of incredible value to me. I didn't know that. I, I don't think I thought about it when I, I mean, I may have thought about it when I went in, but it's more a look back for me to see, to see how incredible that's been. So it may not be that as important for somebody or they, that may not be a priority for them. So a labor position would be more like the ER, the ER setup, right? Where you're on three 12s a week or whatever, right. Where they have more flexibility. They're on and then they're off. So I would say from a life, work, life balance, it's a great option for an ob gyn.

I guess we've been talking a lot about just kind of negative aspects of being an ob GYN and stuff. But like, if you were to go back, would you choose a different specialty?

Yeah, I know people ask me that, Stephanie. It depends on the day, how I answer that question. Yeah, it definitely depends on the day. I look, you know, I want to have, I want to take a long view on this because I want, I want good people to come into our specialty. It's. We started this by saying, we started this talk by saying there really is nothing like it. And so if I take, if I sit here and take the long view, the answer is yes, I would do the exact same thing. It's been a privilege. It's. It's been an honor. I don't want to sound corny or whatever, but it truly is. I mean, to be involved in, in a woman's life in the way that I am on a daily basis, I mean, I kind of, you know, now that I've got a little more sleep and I have a little more time to think about these things, it kind of blows my mind. And I'm Actually overwhelmed by the amount of responsibility and trust people put into me. I can't think about it too much. That, you know, it really is kind of incredible. So that. That's the long view and that's the override depending on the day. You know, at the end of certain days, I just want to throw it up in the air and walk out the door. But, you know, today's not one of those days.

So that's because you weren't in the office. Depending.

Yeah, that's a good point. Now.

No, I just kind of want to talk about too, like, how women's health and how things have changed since when you started or like, since when you were in med school to now. There's, like, kind of a couple aspects of this if you want to talk about some of them or all of them. I'm just thinking about endocrinology in general. Seems to be kind of a hot topic right now, just with people. 1.

On the good.

Yeah, on the good side of things. Like, people seem to have more understanding about hormones and, like, women's cycles. Like, my whole tech talk feed is just like, people talking about, like, their cycle and, like, how it affects their mood and all of these sort of things. And so there is some more understanding there, but with that and then people's understanding of birth control and how those hormones affect you and all these things. So there's some goodness of the understanding. But then there's also so much misinformation that comes with that. So, like, as you see your patients coming in and kind of. With this new. With this new hot topic and with this new front, what. How have you seen things change in that aspect?

Okay, so I've seen some things change dramatically, and I've seen some things stay apparently the same. Okay, and let me. I'm gonna menopause. Once I came off the call schedule, I really, the last 10 years or so, really heavily focused on that topic. And then in the last year or two, just in the last year or two, the topic has just blown up. Thankfully, we are 20 years behind in researching women's health and specifically the physiology of a woman. Almost all of this, as far as I can see, hinges on the 2002 Women's Health Initiative study that broke the news that estrogen caused breast cancer. And it was poorly analyzed. It was horrendously propagated the information through the media, and, you know, overnight, 15 million went. 15 million women went off their hormone therapy, and we had no alternatives. And money, by the way, research money towards women's Health what dropped to almost zero. Very little money compared to other studies. I think only 10% of research money was going towards women's health. So their initiatives in just the last couple years, in just the last few years, where that's changed. Jill Biden just signed for more money to go into this, into this space. And. But we are apparently behind. Twenty years behind, to be exact. And so I think we're going to see from this moment on this is going to be exponential at this point, at least I hope, because we have a lot of catching up to do in terms of the information. Yeah, it's. There's now, you know, now it's flooding the airwaves and it is really hard to weed out what, what is and what isn't. Right. Please know that there's, like I said, we're way behind on research and data. Sarah and I know, taking care of people. Right. We, we have certain gold standards of data and how we like to counsel our patients and the confidence we need in certain medications and things like that that they've been run through the gauntlet that we've been taught to use as, as something that gives us confidence so we can treat people safely and effectively, for that matter. Yeah, but. So we're apparently behind. We need to catch up. I think there's, it's a, it's kind of a frontier and it's really exciting right now. I wish we weren't behind.

Yeah.

You know, it's been my whole career kind of fighting, fighting that whole estrogen is bad. I've, I've been fighting it a little on a tangent here, but that's.

No, no, it's great. I didn't even realize just because, like, even in people in my generation, like pre menopausal women are just rethinking the way that they look at the birth control pill. And I didn't really realize that it was an effect of that study. But I mean, there are like, that is just talk in my group of people, of people just wanting for various reasons. But I do think that the talk is good in a sense that it will hopefully push more research and push people to actually find answers to these questions that so many women have.

Exactly. The more noise we make, the more push there'll be to get answers. And we need answers. We need answers all the way through the women's life cycle.

We're way behind, I guess, also just in regards to how things have changed. Just in regards to the overturn of Roe v. Wade. How have you seen either your peers change And I don't exactly know, especially here in Texas, how medical training might be changed. I guess if you want to speak.

A little bit about that, I'm incredibly lucky because I'm in New York City and we're not affected at all. Nothing has changed in my practice or how we treat, how we counsel, any of that. But I know across the country, in Texas and the other states where the laws are incredibly strict, I never in 1 million years thought that I would ever see Roe v. Wade in my. That we would reverse that, that I would. I am still so shocked by it. And I. We're going to see. We're already seeing the, the effects. Right. I. I think we have a maternal mortality issue in this country. Our maternal mortality rate is way too high for, for, for the United States. We're not a third world country. Right. And we. One of the worst mortality.

Can you explain a little bit on that?

Yeah, it. I can. I mean, that's a whole other. That, that would be another podcast, by the way, but. So maternal mortality, just to make sure we're clear on the definitions, is maternal death during pregnancy, during labor and delivery, and then the postpartum period. And it's defined as the first year out of. Of once you have a baby. Right. That's considered. If you, if there's a death of a mother during any of those time periods, it's counted as maternal mortality. And it varies state to state what's the most common cause? Worldwide, the most common cause is maternal hemorrhage. In certain areas, it's actually hypertensive disorders of pregnancy. So preeclampsia and eclampsia postpartum. We have drug overdose, suicide. But we also have an equity issue that there's racial disparity in terms of how patients are treated and listened to. So even though you factor in all of these things, if you look at the racial disparities, it's a really unfortunate statistic, and it's something that we need to. There are big efforts to try to correct that. So I personally am not affected in my practice, which I'm, again, another thing I'm grateful for. But across this country, we're gonna, we're gonna see the fallout in a big way. Yeah.

And even things like challenges with our profession. Yeah. Like ectopic pregnancies that, you know, or just different. Or problems that, you know, there's a lot of legalities where people, you know, they're trying to, you know, treat the problem, but then they're scared. You know, then the treating physician is Afraid that they're going to get in trouble and you know, somehow they're going to go to jail because they're administering this life saving treatment to the mother. And it's a lot of, you know, nebulous the way the laws are, are very, it's very confusing and so it's really, it's scary. And you know, from what I understand, I think it's really going to hurt the ob GYN residency programs in certain states that you know, when people do their residency they're not going to choose certain states. And so that's, I mean that's, then that's going to of course make that problem so much worse. Right. We won't have trained OB GYNs in certain states and it's.

Lose, it's a lose lose. Right, yeah. They won't train in your state, they won't stay in the state to practice and there's already a shortage. You know, we have medical big swaths of the country where there are no hospitals and no practicing OBGYNs. It's happening with Nevadas, one of them, you know, you hear about these things where they're leaving the Idaho is another one where they've left, they let, they've left the state. So we're going to see a lot more problems with that.

I guess just ending on a positive note. Like just. Do you want to speak a little bit about like how you seem like you are able to enjoy life a little bit?

Yeah, no, definitely. No, of course. Yeah, no, no, no. And again my day when I'm in the office and I'm seeing patients is really intense. And again this is, this is the insurance based version. Right. The fact that, and some of this is I'm based in New York City. So our overhead to your point, Sarah. Right. Knowing, understanding the business aspect of things, we have high rent and you know, we're in a downtown New York City. Right. So the rent that I pay here versus what you would pay in my hometown, Winfield, Kansas is drastically different. So my overhead is an issue. We're an insurance based practice here in New York City and there's just a certain reality with how much they reimburse. And so you know, in order to make ends meet you have to, you have to see a lot of patients and, and that, that is challenging particularly because I've moved into more the menopause space and those women need more time, they have more medical issues. They are, you know, going through a lot perimenopause, menopause. It's a challenging time and you know, I really wish I had a lot more time with them to spend, but I don't. So that's, that's frustrating. It's frustrating for me. It's frustrating the patient. By the end of the day it gets a little, it gets a little tiresome. But Stephanie, I've, you know, I've grown my practice nicely. So the key is to have a good team and you know, when you're gone, hopefully people are covering. And so that's been the most amazing change is that to build. It's a mature practice now. It was not for years, it took a long time, but once we got to that point, that's been amazing. So if somebody else goes on vacation, we cover. And if I go, you know, I get some decent coverage. I know things are, that they're holding down the fort and things are getting done and people are being taken care of. Right. And that's all based on, you know, who you hire. And I have a really amazing team. I'm really proud of this. It built to the mature, I've built it to the mature practice. We, I guess should say that built this to a mature practice. And it just turns out we're all, we're all women and all mothers. So in terms of, you know, that, that's, we built it to the point where my younger associates, if they have a function at their kids school, they're not going to miss it. Right. There's always somebody there to cover so they, they can just rearrange their schedule. The other thing is that people get home for dinner. They absolutely have that option to, to in their schedule as to, to make sure everybody's home for dinner. We've just set it up that way and I'm, I'm really proud of that fact. So I feel like the people that came up behind me have had that incredible benefit. So I'm really proud that we built it to that point. So yes, I get to enjoy life. No question.

Yeah. Just say any words of wisdom for Stephanie or any listeners or any parting thoughts on medicine. Ob Gyne.

Yeah. Well, you know, I think some people go in, you know, depending on what they did in terms of internships or, or shadowing people or family influence or whatever it is. Right. Watching ER. No. ER that dates me. Oh, some of the doctor shows. Anatomy. Yes, that's the one I'm thinking of. McDreamy. Yeah. I mean whatever it is that influences you. Right. I think your approach is the right one. Going in and just being open minded. You will be so surprised. You will have certain views of what anesthesia is going to be like. And then you get in there, right, and you're actually hands on patients and, and realizing, you know, a little bit more what the day to day and the minute by minute is and you'll be surprised by things. And I think it is important to keep an open mind because you never know what's going to really, you know, get you excited and what you kind of have to, you do kind of have to love whatever it is because the residency is a slog. It's hard. But I love the open mind approach. I think that's really.

Helpful keep you for any longer. But thank you so much for chatting with us. This was awesome.

And thanks for such a great guest. Yes, this has been great.

And our first, first guest.

I don't know, I don't know if anybody else is going to be able to live.

I know, I know.

This has been awesome. Yeah, you guys are so, you guys are adorable. I think this is, I love this idea. I just think it's amazing. I think it's going to be great information for people and I just, you know, wish you all the luck. Let me know. You know, I, I can't wait to, you know, see what else you, what else you come up with. Awesome, you guys, it's great to see you. Thank you. Thank you so much again.

Take care.

Bye. Take care, you guys.

Bye.

Bye.