67. Sarah Pospos, MD: Lifestyle Psychiatry for Moms, Athletes, and Professionals

Hello everyone, I'm Dr. Darsha, 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. Before we get to today's episode, I want to take this time to talk you all about learning medical Spanish. Now, if you're a health care worker, you already know what an asset it can be to have Spanish in your toolbox. There's no need to call the glitchy translator line or pull out Google Translate on your phone or find that one colleague who is fluent. It makes for more comfortable and authentic encounters with your Spanish-speaking patients. Now while I may be able to get by with just four years of Spanish in high school, I want to be able to truly connect with my Spanish-speaking patients to let them know that I am able to communicate in their natural tongue. Now this is where my friends at Common Ground International come in. They have been teaching medical Spanish to health care students and health care professionals since 2003. Their mission is to impact communities through language. Now twice a year Common Ground International offers a free 10-day masterclass that helps you take a medical history and perform a physical exam in Spanish. Not only that, but you're going to walk away with a customized learning plan to improve your medical Spanish over the next six months. And that's not all. After you complete the medical Spanish masterclass with Common Ground, you'll earn four free CME category one credits. They only offer this masterclass twice a year, and the next one is coming up very soon on Friday, August 26th, so make sure to mark your calendars. If improving your medical Spanish is one of your goals, and it doesn't matter if you're a beginner, intermediate like me, or advanced, you need to join Common Ground Medical Spanish Masterclass. You can get all the info of dates and scheduling on their website at www.comangroundinternational.com for slash masterclass. Hope to learn Spanish with you. Our guest today is Lifestyle Psychiatrist, Dr. Sarah Post-Post. She completed her psychiatry residency as a chief resident at UCLA Kern and has published extensively on burnout and depression at UCLA, UCSD, and UCSB. As a parianatal and sports psychiatrist, she has devoted to helping others feel their best again when dealing with burnout, depression, anxiety, and other common psychiatric challenges by incorporating lifestyle interventions, things that we talk about all the time on this podcast, things like sleep, nutrition, stress management, and efficient time management, especially as Dr. Post-Post is a full-time psychiatrist and a mom of two under two herself. She currently serves California patients in her private practice via telehealth, and for the non-California residents, she offers additional free resources at www.ListyleTelicyciatry.com for slash subscribe. All right, let's get to the episode. It's going to be a good one. On medicine redefined, we were just talking, pre-recording about what you do with lifestyle telacyciatry, and you are the first psychiatrists that we brought on to this podcast. Ultimately, you're definitely a super pumped to be talking about something that is bringing a lot of awareness now in today's world with mental health, and especially the new hotline number coming out. This is definitely going to be a very, very interesting episode, so thank you so much for coming on. Of course, thank you so much for having me, super excited to be here. Let's backtrack to your journey. You have had extensive training. You've had, I believe, two masters, right, and then as well as psychiatry residency. So take us through your interest in psychiatry. When did that start, and what was kind of your early vision? Yes, great question. So I think I've always been interested in psychiatry ever since I met school, because I've always wanted to help people, especially as humans, we all experience ups and lows, especially in their lows times. I think it's such a privilege to be able to help them get to the best version of themselves during the downs of the lows of the lows, right? And with regards to my masters, though, just for a little bit of background, I was born in racing in Egypt. I'm not from here, and I moved here to California to actually get my masters in applied psychology. So I moved here to go to the ESC for that. It wasn't for medicine initially. And after my masters, I debilt a little bit in business consulting. But one day I woke up and decided, hey, I want to go back to medicine and I want to become a psychiatrist here. That's when all the magic happened. In terms of the second masters, masters in psychopharmacology, I did it within my fourth year of training. The PGY4 in psychiatry residency. And the reason for that is first and foremost, as you can tell, in psychiatry in general, prescribing psych medications, when indicated, of course, is our bread and butter. So it's always important to know more about the subject, so to speak. But especially for me, given my focus in perinatal and sports psychiatry, it became even more important for two reasons. Let's take an example of perinatal psychiatrists, right? For moms, the main concern, understandably, is when you take a medication, a psych medication, when you're planning for pregnancy or when you're pregnant or even beyond when you're breastfeeding, there's always that concern of whether this medication may or may not affect the baby. In any way, whereas for athletes, there's always the concerns of taking medication that may inadvertently affect their athletic performance, right? Could be in a good way. Let's say if they're taking perpanel, it might improve tremors and therefore is considered doping in certain sports. And obviously, they don't want to do that. Or it might go the other way. It may impair their athletic performance. Let's say if medication costs weight gain or lower heart rate in the case of endurance related sports, it also might be detrimental for that. So that's the reason why this two masters, I guess, come about. So that's really interesting, right? So you bring up the point about how it can inadvertently affect performance. And the other thing to keep in mind, you bring up the doping point, I think that's something that we always have to be cognizant of, right? So I have a sports medicine background and we always get trained to screen for this. And then also individuals, one of the most prevalent medications is medications for ADHD, right? Or Ritalin, those kinds of violence, those kinds of things. And that also always needs to be registered and it's also a stimulant. So it can be abused and can be an urgigenic ate or, you know, performance enhancing drug. So, you know, I find that to be really interesting because we had a previous guest who came on here and really talked about the benefits of exercise and pregnancy in the postpartum period. You know, we all know that exercise is a tremendous stressor, right? And of course, I mean, I don't know if exercise is a greatest stressor or pregnancy is a greatest stressor and the postpartum period is tremendously stressful too with all the changes that, you know, person's body goes through. And then making them, or advising patients or clients, hey, that you need to continue exercising because it's going to help recovery and have a host of other benefits is going to be, is going to be challenging from provider standpoint. So you know, I can see the parallels of how you can have those interests, but I think to the lay person, they might not, they might not see that, right? So, you know, I'm wondering, how does that inspiration even come about? I know you kind of highlighted how you had two separate interests in trying to bring them together, but, you know, did you have a significant experience or something like that? They were like, okay, why? I'm really interested in this, but I'm also interested in this or like a personal story, something like that. Yes, absolutely. I'm glad you brought it up. So for me personally, these two areas, sports and perinatal, my interests come from a personal level. So let's talk about sports first. I was a former student athlete back then, back in the day. So because of that, you know, what better way I think to pay it forward than to combine this two loves, right, of my life, psychiatry and sports and becoming a sports psychiatrist myself. And I think for a lot of sports psychiatrists, they may come from a, you know, at the one point, they were former athletes themselves, perhaps, so they might be able to understand just the unique challenges that athlete may face, you know, injury, concussion for some overtraining, performance and anxiety, things like that, and may know a little bit more about the ins and outs of how things are done in sports. In addition, of course, of the training, the actual clinical training on dealing with this specific situations and specific medications when indicated when treating athletes. So that's my motivation behind this sports part of things in terms of the perinatal psychiatry side of things actually became a first time mom during my training, my third year of training. So that makes a huge impact in terms of my interest in perinatal psychiatry, because I myself also have the same thoughts of, you know, like, oh, what's going to happen when baby comes? Oh, you know, during pregnancy, the right thing to do it is just wrong thing to do it, you know, just all these things. And then after the baby comes, obviously, feeling burned out, feeling like I'm pulled in multiple directions with working full time, being a mom full time and all that. And I think I can be having experienced those things firsthand, I can definitely relate and also I'm devoted to helping fellow moms, in that sense, to go through all that in terms of their mental health as well. Yeah, I love that, right? I mean, so it's instant buy-in, right? Instant credibility with the patients, the person sitting across the table or chair, whatever from you. Because I think we've talked about this before that we're just humans is traveled by nature, right? And so when you have somebody who speaks the same language, quote unquote, it makes it easier to register and really follow their advice or the recommendation. I'm wondering though, in your profession specifically, where you're having these incredibly sensitive conversations and there is a need to be tackful in how you approach it. Do you find that you are, or that you're more likely to share your personal experiences to get that connection with the person or is that something that could potentially be disruptive to the physician patient relationship? Very good question. So my answer would be it depends, you know, as always, especially in psych, perhaps it's a case by case basis. But in this case, I would say if it helps the relationship, the therapeutic relationship, I would have no problem disclosing that, right? Just like you said, you know, they might be a little more inclined to or motivated at least to hear what I need to say because they might see me as, oh, this person has been there, has experienced the same thing firsthand and whatnot. But of course, if it's unrelated to their struggles, it might not have the same effect. So I wouldn't do that in that case, if that were to be the case. Yeah, absolutely. Sarah, I wanted to transition into the lifestyle medicine aspect of psychiatry, right? So, you know, personal story, when I was first truly interested in medicine, I love psychology right through high school and I thought I was going to be a psych major in college and eventually go on to do psychiatry. And then when I started shadowing, right, in my pre-med years, I started realizing, like you said, the bread and butter is more of the pharmacology aspects of it, right? And figuring out which medications you want to give and, you know, for me, that was kind of like, ah, you know, it's not really at my alley. I want to do more exercise, more lifestyle. And I didn't really see how you could truly change more in, quote, unquote, a natural way, I should say. But, you know, I'd say about three to four years ago when I started on social media, I started seeing more people write about holistic psychology, holistic psychiatry, adding nutrition. So can you just break down what lifestyle medicine means to you and exactly how do you envision it through your practice? Absolutely, that's a very great question. So what it means to me is, and I want to use an example of personal story for this. So back when I first started my outpatient psychiatry, that would be their ear as well for us. You know, I get more time to get to know the patients, their stories and their lifestyles, right? So that's when I realize, hey, a lot of, if not more, well, most diseases or most conditions in psychiatry, if not all, are chronic conditions, just like, let's say, diabetes, high blood sugar, right? So in case of chronic conditions, yeah, sure, we can prescribe meds to help, but it might not be enough because of several reasons in terms of their lifestyles. If we ignore, let's say, the nutrition, they took the medications, but they keep eating highly processed sugars all the time, what's the point? If we give the medications, but they're not exercising, not being physically active, you know, their insulin response might not work as much. So what's the point? We give them medications, but they're not sleeping enough, they're, you know, being stressed all the time, their cortisol or stress level, stress hormone levels up to the roof affecting all this insulin, glucose response and whatnot, what's the point? So I thought to myself, it might be a good idea to incorporate system, you know, in a systematic way, incorporate lifestyle changes, in addition to all our regular psychiatric care, in the case of psychiatric patients or mental health. And that's when I actually came across the term lifestyles like chiatry, which I believe was coined by Ascentford's psychiatrist Dr. Neal. Okay. So quick follow up then, do you have a specific set of patients in mind then? Because when I'm thinking about, you know, changing behavior and trying to get the message across and then trying to track that behavior, you need to have obviously a patient with capacity, right? It's somebody who's alert and orientated. But what about those patients who might have schizophrenia or bipolar disorder? How do you tend to man, you know, is it still possible to do lifestyle medicine in those specific set of populations? Definitely, so you're 100% correct. I think the quote unquote higher functioning of the patient is in terms of just their, you know, cognitive function or even being psychologically minded, being so invested in their own health, wanting to take parts in their care is absolutely important. And perhaps the ideal, the dream patient to incorporate lifestyle psychiatry techniques. But in the case of let's say schizophrenic patient by polar patients, we might still be able to help them, especially when they're not in that acute state, acute psychotic state, acute manic state, perhaps. And we could always take it step by step, meaning it doesn't necessarily have to be a full on lifestyle intervention, right? That it encompasses nutrition, exercise, sleep stress management, perhaps it's just one stress management techniques that we want to recommend to them, just debriefing, for instance, or just getting enough sleep part by way of, you know, advising sleep hygiene and then take it from there. So it depends on the patient, but it's definitely doable. So I'm glad you brought up high functioning professionals, right? So I'd like to take this time to kind of transition into one of the highest functioning professions that we know, or that's physicians, particularly residents and really trainees of any kind, is what we know is that arguably the most stressful time in our lives, right? And then you mentioned adding a baby to the mix, I can't even imagine something like that or really anything else like, you know, that's challenging during that time. And I remember coming across a study a couple, maybe a couple months ago, this was maybe published back in July 2015, I'm talking about the problems of at least, you know, maybe was depressive symptoms versus depression, I can't remember exactly, at least a quarter of the residents expressed that, right? At some point, and willing to bet that a small fraction of that actually seek help. If any at all, you could probably speak better to this. And I know you've done some work, you know, during your training and during time to help facilitate their process where people can kind of reach out seek help. And you know, we've talked about some strategies before, shout out to Robin Tiger who came back on from stress free MD, who talked a little bit about this and she is a radiologist by training, but really works with a lot of professionals to kind of help decrease stress if you will. But I want to go a little bit deeper in that, right? I want to talk about like actual pathology, depression, anxiety, things that are, you know, are at least anxiety partly that makes us really good at our jobs, but also can be overwhelming and can be detrimental. And certainly long term pathologic anxiety, out of controlling anxiety can be tremendously harmful. You talked about insulin response, you talked about cortisol things of that nature, we don't think about in that acute phase. What I know packed a lot in there, but I kind of want to get your sense of the state of training and how, you know, trainees are handling it. And you know, what potential strategies could there be that can make that process a little bit easier for people to seek help with regards to being a treatment specifically? Yeah, yeah, let's keep it focused otherwise we could be here for you. Right, definitely. Yes, so I think first and foremost, most important thing perhaps is to recognize the problem right or when it is a problem. So in terms of psychiatry, you know, everyone can feel down sometimes, like you said, everyone can feel anxious with the coming exams or upcoming exams and what have you sometimes. But when this feelings, one, started to cause intense severe distress or two, it starts to interfere with your day-to-day life, so it could be impacting your grades, your work, your relationships, then it's a good idea to seek psychiatric help. And in terms of in trainings in that setting, it might be a bit difficult because there's a lot of not only stigma associated with mental health, but perhaps perceive repercussion right? What if people find out, am I going to get kicked out of the program? What would be my reputation? How can I still apply for licenses and things along those lines? So it might be a bit tricky, but there's always an option to first reach out to, you know, your trusted mentors, if they're in psychiatry, that's even better. They might point you in the right directions. You can always seek help outside of your institution if privacy is of concerns. You can first reach out to therapists, psychologists or when more or greater help is needed, you can always find a psychiatrist as well. And I would like to highlight, it's very important to do it soon rather than later because not only perhaps you can prevent it to becoming something, so let's say burnout, you can prevent it to become a full blown depression, but also you could perhaps prevent it to become more severe than what it already was. I'm glad brought up this perceived idea of repercussions, right? You know, I know that the ACGME in the past, or last two years or so, has really made a strong push for wellness, right? And that's one of the core things that they address programs as, I think you were a chief resident, right? And so was I. And so, you know, we had the privilege of kind of being involved a lot of the ins and outs of the programs, at least from the administrator standpoint. So we know that, that being said though, tradition and culture, that's been laid out for hundreds of years, that's really, really hard to break. We talk about medicine being this gigantic ship and it's going to take a long time for to turn around. And so a lot of things that you're talking about, I mean, it sounds great, but I can count on more than two hands and people within my inner circle who've had experiences where they need to take a step back, but they're not able to for a multitude of reasons. And one of them could be because the same anxiety or pressure, if you will, of performing is what makes that person good at their job and makes him recognize and kind of feeds that ego and what everybody praises. And so, you know, the stigma thing that you talk about. And so if you now say, hey, listen, I need help. Or this is actually hurting me. I think it's a little bit more complicated than just the stigma aspect because, you know, if you have to take time off, you have to extend training, right? It's long enough as it is depending on if you're going to do more fellowship or whatnot. And we have loans and all that kind of stuff, so you don't have time for that. But most importantly, you know, I find that just reaching out or even reporting is very, very challenging. How do you foresee that process changing where the friction of bringing it up, you know, not having maybe to find that quote unquote trusted mentor. But the friction of, hey, I'm going to report this and the barrier is not so great. Am I making sense? That question makes sense? Sorry. Just to clarify in terms of other people like, if residents reporting on someone or not just chief residents, right? I just use that as a, because the chief resident is a very high stress job, right? And then residency, I just mean really any residents. But in terms of you talked about step one is recognizing, right? And it's, I think sometimes people do recognize, but after you recognize, you just tell yourself, I just got to get through it. That's it. Two years I got to get through it or six months I got to get through. I just got, I see that finish line, wherever that is, and I just got to get through it. But that's a, that's a short-sighted approach, right? Because I think what happens is people get on that wheel, if you just get through it six months, that's another six months, you just get through it and it's another six months, that's another six months. I'm wondering if disclosing that, hey, something's off, if the friction or the barrier is low, people might be more likely to do that. So do you foresee that process being better? I see, got it. So I would like to think so. And just a couple of examples. First of all, let's take the anxiety part of it, right? You mentioned that, you know, for some people, the anxiety might be at least one of the factors that help them to get things done, to begin that their work, which makes sense because back then, the root of anxiety, you know, back in our ancestors days is to help us survive from a threat like physical threat. So for instance, back in the hunting days, if there's a bear, then this anxiety would alert us to not get eaten by the bear to physically survive. But in this days of age, a lot of things are perceived as survival threat and can create anxiety like upcoming tasks, you know, driving somewhere, you're afraid of driving and whatnot. So it could go both ways in terms of anxiety being helpful in certain scenarios versus not. It's not helpful when it starts to impair your day-to-day function, right? And to your point of, so when to seek help, let's say, should I just power through the six months and then power through another six months and so forth? My answer to that would be, especially in anxiety and just in general, with this mental roadblocks or mental challenges, if we just let it be, it won't go away, especially for anxiety. If we avoid it, it's just going to snowball the anxiety state into bigger and bigger and bigger and bigger and anxiety and it might at one point just disrupt our performance or our functions. And the second part of the questions in terms of how healthcare might help or might be more helpful in this days of age is I would like to throw the telemedicine aspect there here. So you know, because of COVID, it became very popular telemedicine, including telepsychiatur visits, right? And the reason why it might be helpful is for several reasons. One time, as residents, as high functioning professionals, time is very, very valuable. Like you said, if we miss a certain, you know, a week or two weeks or what have you, we might have to extend our training for however long. So don't want to want to go through that. So with telemedicine, you can eliminate the downtime of, let's say, waiting for a waiting to be seen by the doctor, your community time back and forth. So all those valuable time, you can still use it to work and then just be available for the duration of the appointment to in terms of privacy, right? You don't really have to go be there in office, you know, risking people, you know, might recognize you in a psychiatrist office, let's say, but you could do it at the comfort of your home when no one knows you have a psychiatrist visits. And then the other thing as well, perhaps to consider is there's an option for cash base or non insurance base care, which might be more confidential for one because your records, it's not there in the insurance records, right? So when you're applying for things like, let's say, malpractice insurance, disability insurance, things like that down the road, it might not be a part of it, per se. And also because it's cash, but not an insurance base cash base, the doctors would have more leeway in terms of your care, for instance, because some insurance might not cover certain medications, but in cash practice, you could still prescribe those medications or some insurance might require extensive documentation that takes up an actual patient care time. So you can still get that time in a cash base practice, so to speak. So those are the two ways on top of my head that I think might be helpful in this case. No, I love that. That's really interesting though. I was familiar with how when applying for disability insurance policy, your records are fair game, even the mental health records, which is really interesting because there are more protect like I have to break through seven glasses to be able to look at somebody who, so that's interesting. Not actual glasses for those who are not using EMR, but there's this thing, never mind. But malpractice insurance, how can an insurance company, so what you're saying is, let's just use a case study, right? So I'll just use myself. If I had sought out behavioral health or mental health at some point during my training, now that I'm attending and I'm applying for malpractice insurance, that could affect it negatively. I'm so sorry. Why is that the case? My pregnancy brain is not working correctly. What I am meant to say is disability and life insurance, not mental health insurance. Okay. Okay. Okay. Gotcha. Gotcha. Okay. Yeah. That makes more sense. Okay. Awesome. So I'm glad you brought up the telehealth thing. I think that that's certainly changed the game in terms of how we practice medicine, how we will continue to practice medicine. So we'll come back to that in a second, so let's park that. I want to stay on this thread of recognizing because it seems to be the most important step and that's why you brought it up first. There might also be times where, again, training is an intense time. I come back to that just because I'm fresh out and you create these bonds with people, right? And so whether it's your co-chiefs or your co-residents and you see somebody and you recognize it. Maybe they recognize it and they haven't brought it up, but you recognize it and you're like, okay, you need to take a step back. Again, this is a very sensitive thing. So is there an appropriate way to, again, quote unquote, call out your coach training not publicly, but to approach them and say, hey, listen, you need help or do you need help or, you know, it's some way to do that. If so, what might be some things that come to your mind and how somebody could do that? That's a very good point, you know, to discuss. So I think first and foremost, just like with anything, right, in that, in such sensitive situations, one-on-one approach would be better, of course. And it also depends on how close we are to that person, right? For example, if I only say hi and buy to someone once a week or so whenever I see them in the hospital, I probably wouldn't be the best person to approach them with such sensitive topic. But let's say we're close enough and then there's an opportunity for an one-on-one conversation. Perhaps the way I would phrase it is just to give their buy-in, kind of highlights, not in a judgmental way, of course, in the most empathetic way as possible, as much as possible, how it affects their life, things that matter to them. So for instance, if they're really concerned about an upcoming exam, like a board exam or something, then you might bring up the point of, you know, you seem like it's, these days it's hard for you to concentrate how's your score looking in the practice, cue banks and whatnot. If relationships is the most important thing to them, perhaps you can bring up the topic of, yeah, you mentioned to me that you had several disagreements lately with your wife, with your husband and whatnot, how are things then, and then after helping them realizing that there's a problem in terms of day-to-day function, then take a step back and go further into the conversation in terms of symptoms. Yeah, I like that, right? It's about personalization and rather than making it about the culture of the organization, it's actually about what that person's day-to-day looks like, right? And really opening their eyes to their other priorities, right, that we can't forget. And I think so many people that go into medicine just think residency, training, doctor, is the priority in patients, right, and they forget to look to see that, hey, a doctor is what you do, right? It's not necessarily just who you are. I want to dovetail of ultimately questions, because both you guys were chief residents and ultimately you jump in as well in here. So you know, they always say organizations and the culture of organizations don't change. It's the people that change, which in fact changes the culture, right? So I'm grateful, you know, being at Penn State Hershey, I'm an awesome program director who's very much on top of wellness, you know, if I have a terrible call night and don't get much sleep, she'll say, hey, just text me if you're in clinic, like just come two to three hours later, get your sleep in or something, right? So the culture that I'm in kind of stayed throughout, and I think the people that we kind of recruit also help that. But we also know that there are very awful programs out there that are super, super terrible in terms of work hours and, you know, not letting you go home or not being able to see doctors or dentists. What are maybe one or two actionable items that, you know, ultimately, and Sarah, that you guys think can make a difference, right, from a chief resident standpoint at least, because you guys are at least, you know, at the top of that leadership. So for any listeners out there who are residents or in program leadership, hey, these one or two actual items might make a difference within the organization to help improve the culture. I'll let you get the first word since you're with the guest. Sounds good. That's a very little question. I guess you can go in every sleeper for this, but I don't know if there is something that you may be implementing from your end. Right. So I think you're absolutely right, right, when the culture from top to bottom of an organization is, if I may say quote unquote toxic, it's really hard for individuals, even at leadership position to change that like, like in a second, perhaps thing that comes to mind would be to focus on what we can do on a personal level. So for instance, let's say, you know, even if you're even if someone sick, they still have to come to the hospital finish their call hours and, you know, just no excuse. We can try to find someone else to cover in that scenario. So even though in terms of organization, it's not allowed. It's not possible, but at least they feel that, oh, okay, someone cares about me enough to kind of cover for me for this specific call when I'm not feeling well. Just would be an idea on top of my head. Yeah, I would just add, I mean, again, yeah, to reinforce a point, I think a lot of it really has to do with, I really like what you said, Dersavout, that people change and then that changes the culture, right? I think that's certainly true. I think I've seen that personally. If I could think of one thing, I think communication is really, really important, effective and clear communication. I've had people who tried to derail a culture and, you know, when people are like, if you have junior residents or really anybody and you're creating a call schedule or you're doing anything like that and you're finding coverage because I think as a chief resident that's part of your responsibility, cryptic messages of like where somebody has to be for some type of appointment or, you know, some things don't make sense because you brought up the dentist and doctor thing, which is, it's important. It's necessary, but we're also physicians and yes, I'm a sports medicine provider, but I also understand how the cardiovascular system works. So if you're making some weird appointments and you have some, you know what I mean? Like so, you never are, I don't know, I shouldn't say allow to, you never want to ask somebody and like what's going on medically, they don't feel comfortable disclosing that. But at the same time, where physicians were not stupid, so, you know, clear communication, I think that that's really, really important and some people will try to game the system again. And I'm not sure if that's a chicken or egg situation, you know, in terms of speaking of the culture, if that kind of derails it or, but I think that if you are a junior resident and you do have chief residents who are in a position where they are responsible for a lot of these things and that's your leadership, you know, bridge to the faculty, the program director, then I think that this clear communication is really, really helpful. Yeah, no, absolutely, absolutely makes sense. Cool. Ultimately, I think you want to ask any questions you had on this. I was going to kind of switch topics into either perinatal or sports, depending on what Sarah want to talk about, but all right, Sarah, field or choice, I want to dive deep into both. I think both populations are very important and both are very interesting, right? I think from a lifestyle standpoint and there's not much awareness at least from them. So where do you want to go first? You're called there. I'm an athlete, I love sports and let me ask, what sport did you play? So I swim back in the days and then I play basketball and volleyball all rounder. I like it. So playing basketball, track and field, baseball and then transition to tennis in high school. Yeah, yeah, I love sports and so that's why let's dive deep into this. I guess my first question, as I think about sports psychiatry, you touched on it a little bit, but I'm thinking about age, right? And what age should people really get started? Because each sport kind of requires a different skill set and we also say that sports can teach us at a very young age, which is why a lot of parents put their kids into sports. You have golf, which can teach patients. You have basketball, which can teach teamwork. You have tennis, which can teach really the ups and downs of the solo journey. So at what age do you think it's important to kind of weave in these lifestyle techniques into athletes? Great question. So I don't know if I have a specific cutoff in terms of age, but an important concept perhaps would be one sports as an active lifestyle, right? As like you said, it teaches so many good things, both mentally in terms of kind of like the mental aspect of things, but also physically and just get us set up in that healthy lifestyle down the road. So the earlier the better, but with the caveat of, you know, there's a research out there that says that early specialization is not as great as, you know, sampling a lot of other different type of sports for number of reasons, right? So for example, if we, you know, kind of quote unquote, fours or have our kids focus on just one type of sports from the very beginning, it might lead to burnout. They might not like it as much, but they feel guilty to give it up. So it's probably better to introduce it early and introduce a lot of different ones and let them choose as they grow up. Sarah, say a little bit more about the early specialization piece, right? I think that that we talk a lot about that in the sports medicine world, and I'm familiar with the reasons why, but some of the listeners might not be, right? We live in a world where some is good and more is better and more, more practice and you got to get on the grind. So you got to practice, you know, get up four o'clock in the morning and, you know, practice 20 hours a day if that even makes sense and start earlier on. And therefore you're going to get, make it to the pros. So talk a little bit about why that might be more harmful than beneficial. Yes, for sure. So, you know, let's say we have, you know, someone start in basketball, right, from the very beginning, just basketball. It might inadvertently leads to pressure, external pressure, right? Because, you know, this kid might, you know, they just don't like basketball. They hate it. But because of parental pressure, peer pressure, you know, the coaches pressure, perhaps, or just pressure they put on themselves to continue to push on because like it's, as you guys know, in sports, we're taught to, you know, always be resilient, always be persistent, not to give up. We can almost overcome anything. They just push through because of that, just that sole reason. But internally they feel miserable because they just don't like basketball. So it might lead to feeling guilty, you know, perhaps affects their self-esteem and things along those lines, things along those lines psychologically. And also, and perhaps, you know, I'm sure you know, more about this, giving, letting them sample a lot of sports, might introduce them to more movements, kind of like more principles, more diverse skills that they can use, especially if it comes from, if it starts at an early age, and that could be beneficial as well in terms of their just life skills in general, too. Yeah, I'm glad I asked you that because I think often the literature that gets published on it is really looking at the biomechanical aspect of it, right? So the same muscle, the proprioception stuff, that's going to be off. But this psychomotor component that you're talking about, I think is, you know, maybe just as important if not more. So I think it's probably worthwhile. Some people might not even understand what the role of a sports psychiatrist is or what the health sports psychiatrist is. Would it be worthwhile to just define, you know, what a sports psychiatrist is and what kind of, you know, what's their scope of practice and where their practice are they with teams or they employed? Like, how does that work? Yes, absolutely. So, sports psychiatrist, just like general psychiatrists, we deal with common psychiatric conditions, right, depression, anxiety, ADHD, PTSD, what have you, in athletes specifically, how it may differ from, let's say, a sports psychologist is, for instance, sports psychologists, they focused on improving athletic performance by focusing on mental skill sets versus sports psychiatrist would focus on treating, quote unquote, regular mental condition, mental illnesses in the setting of sports. So within athletes, you know, aspiring former current athletes. In terms of the setting, how it works, it just depends a lot of variety out there. So some sports psychiatrist is employed by a team and therefore, you know, take care of the athletes on that team, a new one, a new incoming one, current ones and what have you. Some sports psychiatrists might just be in private practice, so it doesn't limit the athletes in terms of which team they're from and what not, but just see athletes in general. So it depends on that sense. So to use an example for the listeners, when we see, I'm going to, I'm going to send a doll because, you know, he's the goat. And when you see him sitting on the bench and with his eyes closed, his empty breaths and using some maybe visualization techniques, those are skills that have been, you know, worked on with the sports psychologist, right? Is that fair to say? Yes, I think so. And then if you have, I'll use somebody that we've talked about recently, oh my God, Ben Simmons, and you're talking about, you know, a lot of mental health stuff that he's been dealing with. And so he might be somebody, I don't know this for some, I'm just using an example. He might be somebody who's working with a psychiatrist and using all the tools that you talk about before in the tool belt to help address true pathology. That makes sense? Yes, absolutely. Awesome. Um, do I actually get anything else there before research gears here? Okay. So let's, let's kind of make a sharp turn and talk about, you know, peri-natal, you know, psychiatry and, and that's your other passion interest and, you know, you mentioned you have a personal story. You said you're 30 or right? Yes. That's when you had your awesome. And so, you know, one of the challenges we talked about before we were talking about not getting enough time off and extending training and this is not even diving into kind of the abysmal maternity leave policy or paternity leave parental leave policy that we have, which probably adds to the stressors, right? How does that scope work working with peri-natal population? Is that, you know, during pregnancy, postpartum period, what's the bulk of patients that you'll see if somebody specializing in peri-natal? It's actually all of the above. So it begins from the preconception planning, right? If you will. Let's say if a bipolar patient wants to get pregnant as we know, some of the bipolar medications might have an effect on the baby. So even before they're actually pregnant, it's a good idea to think that through talk about options and whatnot, what to do if they were to get pregnant. And then, of course, during the pregnancy itself postpartum as well, because a lot of things might come up in this postpartum period, for instance, postpartum blues effect, 80 percent of moms, 20 percent, so one out of five experienced postpartum mood disorder and anxiety and things along those lines. It could also be extended to breastfeeding for those who choose to, because some medications get absorbed differently in breast milk, so that's an important point. And, you know, just in terms of reproductive psychiatry in general, it extends even beyond pre-prognancy and postpartum, so it deals with things like pre-menstrual mood disorder, or, you know, mood changes that might be associated with very menopausal period, so things along those lines also might get lumped in that way. That sounds insane to me, because that is so incredibly challenging, and I think that people who are not medicine are going to have a hard time appreciating it. You know, I think about my wife, she's a pediatric neurologist, right? She's a trainee still, but she often will tell me about patients who are now anti-apoleptics, and a lot of those medications are challenging to continue during the pregnancy period. So, she has a similar converse, or she has many of the discussions that you're talking about, and for those who don't know, a lot of the medications are, you know, characterized in different categories, right? So, you get a category A, B, C, D, category X, and if I'm not mistaken, most of these bipolar medications and anxiety medications are probably category X, is that, is that right or no? I think. Like, or can you continue them? So, I would say it depends on the medication, and let's say the common ones that come up is lithium, and deprecode, perhaps, fulporic acid. Yeah, that's fast, I can have. Right, so those are quote unquote notorious in terms of how it affects pregnancy, right? But then we probably need to dive deeper in terms of one, if it does cause, or it has, it does have the potential to cause something in the baby, how likely it's not. So, for example, lithium, it may affect the baby's heart, but it's not, the, the chance of that is not as much, as compared to, let's say, the general, general populations. So, the pros and cons, in this case, let's say if a bipolar patient is only doing good in lithium, for one, so nothing else, or two, just given the hormone, and what have you done during the pregnancy and postpartum, probably the manic or depressive episode just might come up, have a higher risk to come up, and that could be more detrimental than taking, than the risk of, you know, having her take lithium. So, it's a lot of juggling the pros and cons in that case, in terms of this medication options. And we typically, we always do give several options to the patient, so the list of pros and cons, if you will. So, let's say, in this case, if you take lithium, this is the pros and cons, they're an alternative of this, these are the pros and cons, and then discuss it further, and make a joint decision. Yeah, you know, I mentioned that this is really challenging to treat. I mean, again, most people know that most things in medicine, it's weighing the benefits against the risk, right? That's kind of what you're gesturing right there for those who can't see. And, you know, I think these conversations are probably more challenging than anything else. I think people might wonder, well, why can't we just switch to different medications, like an SSRI or something like that? And what we know is that sometimes it's extremely challenging. People have to sometimes, with these psychiatric medications, go through one, two, three, four, the fifth medication to really stabilize the condition. And the last thing you want to do is to take them all, right? But at the same time, they're also going through a time where maybe you do need to. So, you know, I mean, it just stresses me out thinking about that, those conversations that you're having. But that's why you're the expert and you're the hot scene, and I'm not. But I'm also wondering at the same time is, as challenging as that is, right, because you have two patients that you're working with, and you have to know the pathophysiology of multiple different processes, you know, from a neurological perspective, again, from a physiological perspective in the babies, in the pediatric population as well. How do you keep up with the literature to look at that, but also the sports psychology, which is drastically different when you're looking at something like that? How do you stay up with that? That's a very good question. I think, you know, just like all of us, perhaps having a high, quote unquote, high-yield resources, right? There's any important conferences that kind of sums up all the new updates for both fields. Or, you know, the simplest thing would be if you encounter a case, a common case that happens, you know, comes up often and often over and over again, comes up often, then you just try to look up more information both in the lens of perinatal effects and in the lens of sports effect, if that applies, of course. And then, I think in my case, though, what helps me is my personal interest and investment in both areas, so that kind of just propels me to continue to learn about these things, moving forward as well. To piggyback on what Ultima was saying about how insane, like, it is, to keep up with literature, also just to understand pathophysiology, pharmacology, in the perinatal period, right? Actually, looking at it from a lifestyle perspective, because now you're throwing in hormones sleep, which is affecting hormones, right, affecting mood, then you have exercise, which is affecting hormones, affecting mood, affecting a bunch of different things, nutrition. It's just, there's a whole hodgepodge of things going on there, so it's good to know that awareness and books and things like that are slowly coming out, but from your perspective, what do you think, you know, is the one thing that a two-be-mother or a mother who just delivered, it should kind of be putting on top of mind, is there something specific that you recommend them to do in order to take care of quote-unquote their lifestyle? Yeah, so first and foremost, I think I just wanted to throw this out there that it's very normal, right? It happens to a lot of us. It's very common to fill this mood fluctuation, fill this, you know, sense of feeling overwhelmed, being pulled in different directions, because it's a new stage of life. Motherhood is not easy, obviously. And in terms of lifestyle, I'd want to highlight that in all of this lifestyle techniques, some is always better than none, so let's talk about exercise, for instance. A lot of studies said that, you know, even just one about one episode of exercise is found to improve mood or to lessen anxiety as well. So don't beat ourselves up if we're able to, you know, stick to our exercise, have an hour routine every day in and day out every single day as a new mom. Some is always better than none. The other thing, perhaps that I at least found helpful in my case is to multitask, multitask in a sense of doing, quote unquote, mindless thing while doing something else. So some exercise, for example, in my case, I'd like, I bought myself a little supper and a little floor desk to put on top of my regular desk is to prop my computer up so I can do some work standing. And then while I work, I just, you know, kind of step on my stepper, get my hard read up at least to moderate level, right, intensity level and get those steps in, get those cardio and every day. I know it's not much in terms of, hey, I didn't specifically go to the gym workout, you know, hop on a treadmill or what have you, but at least I'm doing something in the realm of exercise that could be sustainable at least in this stage of one. Yeah, absolutely. You're right. It's something, right? And something in this period of life is going to mean more than nothing and if that can keep you, quote, you know, mentally fit, why not take advantage of that? And we know that postpartum depression is such a big thing and probably underreported, honestly. So definitely, definitely a big thank you for that advice. Let's transition into telehealth because I know that's something that, you know, you're putting into your practice. Now, when most people think psychiatry, right, they're going to think of probably the Freudian aspect of sitting on a couch in person, you with your pen and book, cross your legs and almost interrogating the client, right? So take us through how a telocyc appointment would maybe be different and maybe what challenges or advantages you would find with telehealth. Sure. So like with anything, right, like you said, everything has pros and cons. So with telehealth, typically, for instance, like I mentioned earlier, you don't have to be present at the office, meaning you don't have to commute to go there physically. You don't have to wait there in person for the doctors to see you. So what you do is you just log in, probably several minutes before your appointment. And then when the doctor's ready, the meeting room is going to open up and then you start your video session. The cons with that, perhaps it doesn't happen often, but like with anything, technical issues might occur. So imagine, you know, opening yourself up, telling this person, you know, very intimate stories, digging deep into your feeling and then boom, the screen froze and you have to redo the whole thing. It's probably not the best experience, but like I said, it rarely, it rarely happens. The other cons, perhaps, is because it's only a chest up, I would say, it might be easy to miss certain subtle nuances. For instance, if someone's anxious and they are actually restless and they're shaking their legs, which just, you know, kind of highlight their anxiety level even more, you might miss that in the telehealth session. But I think especially for the high performers' populations, you know, the busy ones like moms, athletes, students, residents, working professionals, where time is very, very much valued and they're very busy, you know, day in and day out. It could be a great option just for that convenience piece and also that confidentiality. Yeah. I do want to ask. If there's a bunch of companies, I think that just recently came out that offer like mental health services, you know, how comprehensive do you believe those are or maybe what are those companies good for that necessarily don't really cover what psychiatry might? Are you referring to like a company like better health, I think cerebral, yeah, some of those types of companies that are now starting up? Yes. So first of all, for in those companies, I would say or in any type of care, right, you just want to make sure you know who's providing care. So for example, if you have severe depression, severe anxiety and you need medication adjustment, you probably don't want to, you know, it's, you couldn't, it's not a good fit to see a therapist who might be a social workers or who might be psychologists that doesn't have training nor have the license to prescribe medications. And then also in terms of stimuli specifically controlled medications. So that includes stimulants for ADHD, Benzos, perhaps for anxiety and things along those lines. Right now, given COVID, the regulations are still changing. There's a Ryan Heights Act that basically mentions if we should see a patient in person at least once or more for prescribing these control substances and it's still, you know, it's still continuously changing, given the state of the COVID pandemic. So perhaps it's always good to keep that in mind as well because if a company is a pill pusher, so it is big, especially for these control substances, it might not be a great fit or a good idea to go there. So I've heard of better health, but at cerebral, you mentioned another one. Do these companies, do they not have like psychiatrists on board to help manage that aspect of it? So I don't know specifically, but what I heard is, for example, for cerebral, they got into a lot of troubles because they employed a lot of NPs, nurse practitioners, right? And I think their model is for this NPs to either, I'm not sure, in some states, they're allowed to practice independently or in some states where they need supervision, they just have, let's say, one doctor, one psychiatrist, supervised, a huge number of NPs, which may or may not have implied, kind of like the supervision, slash stringency of that procedure or of that protocol of subscribing control substances. I see. Yeah, I'll have to look that up. I mean, I'm just learning about this stuff, like I said, in order to that company, but let's talk about the next thing. I know we're coming through a close here and I know that, like you mentioned earlier on that, you know, it's just, actually, we might have been offline waiting for that, is that you just completed your training and so you're going into practice in the real world if you will. And so what's next for you and what's your practice look like? You tell us a little bit about your telehealth services. Are you doing something in adjunct to that or is that your primary thing? Yes. So, for me, for California patients, my next available appointment, which is by telehealth, is in September this year, so in two months or so. And you can find more info on my website, lifestylecatchery.com. For non-California residents, I do offer free additional resources with regards to lifestyles, changes, sustainable lifestyles, changes, and how it can affect your mental health in psychiatry. My website as well, so lifestyletelesicatchery.com, slash subscribe. And you can contact me too on my Instagram at lifestyletelesicatchery. Awesome. Well, Sarah, I want to thank you for your time. I know that this is a critical topic that, you know, we spent some time talking, but like Narset, you're the first psychiatrist that we brought on, and your perspective is certainly appreciated. I'm excited for kind of what you're doing. I think that overall, I do agree that I think there are more advantages. Certainly, what you talked about the body language not being picked up, right? I mean, here, where we're communicating behind the Zoom screen, and we're going to only see the top half. It's the top people are tapping their legs and things of that nature. These subtle nuances that actually, more people will say body language communicates more than actual words or really any gestures or anything like that. But I think overall, just the availability, opening up and access, that's probably the greatest thing. And so to be able to have that, I think, is a big win. But anyways, thank you so much. This has been tremendously beneficial, and I've learned a lot, and I'm excited to kind of, you know, have you as part of our network as we continue moving forward to make the world a better place. And on that note, you know, one of the things that we talk about is how can we add the health back and the health care? So that's the million dollar question for you and now is, you know, how do we put that health back in health care? Right. So I'd like to break that down into two parts, health care, health and care. So for health, I just wanted to remind everyone that mental health is just as important as physical health, and health doesn't necessarily mean, or doesn't only mean that there's an absence of an acute episode of a disease, so much more than that, right? And on that note, on the care part, I think it'd be ideal if we can be more active instead of reactive. So instead of fixing the problem that had already occurred, so to speak, try to prevent it before anything wrong happened. And with that, I think, naturally, the word sustainable and the work long term in terms of lifestyle comes to mind. Perfect. Thanks, Sarah. Thank you. Thank you so much. I mean, I also say thank you so much, you guys, for all that you do for bringing all this awareness about lifestyle and trying to affect the system, which is very, very much amazing as well. Absolutely. Yeah, it's our pleasure. Thank you. Thanks. Thank you. All right, thanks for tuning in to another episode of Medicine Redefined. If you're enjoying this podcast and these episodes that we're bringing to you, please make sure to share them so that we can try to build our reach as cast or net as wide as possible. If you are interested in Dr. Post-Postive Services, you can check out her website at www.LightStyleTellStyleSci3.com. And of course, if you want to up your medical Spanish game and connect with your patients better, be sure to check out on the International. As always, our disclaimer, everything in this podcast is educational purposes only. It does not constitute the price of medicine and we are not providing medical advice. We hope this is a physician-patient relationship performed 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. We'll see you next time.