13. Giselle Aerni, MD - Part II of II: Strength Training for Females, Perinatal Exercise & REDS

Hello everyone, I'm Dr. Darsha Shah, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined, a podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in health care. Panacea Financial provides banking for doctors because it was founded by doctors. They have nationwide loan, checking and saving options designed specifically for doctors and doctors in training. They're specialized suite of financial products give medical students, residents, and practicing physicians greater freedom to forge their futures and at affordable rates. By reducing financial barriers and burdens, panacea financial ensures that all doctors have increased capacity to serve their patients and the population at large. Do you need a good home for your banking needs? Go to panaceafinancial.com. That is panaceafinancial.com to get started. Panacea Financial is a division of primus member FDIC. Alright guys, it's time to get into part two of our discussion with Dr. Giselle Ernie. If you haven't heard part one, I highly suggest you go back to last week's episode because it was super powerful, inspiring, motivating. This week we talk about relative energy deficiency in sport, also previously known as the female athlete triad. We then go into strength training for women and training during the various phases of the menstrual cycle. We next touch into the barriers to exercise. What are the social disparities? What are the solutions that we can make us staple into our routine? What about pregnant women? How can they shape their exercise plans? Lastly, we touch on her courses and master classes for young female physicians. Dr. Ernie actually just launched one right now called Crush Your Imposter Syndrome. Guys, sit back, get ready to be inspired and motivated because this is going to be a good one. Speaking of doing amazing things, Dr. Ernie, we'd be remiss if we didn't talk a little bit more about exercise and sports and female health, especially with your expertise you talked about. You've been a member of three national championship, right? That's the three national. Did I get that right? We're all through three of those, division one, by the way. Two division one and one division three. Which one of those were you and athlete or physician? None of the above. None of the above. I was the team physician for all three. Hey, listen, you're the one keeping the athlete's healthy, so that's almost even more important, right? Right. Totally me. I did all the work. I completely earned those worries. Definitely. Then, of course, you've been a program director multiple times, so you definitely have expertise in this regard. What I'd love to talk about is particularly this endemic, if you will, that we've had, for instance, athletes, ACL injuries are still on the right. We know that particularly because the female anatomy and the biomechanics that females are possibly a little bit more predisposed to that specific injury. And for those who don't know, ACL is one of the cruciate ligaments. It's pretty much, that's one of the most important ligament in the knee if you want to be an athlete, you want to cut and you want to pivot and you do everything that makes you a good athlete. And so women are, you'll tell me what the stats are, are much more likely to have that injury. And this is one of the reasons there's been a push to do multiple sports in your teenage years and high school and stuff like that, so you're doing cross training and working different muscles. And actually, I remember listening to a podcast with Dr. Nick Denoubli, his Dr. Nick, he's kind of closer to, he's in the PA region, outside of Philadelphia, I'm talking about on the Ready Stay podcast with Kelly Starat that, you know, he's an orthopedic surgeon and he was talking about how 20, 30 years ago when he was doing surgeries, you know, how when they're doing, putting the tunnel and the new graft, he would start with his hand and then have to switch to like the, the drill to be able to put that tunnel in, but over the last couple of years, he's noticed that he can do the entire tunnel with his hand. And that speaks to the integrity of the bones, right, that they're getting weaker, that a man can just push, or just a physician can push through his, with his hand. So you've spoken about reds before. So maybe if you could talk about what, well, first of all, I'm curious to hear your thoughts about that specific thing. I know you're not a surgeon. And then maybe you could tie that into reds, what reds is and, you know, and like, what are we doing about it? Yeah, sure. So women are about two to eight times more likely to tear their ACL than a male athlete. If you look at just numbers of ACLs, men have more ACL tears than women, but that's just because more men play sports. But if you look at it per gender, women have a higher rate of ACL tear, higher risk than the men do. And so, and part of it, like you said, is the anatomy as women. So, you know, about until puberty, the male female body looks fairly similar, aligned the same way, alignment is similar. But then as women go through puberty, then we start to develop like hips, right? And like as our hips are wide and then our knees go in, so you almost like knock knee, the little, little valgus there, that puts a greater strain across the ACL. So some of it is just anatomy, just the way that you're lined up makes you at a higher risk of tearing your ACL. Some of it is also like your slope, your tibial slope, it can be the femoral notch, which you're talking about trying to like get through that tunnel, the size of that, the actual just size of your ACL is going to be smaller. There is some work looking at, you know, menstrual cycle, hormones, estrogen causing more laxity, you know, during certain times of your cycle for your ACL. So, some of it is like we can't change that, right? Like your cue angle, the slope, you know, the angle that your knees knock in, that's just how you are, that's not modifiable. There are modifiable factors, you know, a lot of women are quad dominant, which means our ratio of strength from our quadriceps, the thigh, front thigh muscles to our hamstrings, the back thigh muscles, women tend to be much more quad dominant, so that's much stronger in the front than the back. Hamstrings are part of a support mechanism to the ACL because they're also sort of preventing the mechanism that would tear your ACL from happening. So if you have weak hamstrings compared to your quads, then you're not getting that muscular support. It's preventable, right? That's something you could fix and address. And another thing is just things like your proprioception control, your neuromuscular, your balance. And so we do have some good injury prevention programming that has some evidence behind it that is beneficial and can decrease your risk. One of my guests, Julie Hubbard, she's a physical therapist. She was a matamathlete guest number seven. She's a former Yukon athlete. She has torn her ACL four times. And this is where she has focused her research and her work, her practice. She has a site just for kicks Boston. There's a lot, she puts a lot of information there, which is great, like a lot of scientific information, a lot of breakdown about what happens, how to rehab, how to prehab, how to try to prevent these things from happening. So this is a huge issue for women. And because that ligament is so important, if you blow that ligament, if you blow your knee, that's usually what they're talking about, you tore your ACL. You're out for nine months, you're out for a year. So that's a year you're not participating in sports, you're not being part of a team, you're not getting to have that identity of being an athlete. And you're more likely to do it again. And so for Julie to have torn four ACLs, I actually know several women who have torn four ACLs. And it's because they're athletes who want to keep participating in their sport and keep working. And they keep trying. But once you've torn one, you're more likely to tear another one, whether it's the same or the opposite side knee. And so really it just takes a huge chunk of your life to have to deal with rehabbing one of these injuries and not getting to participate in sport. And you talked about potentially bone density being an issue. And so for reds, relative energy deficiency in sport, this used to be called the triad, the female athlete triad. And this was not having excellent bone density, not having regular periods, and not having enough energy or nutrition. And so that was the three components of the triad. And really it starts from the nutrition, your energy balance. If you're not getting enough fuel in for all the work that you're doing, your body's in an energy deficit. When your body's in an energy deficit as a woman, you're like, well, you know what? I don't have enough fuel to just do the exercise she wants me to do. So let's go ahead and not make a baby right now because growing a fetus right now, that's going to take a lot of energy. So let's just shut that whole system down. So then you start having a regular periods, maybe you stop getting your period altogether. And then part of both the period hormones as well as just the energy deficiency can affect your bone health. So then you maybe get weak bones. You're more likely to have shin splints, stress fractures, just straight up fractures. So that was the original kind of triad. And more recently, in the last, I don't know, maybe seven years now, maybe not as recent. This kind of new term has been coined relative energy deficiency in sport with the idea being that the primary issue has always been the energy mismatch and not having enough energy or fuel. And that yes, it can affect periods, yes, it can affect bone health, but it can also affect a lot of other systems, which, and it can also happen in men. So I would have male, typically like a cross country runner, an athlete whose sport is traditionally a thin sport where the ideal body type people would consider to be like a thin athlete that have tons of stress fractures. And no, they don't have periods, and they're not ever going to have a period, right? Like I can't count that as part of like what's going on with them, but they clearly still have the same kind of syndrome. So more and more people are just using this relative energy deficiency in sport. And that's really, I don't know, that's a great question. I don't know if they have done a look to compare bone density ACL correlations to say are the female athletes who are tearing their ACLs also necessarily having the relative energy deficiency in sport, are they also having that kind of bone density problems? That's a really great question. I don't know the research. If any has been done on that, if it has, I just don't know it. Sounds like a great project if any medical students want to contact us and we can start something with you, Dr. Arnie. Yeah. And in terms of, to your point about reds and taking away the female athlete, try it. If everything we've talked about thus far about not, you know, making a gender specific, right? And not biasing it towards one gender, either for the better or worse, reds, you know, eliminates that potentially sexist component of it as well. But I will say to that, though, I am going to speak about that is that this was the few athletes that tried the triad is one of the first sets of research that was done in women athletes ever, right? Like, so we talk about within medicine, women are never the participants, right? They're never the research trial people, right? Oh, no, they might get pregnant, so we can't give them the drugs. Women are frails, so we can't use them. But that means our science is not based on women. And so you can't just, we're not tiny men, you can't just extrapolate out. And so there's always been a deficit in the research field for women, for people of color, for minority groups, children, people with disabilities, they're excluded from the research that we can't always say that are they, is the science that we have? Does it apply to them? And so even, so yes, I think a lot of people argue, oh, reds is better, it's not sexist because it's including the men like, oh, this reverse racism against men, right? The triad was one of the first things studied in female athletes specifically to try to understand, like women athletes, what are they going through? What are their health risks? What are their health conditions? So I agree with the reds from, that's where we're moving and that's totally fine. But I have a lot of love for the triad and historically as being like, we care about our women athletes, we're trying to figure out what's going on with them. We see this so much more in women than in in males athletes. So yes, we're moving on towards reds, but I got to give my little love to the triad. Yeah, no, I couldn't agree more. I mean, this is one of the things that, you know, as somebody who recently got, you know, bit by the research bug, what I'll say is the front of the first thing that we look at it, you know, is this, when you look at a research study, is this applicable to my population, right? And if it's going to be just, you know, 20 to 23 year old collegiate volunteers who are ready to take any supplement or nutrition or whatever and like that or pharmaceutical or exercise regimen and you're training, you know, the elderly population, geriatric population, it doesn't work for you, right? And this is why the concept of precision and medicine, Darshan, I talk about all the time is, yeah, you, you practice a research, you know, evidence informed medicine, right? And this is just another topic in itself entirely, but this, this helps what you're talking about, you know, expanding the population, the gender, all, all colors, races, everything like that. So yeah, I definitely agree with that and thank you for pointing that out. And I'll say, yeah, the Julie Herbert podcast, that one really shocked me for ACLs. And I was actually recently up in the Boston area and I was visiting my coaches up there and I found out because at the time she was working it, I think it was like athlete, I want to say evolution or revolution. Yeah, that sounds right. But now actually Dars, she's at, she's based out of Eric Cressy's gym, so she's a physical therapist and Eric Cressy is like basically a role model for both Darshan and we follow a lot of his work as well. So next time I'm up in that region and hopefully I will be soon again, I got a, maybe you can introduce us because I love to cut me to her as well. You mentioned that hormonal differences, particularly for, you know, ligament, dyslexia and stuff for that. Could you talk about specifically, like, you know, which hormones you were talking about and just because, you know, some people might not understand the differences and how that makes the ligaments lax and the athletes more susceptible to injury? Yeah. So it's looking at sort of the different, you know, estrogen as a, as a male, your testosterone dominant, right? As a woman, you've got estrogen, progesterone, floating around, doing these things. There's been some interesting research. It's something that we don't know enough about to be honest. And so recently in the last two or three years, there's been a lot of position statements that are almost calls to action to say, hey, we should be considering menstrual cycle when we're doing our research, when we're doing, especially within the sports and exercise science realm to say, is there a difference between injury rates? Is there a difference between, you know, exercise performance capacity based on where you are in your menstrual cycle? Because we do know that, you know, potentially, like, could you have more ligamentous laxity? What kind of things can happen when you're estrogen dominant, when you're in your, like, higher estrogen cycle? And so one recent review article I like wrote it down, so I wouldn't forget, but it just came out last year. It was with McNulty. She does a lot of female athlete work. And it was looking at the effect of the menstrual cycle phase on exercise performance and humanery equipment. So women who just like are regularly having a normal monthly cycle. And they found that the exercise performance maybe, like, trivially, like barely was a little bit decrease in the early follicular phase, so like the first days of your period. And maybe your exercise performance was, like, a littlest bit decrease at that time. Another study did a similar look, taking at women who are humanoreal, having a normal monthly cycle, who were on the pill and not on the pill, to see, did they have any differences in their VO2 max, so they were looking more at their aerobic capacity. And they found that there was no actual difference in their aerobic capacity, their VO2 max, their submax, they did both. But interestingly, for the women who are not on the pill, they had a higher rate of perceived exertion in, I want to get it right, the medleudial phase. So the between your ovulation and your next period, they had, is that right? No, the other way around, mid follicular, they had a higher rate of perceived exertion than medleudial. So their performance was the same, but it felt a little bit worse when they were in that kind of mid follicular stage. But at the same time in 2020, we had like four different articles come out that were position statements to say, we don't have enough research about this, and we need to start doing this and to start taking that into consideration. So I think there's, there's a lot of room for growth in that field to kind of look into that right now and trying to see sort of what correlations are there. Are there correlations? Is this something that we need to worry about? You know, I don't know that you're going to tell an elite athlete to go ahead and not train for a week every month, right? Like that's not going to happen. But and we don't even have enough evidence right now to say, well, don't do any cutting drills, like maybe don't do any jumping explosive drills during this time. I think even if you found a difference, I would just imagine it would have to be such a strong, overwhelming impact to tell an elite athlete to just don't even bother taking this minuscule risk and not train for one out of four weeks. So yeah. So speaking about hormones, right, how do we, so as somebody on social media, a lot of people reach out to me about, you know, what are the best workouts I can do? How do I get stronger? How do I lose weight? And more often than not, they're actually more females that reach out to me than men. So, you know, how do we break these myths that for if you're a woman and you're training, you're going to get bulky, right? When you, when you bring up hamstrings and that being protective, I think of Beth Lewis. I'm not sure if you follow Beth Lewis, you know, for those that don't know, she does functional range conditioning. And so she's really about packing on muscle without really influencing the joints and also using the neuromuscular stabilization that we have in her body. And she always talks about hamstrings, hamstrings, hamstrings. So first off, I guess I'll just ask you, how do we bust those myths? You know, it's, it's tough and it just takes a lot of education. I think this is a holdover from like way back in the day where women are fragile and, you know, they need to be kept slender, right? Like as a woman, your goal is to be as tiny and insignificant and quiet as possible. And that makes you the ideal woman. And if you trained and got these big bulky muscles, well, you would just be a freak, right? But first of all, you won't be a freak. You'll be like serenoliums, the goat, right? Like you'll be amazing if you get incredible muscles. But I mean, the huge difference hormonally is that women don't have the testosterone levels that men do. And testosterone is what allows for true muscle bulk and muscle growth. So if you're a woman and you're not taking testosterone supplementations, if you're not taking steroids, you're not going to get that massive muscular bulk. You will get muscles, you will get some tone and definition. If you're not losing the like fat, because as women, we also have a higher body fat percentage content. If you're not losing that, you might look a little bit more swollen because you have like a softer padding outside your muscles, but like you're not getting this like huge muscle Arnold Schwarzenegger, it's just not physiologically possible. You know, women will have a different testosterone range naturally, and there's like a nice little bell curve. And some people fall farther out of the bell curve. Like you're going to have Caster Semenya, who is woman who has a very high natural testosterone level. I think that's part of, you know, that's a whole side conversation. But as an athlete, you have your like genetic inborn benefits, potentially that make you go to your sport, and then you have your training, right? Like if you don't train, just the fact that you're six, five doesn't make you a great basketball player, you know, if you are five foot, you could train a lot and still maybe not get to play WMBA. But yeah, so for the muscles, for the book, it's testosterone. If you don't have it, if you're not taking it, that's just not going to be a problem for you. Yeah, and then I do want to ask, so I went to North Bend High School. I don't know if you might have heard of it, you know, it's a pretty big sports school here in Pennsylvania. And so I've always noticed that the men, you know, in high school would also hit the weight room more than the women would. And for you being a sports medicine physician at the collegiate level, are you seeing that these women, it's their first time really lifting weights and training outside of just playing their sport when they go to college, because I'm not seeing that with guys, right? They're going, they're, they're training in high school. They're a little bit more prepared for what sports specific drills they might need to do later on. Yeah, that was for sure. That was me in college. I had not lifted. I did Taekwondo. So I grew up I played soccer, basketball, softball, like when I was little and then high school was all Taekwondo. And then in college was the cross and that was the first time that we had, like, here's the weight room and we're expecting you to do this thing. And, you know, at a small D3 school, we had one strength and conditioning coach, Cory Gough. I still remember him and he was like, here's how you do squats. Like, here's how you work out and you'd get a little like, we got a paper and you would just follow it along at my D1 universities, right? Like they have a team of strength and conditioning coaches. They still don't have enough that they never do, but they have a team. And so, like, one strength and conditioning coach might be in charge of four or five teams instead of one for all the athletes, right? So there's a little more, like, directed, we're going to bring you in, teach you how to do stuff. I think for the D1 athletes, depending, even then because they're at a different level, they might have had, even the women might have had some experience in high school because otherwise they didn't get to be a D1 athlete, right? So they've probably still coming in a little bit ahead. But yeah, I remember that was me coming into college and not really having lifted before. You know, I'd been in gyms. I'd like seen the stuff, but nobody had said, here's really how you do this. Here's proper form. Here's what we're trying to accomplish. And I think it was so helpful. You know, I loved it. I also, I mean, my husband, who we met in college, we started dating, beginning of sophomore year. He lifts. That's his kind of main physical activity is he's a lifter. And so that, I mean, for me, I think I also had this little side bonus of that guy that I was dating, like, that's what he would do. So we'd, like, hot date at the gym. Let's go lift weights. I don't know that everyone does that, but there's nothing better. I had a little more exposure to it than than some women probably. Yeah. And I just, I really quickly just want to plug here in our, in our previous episode with Dr. Arnie, we actually go more in depth about the disparities between men and women that we're seeing at the collegiate level. So really quickly, just wanted to point that out. Yeah. And I'll also add on to that. So Dr. Arnie, in her previous life, I, so I was trying to condition in coach. I'm starting to think it's a specialist and my hope is to kind of help bridge that gap between fitness and medicine, right? That's my true passion. And this is why I love exercises, my favorite thing to talk about, favorite thing to do. Well, my second favorite to do is sleep is my number one favorite thing to do. But, you know, I also put it that is incumbent upon strength coaches and just sports performance coaches to understand those hormonal differences, right? If you're, if you're a coach and you coach members of the opposite sex, which is what 50% of the world, then, then you need to understand what, you know, those phases are, at least have a general understanding of why the athlete might not be responding. As you alluded to, so I look only earlier, it's like, you know, you have these hormonal differences and their, their bodies, I mean, it is a complex phenomenon that we will never be able to appreciate as men, but, you know, how they feel and different, every individual responds differently. I think most people understand this concept of PMS and we have a very, you know, root mentor understanding of it, but beyond that as an athlete, as an active female training, they might not be up for it. And so you also need to be comfortable having that conversation with your female athletes or your clients, if you will. And so, you know, I used to work with, in sports performance coaching at a place called Prissy Speed School. And there we were, we were working with primarily, you know, adolescents and even collegiate athletes and stuff. And so these individuals were very much driven to come and they had incentive, right? They were incentivized to be better at their sport. However, on an separate area, I used to work with just the general adult population who were looking to just be healthier, get fitter. Unfortunately, in my younger days, you know, I never had that conversation. I didn't even consider that. But again, going back to Dr. Kelly Starrett who talked about, you know, you need to appreciate this because as a coach, sometimes we'll push these individuals, I mean, maybe if an athlete's in during their, which phase in their menstrual cycle, their end, or if they're not up to it and you're not even having that conversation, it might not be a great day to do a max effort, whatever exercise, right? Because of susceptibility injury or because, or if the athlete is or your client's not responding well and you're like yelling at them and like, okay, because you think you're trying to motivate them. But maybe, you know, you don't have that rapport with them, but they can say, hey, today's not a good day. I'm actually in this phase and I'm not feeling it, right? I'm going through the hormonal changes. You know, Darshan, I talked about this before is we're so privileged in this profession of medicine where within five minutes of meeting a new person that you've never met in your entire life, you can ask them about their deepest, darkest secrets and it's totally fine. They drop their guard. People other profession has that where it's okay to just share things about, you know, your sexual relationships, your menstrual cycle and stuff like that. It's okay. And so, you know, again, the fact that we're just communicating it here openly on this platform, it just, you know, we need to talk about it and we need to make sure it's okay because it's a normal process. And I want to add on this because I think that's fantastic and you guys talked about like personalize medicine and really like, you need to know that individual and that person. And I think there's so much that we do as physicians where we're not always finding out about that person and their circumstances and what's going on. We're just like, great, you have diabetes, all diabetes acts like this. So I'm going to tell you to do this. And so with things like exercise, you know, I was telling you before I started an exercise as medicine clinic at one of my practices and trying to really focus on great, the other physicians would refer a patient to me if they had diabetes hypertension and obesity. And I would then be able to take the full time of my visit, not manage their medical problem, but to help them create an exercise program and to work with them to create that exercise wellness nutrition piece that will help with their medical problems, but that is also starting from where they are. And I think in one of these conversations, you know, I'm talking to someone and I'm saying great. So even if you just start with like a walk around the block and just like, let's, you know, we're going to start small, make a small actionable smart goal, right? And she was like, it's not, it's not really safe in my neighborhood. And I was like stunned, you know, I never even thought about it. You know, we talk about some of the disparities in sport and sport participation, I never even considered like where you live is not a safe neighborhood to go for a walk. So when I'm telling you to go for a walk, which to me sounds like the most basic, simple starting step you could possibly do, they're like, no, that's not quite safe for me. What else can we do? And a lot of my patients, they don't have a gym membership, they can't afford a gym membership, they can't afford a personal trainer, they, you know, maybe can't even figure out how to navigate YouTube and find some free videos. And so, you know, I'm getting like, I'm showing them how to do squats, like I'm showing them how to do lunges. I'm trying to like show them in this little teeny like four by six room exam room to show them stuff. But asking your patient about what's going on in their life, you know, what's going on with their social situation, their economic situation, that stuff matters when you're trying to encourage them to exercise and eat healthy, right? When you're trying to get them on a sleep routine, but they work two or three jobs because that's what they need to do to get their kids through school. Then I can't sit there and just be like, well, you need eight hours a night, you need to go to bed at the same time every night and wake up at the same time every day because that's just not part of their reality. And so I think, you know, I think a lot of physicians struggle with this because why is my patient not doing what I want them to do? Why are they not getting better? This is so easy. Like sure, it's easy. I have a job. I'm making money. Like I have a house. I have a car. I have a spouse. Like, great. Yeah, it's not too hard for me, right? But that's not always our patient's situation. And so when you're looking at disparities in sport, when you're looking at being able to participate, things like cost matter, things like, do you have a neighborhood park that you can access that is safe matters? Things like, are you somebody who has a disability and your neighborhood park is not wheelchair accessible? That matters. Like is your gym, even if you had the money, if you're somebody who is wheelchair bound, does your gym have workout equipment, modifications, a stair to get in? Like, could you even use that facility? So there's a lot of disparities within health care and especially within the sports and exercise as much as we say, hey, exercise and nutrition, step one for everyone, there's still a lot of barriers that get thrown up for people. So just like you're talking about trying to individualize your strength and conditioning program to a woman and to her cycle or to, you know, wherever she is, it's also to what do you know about this? What equipment do you have? What's your neighborhood like? What is your finances like? What alternatives do you have access to? These are important things to try to, you know, work with your patient to get to know them on that level so that you can kind of tailor your recommendations to them. Dr. Ernie, given that, you know, in today's world of health care, we really only have 15, maybe 30 minutes to talk to a patient, how do you go about asking those questions, right? I feel like, you know, me just being an intern, I don't have the skills that I would need eventually to kind of navigate through maybe the awkwardness. But also, you know, there's a lot of data gathering that we need to do, but we know that implementations, what matters, giving actionable steps, how do you go about that when you talk to patients? So if it's something like exercises medicine, I'm trying to give them an exercise prescription, right? Like, and you can go to the exercises medicine website and they will give you all sorts of information about how to do this, what types of exercise routines for what types of medical conditions. But, you know, I know that I need to start somewhere small for most people. So I ask, you know, what kind of exercise do you do, what kind of physical activity do you do? And usually I get, well, none, or, you know, I run after the kids or I'm, you know, up and around at my job all the time, which we know doesn't add up. It's not 10 minutes of moderate intensity activity in a row. It's not adding up. And so then I'll be like, well, what did you use to do when you were a kid? And I like to kind of ask them, when you were a kid, did you run around? Did you play soccer? Did you climb trees? Like, and I have had people just open up to me about the kind of most amazing stories. And then they're also in this like nostalgic, like, oh, man, you know, I had the best time. And so they're, they're feeling good about exercise. They're just like, oh, yeah, you know, I mean, some of them never have done exercise in their life. But for the ones who have, that's a nice trigger to kind of put their mind immediately into a positive, receptive, I'm feeling good about activity mode. And then, you know, depending on what I'm trying to encourage them to do, whether it's a strengthening program first or a cardio program first or, you know, even a mix, I like to, for folks who are doing nothing, I like to pick one and start there and start small. But then I might instead of trying to just ask them what they want to do because that can be overwhelming, I try to give them a couple options and say, you know, some people like to start off by just walking 10 minutes a day. They like to do it outside if they can because then they get the green space, fresh air. We know those have other benefits for their mental health. Is that something that sounds like you could do? Like, would that be, do you have safe places to walk? Do you have a park nearby? Is that something that you think you could do? You do, okay, great. What time would be good for you to do it? Are you going to do that at your lunch break or are you going to do that at 6 p.m.? Are you going to do it at 7 a.m.? Before you go to work and I try to pin them down on what time are they going to do it? You know, and so I try to give them little baby steps and make that very normalized as like, great, here's a normal step. And then I try to ask them how feasible that is. If I have more time with someone that I'm trying to figure out, like, do you have access to a gym? Do you have a safe neighborhood? What equipment do you have at home? Nothing? Do you have water bottles at home? Do you have cans of beans at home, like what, you know, we can make some stuff happen. But I think if you can get them in a good mindset, so that's my one trick about trying to, like, oh, think back to childhood, life was fun and carefree and I used to be active, then kind of taking it from there, I think is a nice way to kind of quickly get in a more positive, receptive mindset. I absolutely love that. I mean, you take this concept of exercise, which a lot of people sometimes have hesitancy and resistant to order because they look at it as a work, right? Like, I know I need to exercise. I know I need to exercise, whereas I look at, I was like, yes, I get to exercise today, right? Today is my day. I get to live because I love doing that. Still having developed that relationship with, you know, zone two training and cardio, but we'll get there. But and you bring it back to a time where it was play and it was fun for them. And so I absolutely love that. But a lot of what you're talking about is the art of coaching, right? And we've had so many awesome guests come on here and talking about how they're talking about habit coaching. John Brody has this amazing book called Change Maker that was one of the best reads that I have. I highly recommend that for you as well, because I think you'll enjoy it. And we're talking about, you know, how to instill change and not overloading because there are statistics out there to show that if individual, for instance, right, we talk about January 1st, people are like, I'm going to go exercise six days a week and I'm going to go on a keto vegan diet and I'm going to do this and this and this and then four weeks in there and doing none of it, right? And so the more things changes you add onto your plate, the less likely you were to do it. It's supporting that. And to your point about the disparities and, you know, the exercising communities of color, this is actually your conversation with Lisa Carter is the first time I actually considered this, which actually broke my heart in my own sense that Darshan and I are always talking about, you know, we talked about exercise on this multiple times. And we're always just telling people the same thing. Just get up and move. Just get up and move. Just get up. The weather's getting nicer. Let's get nice. And I never in my life, and I've been an advocate for exercise for 20-something years, thought about that. And I was kind of upset at myself, I didn't beat myself up too bad. I'm just going to get better now. And so I'm, I want to thank you for actually bringing that up coincidentally, though just last week, I finished up my sports rotation and last Friday I was doing a procedure on a patient. You know, she had bilateral knee-o-a and we're doing procedure and I was doing it with ultrasound. So I was fumbling a little bit and I was trying to distract the patient and talking about exercise. And she mentioned to me, you know, that now she can walk because in the previous neighborhood that she lived in, wasn't safe. And I actually never had a patient tell me that, but again, to be fair, I never asked a patient that. And I live, you know, and I work in Baltimore and I imagine a lot of patients, you know, share that concern. So, so I just share that story to one, thank you and two, to my physician, my healthcare practitioner colleagues, that hopefully this is something that we'll put into our repertoire of questions when we ask and when we're trying to implement exercise. But there are so many nuances that you've touched on that you have to, there's so many barriers and we try to try, I have to try to prevent that as physicians. And then to the other point, in the era of COVID, where, you know, we as a sports medicine physicians, we physical therapies is our staple, right? A lot of patients don't feel comfortable going to physical therapy. And we need to know principles or rehab and we need to be able to coach them in the clinic. Hey, okay, you don't feel comfortable doing physical therapy and your therapist not offering virtual visits. Well, this is how you can do this exercise. This is how you can do for training. And you need, again, also more than 15, 20 minutes to be able to do all that stuff. But it also all, all, all it all starts with education and education, educating ourselves and our colleagues that how do we even do these things? We can't just make blanket statements saying exercise is good, exercise, walk, eat better. What does that even mean? Yes, so much. And I think, you know, with the disparities a little more, right? I think Leija's episode was eye-opening. I think that, you know, Ahmad Arbery, like, just going for a jog, you can be killed. You can be like hunted down and murdered in the United States. If you're a person of color, just trying to go for a jog. So shoot, I would also not think that exercise is very safe. And that would definitely make me hesitant. And so, you know, trying to figure out what are those barriers to exercise? And it's not necessarily what you think it is, right? As you, the physician who has the finances, who lives in a safe neighborhood, who has access to a gym, right? Like the things that slow you up to exercise may not be the same things that are slowing up your patients and being the barrier. And even, you know, so like another thing we kind of get, where we're talking about is like the gender disparities. And for women, for young girls, they drop out of sports about twice the rate of boys around starting at age 14. It starts a little earlier, but by 14, they're dropping out at about a rate of twice the rate of boys dropping out of sports. And by 17, something like a third to half of women will have stopped their sport altogether and completely dropped it. And there's other science that if you're a woman and you never participated in sports, by the time you're age 10, if you have not participated in a sport, that you are unlikely to ever be physically active, that of all women who didn't participate in a sport by the age of 10, only 10% of those women will be physically active in the future. So like we have a duty to help educate our patients and their parents from the beginning, like from the earliest age, it's important to be figuring out what are these barriers? There's some of those barriers. They're cost. Some of it is the like safety accessibility. If you're a, if you're a girl who's going to the neighborhood park to play wreck basketball and it gets dark out, you're not going anymore. If your parent can't walk you, the boys can still go because, right? Like who's going to get abducted off the playground, right? It's going to be the girl more likely, right? And so it's not as safe. You know, I talked about this with my husband recently, because when you're a woman, if you're going into a parking lot late at night, you're going home from work, you have your eyes on a swivel. You are watching your surroundings. You have your keys in your hand, your phone ready to go. You're not listening to your AirPods. You're like, I need to focus and watch out for who's trying to like come attack me. And my husband has never had to think these thoughts. It's just never crossed his mind. And he also didn't even realize that I was thinking those thoughts and worried and watching where I was in the parking lot and where was I in the garage, you know, as somebody in the garage, did the door come down fast enough? Did somebody sneak underneath? And it's just, it's a different thing when you are a woman. And so if this is something that is going to impact the time, the location, that you as a girl or woman can participate in sports, then that's going to be a real barrier to your ability to be physically active, to be healthy and to be well because you don't have that same safety level at baseline. That's such a good point. And again, going back to the fact that it's difficult for us to appreciate that. As you mentioned earlier, that's not something that we've kind of been taught. And you know, it's kind of put into our minds from a young age, as you grow older. You know, I mentioned again, you know, my wife is a resident. And just a recent story, we're looking for apartments as we're thinking about transitioning to the next year. And, you know, unfortunately, we're going to be living separately because my fellowship is in a different location. And me, you know, my upbringing in Northeast, being in New Jersey, New York area, it's just been a little bit different from Southern California. That's where she's originally from. And just trying to appreciate what she considers, quote unquote, safe versus what I consider safe. It's just completely different. And quite frankly, it's a little frustrating for me. I'm like, this is completely fine. But again, my lens is completely different that I'm looking at it from, right? And it's that earlier standpoint when you're a young girl and you've been taught, no, you can't go, no, you can't go, no, you can't go. It's going to be really hard to break that mold. And so, you know, just having that appreciation is something that I'm so grateful for now. And of course, it's going to be a constant process of refining and making sure that you're having that conversation with your male patients, female patients, you know, and patients of all ages, that that's another consideration you should have if you really want to make substantial change. And do right by the patient. But I want to switch gears a little bit. You earlier talked about how, you know, females are excluded because the, in studies, they might be able to, they might get pregnant. And so, you know, nobody wants to put them because you want to make any pharmacological interventions and such. So that begs a question is one of the things that Darshani, as we talk about when we counsel patients to exercise, is, you know, a vulnerable time in a woman's life is the pregnancy period. It's a very sensitive, very vulnerable time, it's a special time. And often there's this misconception that you shouldn't exercise because it's going to be dangerous for the pregnancy, right? And there's a lot of misinformation out there. So I'd love to hear your thoughts both, you know, as a woman and also as a sports medicine physician, how do you counsel patients about this special time in their life of how should they modify it or can they even start a new exercise resume during this time? Yeah, this is a really important time. And it speaks to a lot of just the history of medicine, the history of just women, where women were considered fragile, right? And if you exercise was too strong, that was for men. That wasn't for women. Women are supposed to be weak and dainty, quiet. They shouldn't exert themselves. They shouldn't sweat. They shouldn't grunt like, you know, they should just be quiet, gentle, things tiny in the background. And the concern back in the day when we did not know any better was, you know, you'll shake the baby loose like, oh, exercise is going to be terrible. And it's just not the case. And it's one of those things where, like you said, within medicine, women have traditionally been excluded from a lot of the research populations so that if you're doing a study for a new drug, no one's going to just sign up pregnant women because there's concern of what will happen to the fetus. And that's a fear concern. But then what happens is that women get excluded altogether. And women are not tiny men. And so how the medicine and science works and men is not necessarily how it's going to work in women. So with exercise, you know, originally it was just don't exercise because that seems like it's dangerous. Your fragile, we don't want to shake the baby loose. And then we, you know, over time, you start to do some studies. You start to just watch women who are like, I don't care, I'm going to exercise anyway. And they actually do really well. And so now we know exercise is fantastic. Exercise in most situations. There's a few in which it's not. So, you know, this is talk to your own doctor, find out whether it's safe for you to exercise. But in most situations, for a healthy woman with a healthy pregnancy, exercise is fantastic. It actually can help your pregnancy. So you can have decreased back pain. You have decreased constipation with exercise. You have decreased risk of gestational diabetes, preoclampsia, C sections. You can potentially recover faster from your pregnancy. You can lose your weight faster after pregnancy if you're somebody who exercises. So there was a while where we said don't exercise at all. We're terrified of this. And then we said, well, I guess if you're somebody who already exercises, you could keep exercising. And now we're at the point where the sports medicine physicians, ACOG, which is the OB-GYN association, agrees like, hey, we have great evidence that exercise is beneficial. And even if you haven't ever exercised, go for it. This is the time to start. For a lot of women, pregnancy, especially, you know, first pregnancy, this is a time of big change. This is the time a lot of women will quit smoking. They'll quit drinking. They will make other healthy habits because they're focused on somebody else, this, you know, future fetus baby situation. And so that can be a great time to harness, they, hey, let's start exercising. Let's start a plan. Even if you never did before, this can be a time of change in which you can get a little motivation. You can get a little hook and you can help a woman start to exercise. Recommendations are the same as a non-pregnant woman. You want to be getting about 150 minutes of moderate intensity exercise every week. You want to be cautious about a few things. You want to be cautious about high temperatures and dehydration. You want to be cautious about altitude. So, you know, this is not the time to climb Everest. If you're somebody who lives on land. And you want to avoid prolonged lying on your back just from pressure, squishing, squishing veins. But for most women who are healthy, if you don't have certain medical conditions, certain conditions with your pregnancy, it's actually beneficial to be exercising and it's a recommended thing. So I think, you know, and I will say, I have never been pregnant. I have no particular plans to be pregnant. But this is something that I have seen with my friends where this is a time that sometimes is like, you know what, I got to get those good habits in gear because I'm gearing up for someone else. I'm gearing up for something else. And so you can really, I think, help your patients take advantage of this and encourage it. And maybe this is the moment that you're patient who never exercise, who's not used to this. Maybe this is the thing that will finally get them into this new habit of physical activity. Yeah, Dr. Arnie, I really love what you said there about, you know, this might being that time, right? Especially during a daunting period. And I look back in my medical education and oftentimes I feel like this population, right? The pregnant population is sometimes skipped over. I mean, sure you're gonna learn about it, you know, during an OB-GYN block or something, but mixing the two really exercise and physical activity with pregnancy is not something that, you know, we truly learn. But as an osteopathic doctor, ultimately I, you know, there are certain OMM that we learn, right? And one of those is, you know, rolling the back so that you can get rid of the SI pain or, you know, if you can hold the belly up to get rid of that round ligament pain. And you know, I've done this with some patients, I've done this with family members and it feels amazing, right? And I really honestly look forward as I become a physiatrist working with this population because I wanna be someone who can make this daunting time, obviously, you know, less stressful. And just like you said, you know, this could be that spark, you know, in pregnancy, in a vulnerable time, to show them the life that, hey, physical exercise can be something great, even when you, you know, are going through all these emotions and a stressful time. Absolutely, I think it's so important. And when you have the ability to help out in that way as a physician, right? Like what a great thing to really be able to relieve pain, make things easier, you know, give them some alternatives to, you know, maybe when they're getting really heavy, maybe they start in like a aquatic program because that takes the weight off and the pressure off. Like you said, just taking the weight off the belly, talking about using pelvic belt straps like to help hold pelvis together because your ligaments are getting loose around purpose. You're trying to like open that whole pelvis, get a baby out there so you want things loose. But, you know, when you're exercising, you can overstretch, you can, you know, potentially be at risk of injuring yourself from your increased flexibility. And you got to watch your balance, right? Now you've got this baby hanging out there. And so the further along you go, your balance is shifting day by day, your center of gravity is changing. So, you know, thanks to watch out for it, but at the same time practicing your balance is fantastic for you. Like that's a good thing that everybody should be doing. You do it when you're a kid, when you're always walking on the fence and you're trying to like balance on every single thing you walk across and when you get older, you stop doing that. But, you know, it's a great time to make a difference. So, I think it's wonderful, especially with you guys having your skills of the OMM to be able to help in such a specific clear way when they come in with some issues. So, definitely. Absolutely. And what I'll add onto that is you earlier mentioned in terms of blood pressure regulation, you know, and a lot of other medical things aside from the musculoskeletal stuff that it's beneficial for, there is literature, we have enough data to support that. Obviously, you know, gestational diabetes is a very real thing. And, you know, glucose alterations or impregnancy can affect the fetus and then later on in life for that child to be pretty supposed to diabetes that are much earlier on. So, from that standpoint as well, as you mentioned, you know, now your body's gearing up, not only are you gearing up and take care of yourself and yourself after, you know, in the postpartum period, but also this little human that you're going to carry for nine months and then be responsible for 18 years, but really forever because when this parenting stops, right? So, yeah, I mean, there are so many benefits to it that, you know, I would encourage obviously patients, but again, not giving any medical advice, it definitely speaks to their position, but also our colleagues, because I think that we're just, as our mentioned, these two specific things together is not something we learn about, not even in an OB-GYN rotation. It's not something that I talked about, and I'm willing to bet that a lot, not a lot of people have gotten that education. And, you know, this is where social media is really awesome, right? I want to give a shout out to Ben Bruno. He's a trainer from Down in Southern California and he really publicized his training with Kate Upton a lot. And even during her pregnancy, all the way when she was like eight, nine months pregnant, like she was doing hip thrust, she's doing goblet squat variations, all kind of cool things, and that really empowers people. Hey, she's doing strength training, she's doing these bad ass things so can I. Another person, Molly Galebrett, she just wrote up, she's awesome on Instagram and social media, and she just came out with this book called Strong Women Lift Each Other Up, another bad ass woman, and she's doing all these things about, you know, very women-specific thing, and that's why I love. So on that note, I'll ask you, you mentioned 150 minutes per week, right? No different than it would be for a non-pregnant female. Is that a combination of cardiovascular exercise, and, or is that plus, including strength training, because again, going back to that strength training concept, I mean, now we're mixing two scary propositions together. So what are your thoughts? Yes, this is a great question. So I will first just hand you to a resource, exercises medicine, ACSM, this is like one of their babies, it's fantastic. There's resources for physicians, things that you can hand out to your patients, and it takes a look at specific medical conditions, as well as just general health to say, hey, if you are somebody who has diabetes, here is the very specific concrete exercise recommendation that you should be doing, and it basically is trying to give you a prescription that you can give your patients. So just like you're giving them insulin, you're gonna give them a prescription that is saying, I the doctor am telling you that you should be doing 150 minutes of moderate intensity exercise per week. And so with that generic term, the 150 moderate, so it is cardio exercise, so that's a great question. And that is specifically referring to the aerobic exercise. You can break it up, right? So you don't have to get, well, first of all, it would be ridiculous to get 150 minutes one day and no exercise the other six days a week. So this is usually we talk about it as 30 minutes a day, most days a week, but you can actually get it as increments as small as 10 minutes. So often when I'm counseling my patients, I'm saying, look, if you get out for 10 minutes, that counts, you don't have to do all 30. Maybe you've done none, but 10 minutes counts. This is also part of why when I have patients tell me, well, I'm up all the time. I'm running after my kids, you know, I'm busy all the time. Though if those 10 minutes are not in a row, they don't actually count towards the health benefit. I always tell them it's still good. It's still great that they're up, they're active, they're using their muscles. But if it's not 10 minutes in a row, it doesn't count towards the health benefits. So anyway, so the 150 is the aerobic and then the recommendation for general health is basically two strength training programs per week, where you're hitting all like eight to 10 muscle groups and you're doing somewhere in that like two sets of eight to 10 reps of each major muscle group. So that is an addition to the 150. There's also recommendations that you should be stretching and you should be practicing your balance. There's not as like clear cut, do this for your stretching, but those are just also important parts of having a healthy body to whatever you can do and use. These are the sort of four recommendations, but the key ones we always focus on are the aerobic and then the strength training. My favorite part about all that, that prescription when you're ready to go to the pad, there's no copay, right? Insurance covers it, all insurance, Medicare, everything like that. Nothing to worry about, that's the best part. Yes, and this is where you get creative and you have a lot of fun. Your patients who are like, I don't, we talked before about what are the barriers cost? I don't have a gym, I can't afford a gym membership. That's great. Can you do a squat? Can you do a weight bearing squat? Can you do a lunge? Could you hold a gallon of milk? Could you hold a gallon of water? So your milk doesn't get bad under the fridge, but there's so many things that you can use at home. And this is when I'm in a patient setting in the clinic, I'm like doing a plank on the ground. I will like get on the floor of the exam room and show them what I'm talking about, because I don't always have the ability to send them to a physical therapist or an athletic trainer or an exercise physiologist. I would love to. I worked at my last position on starting an exercise in medicine clinic and bringing in an exercise physiologist. So after I saw the patient and figured out their medical conditions, figured out their specific exercise prescription, I could hand them off to an exercise physiologist who could then lead them through a program and do some of that mindset work, do some of that goal setting, that motivational work and then build them a program. And I think the other thing I'd think about with these prescriptions is that, you know, I sort of already mentioned, sometimes you have to start small. And if I tell a patient, hey, 150 minutes a week, lift twice a week, balance flexibility, go. If they are starting at zero, that is far, far too much. And so when I'm working with a patient to figure out an exercise routine for them, it's figuring out what are their goals? It's figuring out what are their medical conditions that are of the highest priority right now. You know, if they have arthritis, it might be that I'm working on the strength and conditioning first because I'm working on their muscles around their, you know, knees, if it's knee arthritis before I'm starting to add in cardio. If they have heart diabetes obesity, then it may be that I'm adding and trying to get the cardio going before I start adding and strength training. So you got to meet your patient where they're at, but that includes their safety, their cost, what facilities they have, what equipment they can use and what things you can maghiver and Jerry Rigger. Something you said there really stands out to me and reminds me of this time when I was an enthusiastic 30-year medical student, you know, trying to prescribe exercise in my internal medicine clinic as my technique was like, go take your time, don't worry about anything. You know, I've been training for 20 years, been an athlete in my whole life. And so if you're training to me, it's just as natural as it can be, right? It's not really a barrier, the exercise I understand it, I understand it with the difference between soreness and painness and discomfort and all that kind of stuff. I remember talking to this patient about exercise and the patient was buying in, they were interested in weight loss and those kinds of things. And I told him to go to the gym, you know, put the treadmill at like a 10% incline and then run on it and run on it for 20 minutes. Now to me, that was very, very, very easy, right? It was a basic workout. But the patient just looked at me like I had six heads. And I was just confused. And then he said, Doc, I can't do that. And I was just, I was so taken back in that moment. I was a little embarrassed too, because I never, to your point, never met the patient where they are. I never assessed, I just guessed, right? And maybe I lost that patient because now they were like, oh, this guy has expectations. So I mean, I was a rotation, so I didn't necessarily follow up. But I was really humbled in that moment is that, you know, to your point earlier, as you know, we can't just tell them that why aren't these patients listening to us? Why is the patient not being compliant? I'm telling them to do the exercise. I'm telling them they need to lose weight. I'm telling them to stop smoking. They're not doing it and it's killing them. You know, maybe you got to look in the mirror and say, what could I be doing better for this patient? So I just wanted to share that because that wouldn't hit home with me. Yeah, you know, I think oftentimes as physicians, right? We just, when we need to prescribe or when we need to give advice, we only think of what it's like in our shoes, yeah? Like it's tough to, and again, it's, I think this is the theme of our conversation, right? Is understanding what their life is, right? Is it safe? Do they have the equipment that they need? How, you know, can we meet them halfway? You talk about 150 minutes, and I'm all about, you know, like you said, breaking it down, time management. I could probably honestly do 100 minutes every day, but am I gonna tell a patient to do that? No way, and you know, I 150 minutes is overwhelming, but you break that down into 10, 15 minute sessions. Well, there you go, right? So I just, this has been honestly a phenomenal discussion and conversation. You know, you talked about programming and making courses. So I kind of wanted to transition to that because I know you have something brewing here as far as courses. Can you touch on that a little bit? Yeah, sure. So one of the things that, you know, I've got my podcast, Madam Athlete, where I interview women working in sports and athletics. And in my brain, that is like step one to what I'm building with Madam Athlete. That's the inspiration piece because hearing another woman, hearing about her career, her journey, her challenges, her triumphs, getting to hear what advice she has for other women, that's inspiring to me. You know, the women that I have had the opportunity to talk with on this podcast have all just blown my mind. They're incredible. They are wonderful human beings. And they have not always had this straight line journey in their career. There's been twists and turns. There's been failures. There's been setbacks. There's been things that have just changed. And so they're at this like amazing place now, which is, you know, I'm interviewing them. They're at an amazing place. But I'm specifically getting into what was this whole journey like? And the more you hear what these other women have been through and what they've done and what they've accomplished, even with whatever challenges they've had, it's, to me, it's just been so inspiring. And so I think that's like my starting place. And then this next piece that I'm hoping to build with Madam Athlete is to create content, courses, resources that are the empowerment piece to empower women, working in sports and athletics to take ownership of their career, to feel like they can craft their own identity. They can brand themselves. They can have the mental mindset to handle perfectionism and imposter syndrome and all these things that typically women deal with more than men. Both genders can have these issues, but that often plague women in their careers. And you know, obviously we have so much evidence about gender discrimination and differences in careers. So we have the gender pay day, like pay equality day, which is when white women start making the same as men. But if you keep going further out and you look at black women, native women, Hispanic women, Asian women, like it just goes down the line. And so even things as simple as that, but we also know that when you negotiate for yourself, it's different for a woman than it is for a man. And it's expected of men. And it is, you know, that doesn't maybe make it easier for a man to negotiate for his own pay raise, but it's expected and there's no negative consequences. When a woman negotiates for herself or stands up for the things that she needs, she's seen as being like needy and not a team player and why isn't she being nice? Why isn't she just like playing along with everyone? Because the role of women is to be subservient and to serve others. And so when she's standing up for herself, it's like, whoa, what is this? So there's different ways to go about this. Knowing kind of the cultural issues that we have and figuring out how to your bans yourself. So, you know, got the podcast. It's going. It's fantastic. I'm loving it. And this next phase I'm hoping to start creating courses so women can learn some of these skills. Be also with a group of other women. The same thing when you have that community, I think it is so strong to hear other women going through the same things to go, hey, this happened to me. How did you handle it? Did this ever happen to you? I have a few resources on the website that I've already created. I have a goals mini challenge. It's free challenge, but just learning how to set goals in a way that is science-backed evidence-based to help you be more productive. That's matamathlete.com slash goals. And then I also have one on perfectionism. It's just a free handout about three exercises that you can do when you are struggling with perfectionism and that fear of failure is stopping you from moving forward. So that's matamathlete.com slash perfectionism. Feel free to check them out. I'm going to hopefully keep adding to the list, but I'm starting work on that stage as the next phase of my matamathlete entrepreneurial journey. That all sounds absolutely awesome. And we are definitely going to link all that in the show notes. And hopefully people will check that out as soon as it come out because I know there's going to be a line and it's going to sell a quick. But listen to your podcast, Dr. Arnie, and have this conversation with you today. I know you're targeting primarily women and badass women, but you know, of course, Darshan and inspired as well. So the million dollar question is, and especially when talking about issues like perfectionism and imposter syndrome, it sounds like it's going to be an angle specific towards women, but they're not unique, right? These issues aren't exclusive to women. So the million dollar question is, is can individuals like us with a Y chromosome is that something we'll be able to capitalize on or is it only going to be for females? We will tolerate the Y chromosomes. You may feel free to use my resources. Listen to my podcast. I think, you know, this is something where having the representation from other points of view and even just hearing how they perceive things sometimes you learn so much out of this. So in your social media, are you following people specifically who don't look like you on purpose, right? And you know, I think we were talking about this earlier when we looked at following sports, right? And I heard about this basketball foul immediately because I follow like six female journalists, sports journalists. And so I heard about it right away. And so for this for my courses, yes, please come on in, see what you like, take what you want. I think that part of what I discussed though is how things are a little bit different for women, right? And some of that is that cultural perception. Some of that is the challenges we face, the patriarchy. And so when a woman has imposter syndrome, it's also because society and patriarchy has gone ahead and told her that she will never be good enough. She's not going to get the CEO position. She's not going to be voted in as president. She is not going to get the same salary. And those are outside external forces that recreate and reinforce that imposter syndrome. And so you're hearing this externally all the time as a woman. Whether you're having imposter syndrome as a woman or a man, you still struggle with it. The exercises will still help you. But for me, I try to get into a little bit where it's appropriate to say, you know, here's what's going on that you're dealing with and what you're up against. And sometimes that's a matter of how do you approach things a little bit differently, knowing these situations and discriminations are at play. So when you are going for a promotion, if you are going to try to get a raise as a woman, you're better off having other people advocate for you and talk you up before you go in. As a man, you just go in and you just tell them, I'm doing awesome. Here's all the things I've done for you. I deserve a race. Done. There's, you know, you get a raise or you don't get a raise, but no one is looking at you negatively because you advocated for yourself. As a woman, we have science that proves that if you go in and advocate for yourself, you're going to be looked at differently and it could be detrimental to your career. So that sucks it, right? But that doesn't mean you don't get to do that. It just means you have to do it a little bit differently. You have to recruit your colleagues and your allies to help talk you up to make sure they're mentioning in meetings, to make sure that they're sending emails to be like, man, she's out to this awesome thing. She put this awesome project together. She's just fantastic. We should totally be paying her big bucks. You know, and just like casual things, get that floating around the office and then you go in, right? And then even when you're talking about your approach, as a woman, when you come in and you talk about it as a team approach, that's perceived better than if you come in to say, here's what I did. So I think, so, yes, why chromosomes? You're welcome. You will hear a different perspective. The exercises, the skills, those are the same, but sometimes these approaches or the history or what's going on behind it can be a little bit different. Yeah, absolutely. I think this course is going to have so much value, you know, not only from an educational standpoint, but also self-awareness. You know, people actually learning about, maybe the trauma they had as a childhood, right? Like the things our parents have been telling us, the way society and what it's been telling us, and then also just the amount of growth that I think people will have throughout this. But I got to ask you this question because it's staring me right in the face because you have a beautiful bookshelf behind you and Ultimax and I are both avid readers and I know you are as well. Are there any books that you recommend for anyone, you know, to kind of experiences growth or just be empowered? Yes, I'm also a reader. As you see my bookshelf at Love Books, I read too much probably all the time. That's what prevents me from going to bed at night because I just keep reading and I don't put the book down. But one of the things that I started on the website is the Matamathy Bookshelf to specifically highlight some of the books that are personal and professional development to help you out. So I have a few favorites. Those are the ones that are up right now. And mindset by Carol Dweck is one and grit by Angela Duckworth is another one. Those are, I just think both fantastic books, really great information. They're not brand new, right? They've been out for a while, but they just have really incredible information, well researched, really just interesting things about having a growth mindset. How do you stick things out? How do you keep pushing through in the face of failure and then keep trying? And I think they're really intertwined. Actually, I think they go really well together. And then a couple other books that I have, which are sort of just personal development and encouragement and motivation books are untamed by Glennon Doyle. And I swear when I first read that book, I just devoured it. And usually I devour fiction books, read them very fast in the nonfiction I like to sit, think through read a chapter to time. And this one I just like consumed. And it was just so inspiring to be like, hey, I am a woman. Sometimes life is difficult, but I'm still pretty badass. And I'm going to create my own situation and my own world and my own identity. And I'm going to present myself as me. And I'm here for it and I don't care if you are. Like it's just kind of awesome. And then the other one is Heart Talk by Cleo Wade. And she's a poet artist. And this is a little adorable book. And it just has little poems or little sayings, little just word art. And every single thing is, it just feels like a hug from a friend who's just encouraging you and lifting you up and reminding you that you have value and that you have worth and you're important. And we need you and we love you. And it's just like you could just look to any page and just read a little page and just feel better about yourself. So I love that one too. Dr. Arnie, thank you so much. And speaking of needing people, everything that you've shared with us today and your podcast and everything that you've done in the field of sports medicine, I mean, that's absolutely needed. So I want to thank you for coming on today and thank you for everything that you're doing. I consider myself so lucky that I had the opportunity to meet you and I have to thank one of my mentors, another badass woman, Alexis Coste, who made that introduction for us. And as we spoke about offline, when we met, you were in one of your leadership program director positions and part of the thing that attracted me to that program, of course, was everything they were doing from just a clinical and academic perspective, but also the leadership, your mentors. And from everything that you've talked about today, from what you continue to speak about openly on this podcast, our titles and medicine redefined. And there's perhaps no other issue that needs more of a redefinition than this aspect of women and disparities within sports and medicine. And you're speaking up about that. And so that encourages us that we can speak about some of the things that we're passionate about about how we need to do it a better way. And so I want to thank you for that and for everything you've shared with us. Thank you so much. Thank you. I love what you're doing here, guys. You're contributing in a big way and I think you're doing a great job. Thank you. And yeah, I just have one last question for you, but I also just want to echo what Altamash said and just, you know, acknowledge you for being so open during this discussion. I was very heartfelt. I was moved, honestly, just as you were speaking, everything just hit me really hard, having a wife Altamash too and seeing our wives go through some of the things that you touched on. And thank you for just being such a badass and being a leader in this field, you know, and speaking up on it and teaching us also how to be leaders. And so my last question to you is how do you think that we can add the health back in healthcare or redefine medicine? Oh, probably one million ways, but I can give you two. I think like what we talked about today, getting everyone physically active, participating in sports and being, you know, just exercising as part of life from the beginning that has to be in healthcare and having a priority to make exercise accessible and available and safe and make it, you know, equal and have the resources to it, that will help everyone. Be healthier, have a healthier population. So I think, you know, it was a great topic to talk about today. So that's definitely one. And then the other one ties in again with this gender discrimination we're talking about. And I'm more than just gender discrimination, but I think in medicine and in healthcare, we need more representation. We need our physicians, our nurses, our leaders to look like our population. We need to have more women. We need to have more people of color, more women of color, indigenous. We need the whole thing, women with disabilities, people with disabilities, like we need all of it. We need our healthcare to look like us to have more diverse views and opinions and people coming from different walks of life to be at the leadership table of healthcare. And I think that will make a big difference. Awesome. Thank you so much, Dr. Arnie. Thank you. I wasn't kidding when I said this was going to be a very inspirational episode by Dr. Arnie. You know, she really touches on a lot of key issues that we see not only here in the US, but globally. You know, gender disparities is not something to be taken lightly, you know, in the world of medicine, sports, politics, business, whatever it may be, it's a pretty big issue. And, you know, I definitely share the values that Dr. Arnie does. She's inspired me to become a better man, become a better leader, become a better coach, and also look out for our female counterparts and help them along the way. So if you were inspired by this episode or the last two, please send them to the females in your life that are bad asses, right? That have dreams and have goals and have plans. I think this episode can really motivate them to kind of get one inch closer to those goals. And I'll send these to the men in your life as well, right? The ones that can at least stand side by side to our female colleagues and so that we can all have a call to action because again, this issue of gender disparity is a problem for all of us to solve and it's not just going to take one person, it's going to take a entire community. And again, guys, don't forget to reach out to panacea financial for your banking needs as a physician because they are built by physicians. Panacea as needed personal loan was designed specifically for physicians and physicians in training. Go to panaceafinancial.com and open your new account today. Panacea Financial is a division of primus, member of FDIC and quickly that disclaimer. Everything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing medical advice. No physician, patient and relationship is formed and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health related issues. If you're loving this podcast, go ahead, give it a five star review, leave a review. And we enjoy you coming here. Take a look at our previous episodes. We touch on a variety of things. And if you've already caught up with all the episodes, sit back and just wait till next week, next Monday, we have some more fire episodes coming your way. Thanks for listening.