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Welcome to the Healthy Brain Toolbox. I'm Dr. Ken Sharlin, neurologist, speaker, author, and host for this show. In each episode, I interview influential people whose work impacts how we live and how we think. My guests are leaders in the health and fitness industry, physicians, scientists. Here, you'll find conversations that break down barriers, expand your horizons, and give you the tools you need to protect your health and nourish your aging brain.

Dr. Ken Sharlin: 0:30

Welcome to the Healthy Brain Toolbox. I'm your host, Dr. Ken Sharlin. On today's episode, I have Dr. Efrat LaMandre, DNP, FNP-C. She is a nationally recognized nurse, practitioner, educator, and healthcare leader. She is the founder of Dr. E's Healthcare Consulting and a senior leader with EG Prep where she helps nurse practitioners bridge the gap between academic training and real world clinical experience. Dr. LaMandre is a passionate advocate for inclusiveness, compassionate. Team-based care and for empowering nurse practitioners to practice with confidence, integrity in a rapidly evolving healthcare system. Wow. Dr. LaMandre, welcome to the Healthy Brain Toolbox.

Dr. Efrat Lamandre: 1:29

Thanks. That was a great bio. I want you to write all my bios from now on and feel free to call me E.

Dr. Ken Sharlin: 1:35

E.

Dr. Efrat Lamandre: 1:35

Yes.

Dr. Ken Sharlin: 1:36

Perfect. We were saying before we started the podcast that we're kind of homies, I suppose.

Dr. Efrat Lamandre: 1:42

Exactly right.

Dr. Ken Sharlin: 1:43

From New Jersey and Staten Island, there you go. This is gonna be a really interesting podcast I have to say that I have not, publicly necessarily done on other podcasts, so I'm really very excited. And for the listeners, I think we're gonna divide it, into two broad areas I really want to talk about. The whole role of the nurse practitioner in healthcare and how it's evolving. And, let's see where it goes. Dr. E and I might have different perspectives and make it exciting. And then I think in this time of, strained politics it's important to talk about inclusiveness in healthcare and I can't think of a better guest to open up that discussion. Maybe an opening is I was watching the news or listening to news. I do both. I'm a news junkie and I'm in Missouri now, even though I'm from New Jersey. there was a comment along the lines of just physician shortage. And I'm assuming DOMD doesn't really matter, physician shortage in the state of Missouri, something like at least 2100 or 2300 doctors. I also read that the, in the new, the big beautiful budget or what, that were in the midst of that there was major cut, there were major cuts to nursing education and nursing research, which is, at a time where, of course our population is growing access to healthcare, how we access it, what we access it with. In other words, the healthcare insurance situation, the present time of the cuts and Congress and so forth. This really brings a lot of different issues to the head. And I wanna throw one other thing, into the mix. I'm a specialist and I want to speak to some of this from that perspective and what I hear from my patients. Not only is there a general physician shortage, but try getting into a neurologist. It could be a year or two. Many practices are bringing in what we call mid-levels, nurse practitioners. My patients do want to see the neurologist, and often they wait a long time they're my patients now'cause they've come to see me after this experience. They said I waited a year, I went there. The neurologist, spent five minutes with me, didn't answer my questions, gave me a prescription. I didn't even know why. I saw the nurse practitioner. I never saw the neurologist again. I just wanted to put all of those things into the mix. I am a huge believer in educating healthcare practitioners, educating the patients, and spending time with them in I collaborative relationship with nurse practitioners. How are we gonna juggle all of this stuff from shortages to maybe. Sort of a implication that to be a neurologist, I had to go through medical school internship, three years in neurology. I've been practicing for 30 years, the education for a nurse practitioner is much more compressed, right? It's not gonna have three years of neurology, residency and all that. Yet we ask the nurse practitioner to carry this level of expertise because in the end, we're in the care of the patient and have this oath that says, first do no harm. So how are we gonna juggle all that, meeting, all those needs, educating partnering, collaborative relationships or maybe, I think, you've said before that you think there should be a lot more autonomy. As opposed to collaborative relationships. What are your thoughts here?

Dr. Efrat Lamandre: 5:01

You made a lot of very different points and so if I'm gonna have to address as many of them as I can. First topic that you brought up was the shortage. The shortage is real. It is happening. And so we can get into some of the nuances that you brought up. Whether anyone likes it or not, has to fill the gap. We have a growing population, an aging population, absolutely one wants to be in primary care. The MDs and DOs do not wanna be in primary care, and I don't know who your audience is, but if they are lay people, you need to understand that to go to so much schooling, to go into so much debt. To practice, primary care, where you're unlikely to pay down that debt in a normal amount of time and still put food on the table. It's just not as lucrative as becoming a neurologist. It's also not so there is when students, young students are going to make a decision as MDs to be going to primary care versus ortho versus derm versus whatever. They're less likely to go into primary care or pediatrics'cause of the reimbursement. So the shortage is real. So whether it doesn't really matter what anyone's opinion is. We will get there, I promise, but it doesn't really matter because someone has to fill the role. And right now whether people like it or not, NPs are stepping into that role. NPs are in communities where not only are MDs not choosing this specialty. They're definitely not choosing it in marginalized communities. They're just not going there. They wanna go to the best hospital in the top city because that's what they want to go to. Again, generalization, but they're not opening up in a rural area of a town of 3000. They're just not, it doesn't make sense. But NPs are, I'm seeing NPs all over the country. I drive around to see them. I see nothing but tractors. I'm like, there's not even a building here. And then lo and behold, the only building in the middle of this town is a building owned by an NP, and she's taking care of every single person in the community. It's usually women. And so what's happening in reality is that NPs are opening up practices, taking care of people that no one in the country wants to take care of. And that's why it really doesn't matter, like if we're talking about, should they do it, should they not do it? Am I insulted by it because I'm a neurologist and I've studied for 11 years and why is somebody else doing it? We need to get comfortable with the fact that nurse practitioners are leading the charge and currently are the only solution for the primary care shortage. If somebody else wants to create other legislation, even if they legislated it now, It will take at least a decade to see the fruits of that legislation. So this is where we are right now, the faster we get to it, the better. But then what happens, and inevitably in this conversation is this conversation of if we're talking to MD and D and by the way, my son's in med school, many of my friends are doctors. So like there is nothing but love for MDs but there is this feeling of I went to school for so long and now these mps are just coming along without the same schooling and how dare they, first of all, as I said, it's happening whether we like it or not. This is the time. And I do think that if we had a better system, when it comes to specialists and you're specializing in one area, that is a certain tier. when we're talking about primary care, pediatrics, general care, in any industrialized country that has successful healthcare, they understand that primary care has to be large has to be wide, and then we have to have a pyramid of specialties going up. And because most people don't need, don't have a rare kidney disease, most people don't need a nephrology in their city or, and honestly, a neurologist in the city. As you get sicker, there's just less people who are, have these need specialists and so in a well tiered. Healthcare system, it would be a pyramid, huge primary care. I'm including pediatric in there and women's health on the bottom, and then specialties going up. Our country does it backwards because of finances is very specialty heavy. We're not primary care heavy. And so that's where we're filling the shortage. If we had this system set up and everyone was bought into the fact that at first you see your NP, because 90% of the issues world is gonna be generally, we can manage your migraines, we can manage your hypertension, all those general things. And once it is discovered that you need more specialized care, then we refer up to the specialist. I think that would actually be an ideal system.

Dr. Ken Sharlin: 9:17

Absolutely agree.

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Dr. Ken Sharlin: 11:13

What it looks like at that level. In other words, I always say that healthcare is not healthcare today. And to your point about you don't need necessarily a an MD or DO to give someone blood pressure medicine. We are still in this moat of disease centered care, but nursing has such a long tradition of education, teaching patients and all that. What if primary care was really where you go to improve your health so you don't get sick.

Dr. Efrat Lamandre: 11:43

That has to do with the way our reimbursement is set up, whether you're NP, MD, DO, PA reimbursement right is set up based on how sick your patient is. The sicker the patient, the more reimbursement it is. The more complex your patient is, the higher the coding level becomes from a three to a four to a five. Because they have all this complexity, you do not, if the system does not reward spending time for education or for prevention and wellness screening doesn't really count. That's already after the fact, so it doesn't reward it. It doesn't say, here's an extra a hundred dollars for sitting with Mr. Smith and talking about his diet, it's oh, send it to a nutritionist. So that is outside of the MD versus NP conversation. We have a system that absolutely is built on reimbursement for complexity, which means the sicker you are, the more you are worth in the system.

Dr. Ken Sharlin: 12:32

It's very crazy. I am not a healthcare management specialist, but for those listening who are not necessarily in tune with this we use terms like value-based care versus fee for service most of the time we're all doing Fee for service because it's just easier for a lot of people you have high blood pressure. Here's your medicine next patient. You have these high volume practices as opposed to setting up a system within your practice that actually is able to measure outcomes on your patients and say, look, as a result of spending more time as a result of incorporating nutrition and sleep and having some stress resilience practice or whatever my patients are, they're not as sick, they're not going to urgent care. They're not having to buy as many pharmaceuticals. Therefore, I should be reimbursed at a higher level.

Dr. Efrat Lamandre: 13:21

Gladly brought up value-based payment. it is an area that nurse practitioners shine in. I work closely with a company that helps NPs who own their own practice. Insurance companies are recognizing that when it comes to value-based care, nurse practitioners out just outshine MDs in this area. So value-based care just to add to what you were saying, it's this idea that we're not just going to dispense hypertension medication and just see you every six months blindly. It's this idea that we are also responsible to make sure that your blood pressure is low. Which means does that mean we have to see you more often? Does that mean we have to educate you? Does that mean have to send you home with a blood pressure monitor? We have to find out what are the obstacles on your way because there is a system out there that will reward primary care providers. For keeping their patients healthy. And that requires metrics and data and nurse practitioners are great at that value-based metrics is where they shine, which strengthens the argument that in primary care, we should empower NPs as much as possible, It would make your life easier if the patient's well managed and by the time they come to you, you're really, you're not dealing with uncontrolled hypertensive is coming to you with headaches, right? I don't really know what's coming your way, so forgive the example, but if you have someone who is otherwise stable you can focus on your area of expertise without variables that are maybe obfuscating the picture, I imagine your world would be easier.

Dr. Ken Sharlin: 14:44

it's a real culture change all the way around. I had with a patient yesterday, so obese, he obstructive sleep apnea probably doesn't wear his CPAP consistently. So veterans, he's been around some blasts. He's got narcolepsy, which has all sorts of implications from a functional medicine perspective, like gut permeability and all these other things. This is autoimmune disease and where I'm going with this low testosterone, severe fatigue. And then I investigated his testosterone level. and which of course it was. And as part of the blood panel that I order as a complete blood count and his blood sugar's 298 and he said I'm so fatigued and I don't really feel good. And I said, yes, because you have narcolepsy and we're working on that. He's taking the standard drugs for narcolepsy. It's not helping that much. Because also sleep apnea, are you wearing Your pap machine, your mask and all that. And on top of that, you can't walk around, with blood sugar of nearly 300 and think that you're gonna feel real good. I convinced him to see our dietician and you got some testosterone you have to ease people into that conversation about health behaviors. We'd round up the conversation and I'm not the type of doctor who's five minutes in and out. He says, yeah, but what am I gonna do about my fatigue? And I said you're gonna work on your health. You're gonna work on your health. you see the dietician? wear your CPAP. I'm gonna give you a testosterone, we're gonna start building health. But that's the culture change.

Dr. Efrat Lamandre: 16:14

That's functional medicine, Primary care, if we could do that for our patients, had the time to really go through each lever of health. But that's also patient dependent, right? Not every patient is ready for that. That used to be something that frustrated me, where I was like I want to do functional care for everyone, but not everyone has the ability in their life, whether it's mental capacity stress or financial capacity to embark on that journey. Primary care is such an important place because without medication, they would be lost. There was a time where I thought functional medicine was the only way, but I think there's a spectrum depending on where the patient is, we have to meet them where they're comfortable.

Dr. Ken Sharlin: 16:52

It breaks my heart that you and I have to get extra education and learn those root cause medicine principles because it makes the toolbox bigger. It means we can meet the patient where they are, some are ready for that, some are not I always say, we learn the science, but doctors or nurse friends, we're not scientists per se. Some are in the lab all the time. But my point is we're mostly behavior experts, This is shaped by normal human behavior. Most of disease that we deal with, either environmental exposure or human behavior, very little is related to genetics or at least genes, regardless of what you do in your life, it has no effect on the expression of that gene, more often than not, it does. I certainly think the ability of a doctor to engage the situation and say, not only, what are you ready for? But to use language to hopefully lift that patient to the next level, to open a little door and say, oh, I never thought of that before.

Dr. Efrat Lamandre: 17:52

I love that you said toolbox, and I love the name of this podcast, the Healthy Brain Toolbox, it is precisely that. And I think many of our colleagues who have not yet been introduced to functional medicine very much think that their toolbox is the only toolbox. The metaphor I use when I speak about medical gaslighting but as you get further educated, and you're right to say it is a shame, we have to do it in our own time or our own pocket, that we have to go back to school to figure out that there's another layer. But the more tools we add to our toolbox, the better providers we become. So it's a great metaphor. I'm loving it.

Dr. Ken Sharlin: 18:25

I read, on your website about medical gaslighting, and I'm really interested in hearing more about that and how you are seeing the gaslighting on one end, but on the other end where you see the future of nurse practitioners, their role in healthcare, bringing in AI and how does that, go into nurse practitioner education and the clinical application of this enormous skill set what skills are they gonna need to have in the future?

Dr. Efrat Lamandre: 18:55

Okay, so you asked me about the role of the NP. You asked me about the role of AI. You asked me about their clinical future, and then you also asked me about medical gaslighting.

Dr. Ken Sharlin: 19:03

It seems like they could be diametrically opposed to one another.

Dr. Efrat Lamandre: 19:07

I think Medical gaslighting stands on its own from that. Medical gaslighting is from a patient perspective, Medical gaslighting is the patient experience what they are saying is being dismissed. It is without question a bit of a click bait phrase.'cause people know what gaslighting means in a medical and they can get there. They know what that feels like and if they never heard the term before, but in fact when we unpack it gaslighting by its strict definition requires malice and manipulation. And I don't think that medical gaslighting happens for mal intent on the part of providers. There might be a percentage of people who are just not nice people, so let's just remove them from the equation. People who are not nice or purposely malicious, just in general, let's acknowledge that they exist, but that's not what's happening. I think what happens is many of our colleagues, NPs and MDs alike. Truly think that what they learned in med school is the entire scope of medicine. I see it, I hear it in every conference I go to. I see it on the internet. And like they really, the hubris and the really, and so what happens is if a patient comes in and says, X,Y,Z feel this when I have gluten I really think, I don't feel well ever going to the basement of my mold. And these are not conversations that happen in the medical community. And so there's just no, that's not true. What are you listening to? And the patient walks out saying, wow, I was really dismissed. And to a certain degree they are dismissed. But what I try to tell patients is don't take that on yourself as wow, that just happened to me. Take a look at your provider as have someone who has a very limited toolbox. It is like asking your plumber to fix your electric and then getting mad that they can't fix your electric when you go into a conventional medicine practice, and I don't care PA MD DO. They only know conventional medicine, will dismiss any other non-conventional medicine concerns as part of their curriculum because you know that in our curriculum are taught that anything else outside the curriculum is dangerous. It's nonsense, We had to unlearn that when we went to functional medicine. You have to like really wow, there's more to it. So Medical Gaslighting is experience. And then my goal in life is to educate patients so that they either know how to speak in the exam room or that they can reframe what happened in the exam room so that they don't walk out second guessing themselves So that's the medical gaslighting piece. Let's pause there and see if any questions come up.

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Dr. Ken Sharlin: 23:32

I definitely see that aspect of it in my own, world and interacting with patients. I wonder to what extent, it's layers of gaslighting because the provider as you implied in their education coming out of medical school or NP will. This is what you do, this is the way it is, and there is no other way. Take the pill and I'll see you in six months. I saw a commercial from Medtronic the other day that just nearly knocked me outta my seat. I couldn't believe it. And I guess they are one of the makers, of insulin pumps. Now granted, this commercial was directed toward type one diabetics, but I think they knew well that. All too often type two diabetics are put on insulin. And the message of the commercial was really, to me, very unethical. The scenario was, a guy goes into a pizza shop and he's about to order a slice of pizza. There's, a little voice saying," you can't just eat one slice of pizza" and the guy behind the counter is in this guy's fantasy world saying that or whatever, and the guy goes, you are right. I'll get two slices'cause I can turn up my insulin pump.

Dr. Efrat Lamandre: 24:41

Wow. That's really bad. Oh my gosh. You are so right about that, this thing.'cause they know that the type two diabetics are listening to that they know that they're gonna run to their endocrinologist and say, can I get that pump so that I could eat three slices of the pizza? That's the extrapolation you're right to have.

Dr. Ken Sharlin: 25:00

I sometimes say to my patients, do you do the take some insulin? I say yeah. Okay. Where do, what do you think happens to your blood sugar when you take insulin? I thought I just peed it out. Oh. Shoving more of that glucose inside the cell and just creating even more damage that got you there. More inflammation, more oxidated stress and so forth. So yeah, it's really very unfortunate. I do think that this sort of business about gaslighting dovetails in the topic of culture change and the new technologies coming in, and even the frustrations that so many of our patients feel this. Term that, Ooh, it gets me. But it's evolved over, the last 10 years is I research, I research on the internet because people aren't being heard.

Dr. Efrat Lamandre: 25:42

I can appreciate that because someone who's truly spending their life researching would balk at the idea that if I ask Google or chat a question, that's considered research. The democratization of information secondary to social media is a double-edged sword. I think it behooves us though, as providers to embrace it as much as possible if we don't embrace it, It's not going anywhere. So if we don't embrace it, we're just gonna become irrelevant. We'll have less and less people who will come to us for advice. this is The way of the world patients are between visits, going into their patient portals. Googling and chatting the faster we accept that, the better clinicians will be. I welcome it. they come in and say what they say, and it is my responsibility as a provider to walk them through what they think they saw and either to say, you know what? This has some validity, Let's do some testing to explain to them why it's not. But that's my job now to help them through that, because anxiety is also a medical issue. So if they're anxious about this, if chat told'em that they have cancer and that's what they're believing, right? That is also a medical issue that is my responsibility to address, I have to show them why it is or it isn't. So I do see that as part of my responsibility now. On the other side, sometimes they come in with some pretty good things and you're like, wow, I didn't consider that. Let's test that. I think it's great. when we talk about inclusivity, we tend to think of LGBT and the black and brown community, which is all very important. But we also have to have inclusivity to this technology. It's happening. Our patients have it. this is why I lean into it. I have TikTok, I have a YouTube, I have a podcast like you, like I lean into it. I try to give the best possible information out there so that people have a good resource if they're going, I feel like's my responsibility to at least create a channel where there's some valid information there. But yeah, my answer to you is to embrace it.

Dr. Ken Sharlin: 27:34

You think the profession itself is, faced with having to embrace the reality of AI and healthcare AI in our lives. Where's nurse practitioner education and the practice of being a nurse practitioner going with all that.

Dr. Efrat Lamandre: 27:48

It's going in the same direction where the rest of the world is. There's no difference. The faster, everyone just swims upstream with it. Do you see a place where it's specific for NPs compared to other providers?

Dr. Ken Sharlin: 28:00

No, Not necessarily right now. We're all exploring different tools out there, and some are. Surviving the test of time and others have become less relevant. But, I do think and building trust in them as I have had to, I have been playing with a AI scribe for the last maybe. Three, four months. I was very hesitant. And at first, I still took my own notes and used the scribe as a backup to see how well it did. I'm so shocked at how good it is that at this point, if I have a new patient evaluation, I don't even type anything in my computer because it, does a fantastic job of gathering the correct historical data, but allows me to have more eye contact and a better listening experience.

Dr. Efrat Lamandre: 28:47

A hundred percent. I discovered this when I've had scribes in my practice for a long time the notion of scribes just makes you a better provider because of eye contact. You're not on your computer, so every provider should have scribe because you're not busy with data entry.

Dr. Ken Sharlin: 29:02

Do you think that nurse practitioners are, there are u unique messages that nurse practitioners get in their education that's different from a physician that really makes the nurse practitioner stand out as a truly gifted, unique person in the equation that is healthcare?

Dr. Efrat Lamandre: 29:19

The unique thing about nurse practitioners is coming from the bedside, I spent many years at the bedside, I was a nurse first, For anyone who doesn't know, you have to be a nurse, first and then you go back to school to become as an NP being bedside makes you automatically more patient centric than someone who's only going to the bedside. The very first experience of the bedside is the one giving the orders. Which is MDs are right. Once they're able to practice medicine, as soon as they hit the residency, they're the ones giving the order. There's already a bit of a distance. and coming from the bedside I would say it's not necessarily the NP school that makes me unique. It's the nursing school that gives'em that perspective. And just being much more patient centric, where MDs and DOs are more. Protocol and guideline centric, not that they're opposing, they're both needed. They're not opposites, but it gives you a different lens and then you, that carries with you as you become nurse, generally speaking. Again, broad strokes here, nurse practitioners, ones that you know, they're very big on the education, understanding the obstacles in the way. they're more about the nuance of the patient standing before them. speaking than someone who has been indoctrinated to be around. The, a lot of the indoctrination is and how do we get the history and interrupt the patient and make sure we get this question right and then let's, and what is the guideline? And just it narrows and an effort to get to the diagnosis is almost narrows the patient experience it has validity and importance, but it's just a different lens.

Dr. Ken Sharlin: 30:49

I've likened this to a quantum physics situation, Schrodinger's cat, because truly integrative medicine means that you have to understand the patient as unique individual. Depending on how much your know, what your knowledge depth is and functional medicine, you can go, I understand you as a person. Mental, emotional, spiritual, but then I can even get into all the cell biology and all the drivers of disease. I also need to understand what we might call the natural history of a disease, even though realistically we're shooting our arrow through middle. And that statement would say that everybody with Alzheimer's the same, everyone with Parkinson's, they're not. But we still have to know something. When someone says, I'm experiencing this, I'm experiencing that. it's my role to sometimes educate'em that is actually really part of the greater spectrum of what this condition is and what we often see and how we typically handle it.

Dr. Efrat Lamandre: 31:45

Yeah, absolutely. You need both. we've talked about our colleagues who are completely indoctrinated and are not willing to think that there's other tools, but on the other side are those who think that those tools have no meaning or should be fully discounted. And that's not true either. So I think we need to take, we need to have true understanding of our disease process, understand the limitations of the expectations that we could have in a disease process and then broaden our horizons with the tools that we are allowed to use to solve it. It's really important to respect all the tools and use them for each patient individually.

Dr. Ken Sharlin: 32:20

I think still a very important related topic and that is LGBTQ+ and looking at healthcare through that lens. There's been such a shift in the present administration. Away from looking at things from a diversity perspective. And of course there have been changes to women's rights in terms of their choice to seek abortions, The very, unfortunate way that we're seeing in this country targeting transgender individuals. Having been through the AIDS epidemic myself, professionally seeing, what happens to a whole subset individuals who in the beginning, got ignored for who they were. And that's what made the whole thing that much more tragic and horrific at Grady Memorial Hospital in Atlanta, when I was a medical student intern it was horrible I did not go through that hospital experience with COVID, but I imagine it was equally barbarically horrible, in the ERs and the ICUs with all these young people intubated. But it grew my respect for a broader way of seeing healthcare and how we still meet people where they are. I'm curious about your experience and how you inject some of this into the education of nurse practitioners.

Dr. Efrat Lamandre: 33:37

First, I just wanna acknowledge that emotion that you shared. I think it just elevated the type of provider that you are, that you brought that to this conversation. So thank you for that. I wish that I lived in a world where we wouldn't have to say gay patient or the black and brown patient. I wish we lived in a world where it's just like patient was a patient, but it doesn't happen, right? And I understand that some people don't wanna hear about DEI anymore. But that's just not what's happening. I hope to one day get to that place where we don't have to have these delineators and humans are just humans but the fact is before there are still places in this country that I cannot walk around holding my wife's hand without being in danger. there are absolutely places where I know that just me looking the way I look, and I'm not transgender, I just happen to have really short hair and kind of wear boy clothes. That is just not safe for me. I just can't walk in certain areas in America at this point. And so I can't walk down certain areas or certain areas where I probably wouldn't be able to share a hotel room with my wife without being a victim of some sort of, and so that's just, hotel, let alone if I needed something from my provider let alone if my wife and I were bringing our children to a pediatrician who didn't accept it, I tell this story, it's actually in my upcoming book as well, a story of a young man who was going to his pediatrician who the pediatrician knew the parents, and so he had to stay closeted. He never came out to his pediatrician, never got prep. Never got any advice for safe sex. And so when he turned 21, he was so excited. He came to my practice and it was his first time getting an STD workup, was able to say where, what his life is and on his very first STD test, he was positive for HIV, which is insane. And that happened in 2024. So these outcomes are real, right? If you are scared to talk to your provider. If you're not going to have this conversation, my patients, I immediately ask'em, we're having anal sex. Are you a top, are you a bottom? It's just conversation let's make sure we do an anal pap smear. These are things that are just not happening in certain parts of the country. And the ramifications are huge. LGBTQ patients are at least twice as likely as non LGBTQ patients to experience. Just, delay dismissal. So it's real and it's there and the impact. And even if you as a human don't care, I always try to bring it back to finances because if we have our weakest links, our most fragile links are the ones that will bankrupt the system. You have to take care of your weakest links, even if you don't like them. So if you can prevent people from getting sick, if you can make sure people have access, it costs the country less. So even if you're not doing it for humanity reasons, do it because it makes sense. You always wanna take care of the people who even our diabetics who are the ones who don't get treated right, we know that in the Indian reservations, diabetes is outta control. They're not getting access that costs the country more money. No matter how you get to it, whether it's from a bleeding heart, or fiscal responsibility, take care of the people who have trouble accessing healthcare.

Dr. Ken Sharlin: 36:41

The curriculum side I come from like a northeast Jewish liberal, kind of background. Our family is very connected. Very connected to the community, very open. We don't have, the hangups or anything, but I am also 61 now. I'm a product of my generation and what I don't know about doesn't always mean that I intellectually exclude myself from a whole subset of culture, but it also means that I just missed the boat. I have to learn what some of these words actually mean. I'm not really naive. I'm just being transparent and I'm okay with that. I wonder if maybe we need to broaden the education What does it mean to be a top or a bottom? I know what it means, but I would not necessarily automatically think of doing an anal pap smear. There are other things, besides, where we're pointing the genital component of this. It's really what are you about as a total human being and what do I need to know to understand you better to provide patient-centered healthcare.

Dr. Efrat Lamandre: 37:42

Yeah. I love your vulnerability in saying I may not know. And I think ultimately that's the most important thing, every so often I'm asked to, give a lecture about LGBTQ Care health, so you, we give the lecture, but at the end if you're a provider and you don't know or are not sure if you just share that vulnerability with your patient. If you're like, Hey, I'm so sorry I'm not great at this product thing. I'm learning. I'm really trying. if you show that vulnerability as opposed to not asking or dismissing. Unless the patient is really just a jackass, that patient's going to just be more than happy that you created that space. So it's better to trip up and apologize and try and let the patient know. I still misgender some of my patients, right? You would think I get it right all the time. I don't get it right all the time. even though I am in the LGBT community. I am not well versed in trans or hormones, but I have specialists who are so I'll say, I'm not really sure how to titrate up your estrogen, but I know someone who I can talk to about this so you don't have to be the expert all things LGBTQ.

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Dr. Ken Sharlin: 40:26

Do you see a space for that in the formal education nurse practitioners or physicians?

Dr. Efrat Lamandre: 40:31

A nurse practitioner at school I'm often asked to deliver additional as part of an elective course. Yeah. So I don't know where it is right now in the medical curriculum if that's like. Hopefully they're teaching it slightly more than nutrition.'cause nutrition is like one, one time. If you're asking me if we need to, I think we could all do a better job adding it to all our curriculums across the board.

Dr. Ken Sharlin: 40:53

Special topics or, for populations or whatever. Things come into play and they come into play in surprising ways. In my practice, I have a woman who, is transgender, I didn't. for sure know that to begin with, and I was seeing for something really on the surface, you would think that's just totally irrelevant, has nothing to do with it. There was some neuropathy type issues and the narrative of the neuropathy made it sound like she had a very fairly rare and common genetic variant called Charcot–Marie–Tooth hereditary And in a particular subtype of Charcot–Marie–Tooth hereditary pressure palsies. Anyway, long story short, she also said that she had a son who had some inherited neuropathy. So I thought that probably this what's going on, so it go ahead and do some genetic testing. And I get a call from the lab company saying, we're having trouble interpreting this genetic test. And I'm like, okay, so we need more information for the patient'cause there's some Y chromosomes here. I called the patient And she said, yeah I transitioned decades ago at a time where we weren't even talking about this stuff. And she said, quite honestly, I don't even think about it anymore. Maybe I should have told you, but I didn't think it was relevant. it was back in the eighties or something. So it's maybe 40 years ago or 30 years ago, now that I worked with this person quite a bit, it's much more than neuropathy, being more patient centered, if I had known that from the beginning or know it now I really do think. That piece of her personal life narrative has very much played into her present health issues. Not because of taking hormones or anything like that, but the angst of those decisions and how it affects us at an energetic level, proud to make the decision that is in line with who we truly believe we are. I think those things still live with us. We're still subject to society judging us and all those sorts of things. I think it gets hardwired into the limbic system.

Dr. Efrat Lamandre: 42:59

It's funny, but isn't it's interesting. In this case it was that she was transgender, but don't we see that with our patients all the time where they're like, oh yeah, I didn't think that car accident when I had a concussion for three days was really important to tell you about. I think that goes back to what we said earlier at some point of having time, with our patients, because they might pre-filter things that they don't think are important for us to know. in this case I'm sure you hear this all the time in medical history oh, why didn't you tell me you had this bypass 10 years ago? That's really important information. And then getting to know the patient and to your point for those, again, this is definitely an out of the box thinking. that the stress around that and everything and how that affect your limbic system, your central nervous system your everything comes from that. And that is part of the health. Her entire health spectrum is really important and we cannot do that in this current model, regardless of what kind of provider we are.

Dr. Ken Sharlin: 43:51

I wanna ask you the big, bold question as we wrap this up. If you could design the ideal healthcare system for the next generation, what would it prioritize that we're currently missing?

Dr. Efrat Lamandre: 44:04

it would be two things. One, as I mentioned earlier, it would be a pyramid where a specialists were refused depending on the actual incidents of. In the population, How many specialized nephrologists, many specialized neurologists we need, depending on what's actually happening So that would be first, but then I would change. So if on the basis pyramid is primary care, I would change what primary care is about. I would include the rest of the social determinants of health access to care. Is only 20% of health, when we're talking about health, we have to talk about can people access food and can they safely walk in their neighborhoods and how is their water and do they have access to education and can they read and write and do they have a job and do they have shelter? And so if we don't manage all of that, but yet they can, we can get them in to see their primary care provider, like what have we really done for their health? So it would be the pyramid, but then that base of that pyramid would really talk about the entire human making sure they have access to the rest of the social determinants of health so that we can prevent them from ever needing to go up the pyramid.

Dr. Ken Sharlin: 45:07

Great. I wanted that to be the last question, but I want to share a vision that I have and see if it resonates when I joke, I say I'm gonna form a third political party called the Reasonable Party. But the current argument Republicans Democrats would like to see passing of the tax credits and lower keeping the premiums for within the marketplace more or less where they are. The Republicans want to get rid of those tax credits. And there have been some ideas floated around. About, instead of making it essentially subsidizing the insurance companies to keep the premiums lower, give the money back to the people, and then you choose what healthcare you want. And I think there's some merit to both sides. Personally, I do think that one of the things that's not being discussed presently in this debate is that because the Republicans forced this big, bold bill through without the healthcare tax subsidies, if they were to even vote on that now, it actually grows the deficit quite substantially. Over the next 10 years, and that's just for one year of healthcare. We already figured out how much money we're gonna borrow and they're gonna borrow even more, which to me, on the, just the purely economic side of things, it's just an insane way to do things. On the other hand, what I'm seeing in my community, and I'm sure in yours and all around the United States, is the growth of these concierge practices. Right where people pay a membership and what do they get? Mostly they get access to their provider, nurse practitioners, physicians, they get more time. Sometimes if it's a generic drug that's free, they need an x-ray. That's part of the membership. But my point is that those concierge practices seem to allow us to return to that old provider patient relationship that we all yearn for, both as providers and as patients. So I'm wondering if there is a happy medium. This would actually save a tremendous amount. But we say, okay, what if we had. Catastrophic care coverage, keeping the premiums low, but knowing it's I get 10,000 doctor dollar deductible. But if you have cancer, if you have the heart attack, if you have the stroke, whatever, you know you're gonna get good care. You're gonna get the coverage. But that everyday care, going to primary care preventative medicine, we actually put some of the money in the hands of the patient, say, now invest in your provider directly so that. Your provider can then get reimbursed for the type of care that you truly deserve.

Dr. Efrat Lamandre: 47:39

I would tell you that financial

47:41

model, despite what chat said, would not work,

Dr. Efrat Lamandre: 47:44

and I would tell you why. the reason why other countries make sure that the entire population is covered is because the premiums of the people who are healthy will cover some of the costs of the people who are not healthy. this happened in the thirties in this country, if you have an insurance that is only dealing with catastrophic events, it will bankrupt in two months. The way insurances work is that everyone pours in so that when you need it, you can have it. But if everybody in that group needs it all the time, there is nothing left. The reason the mandate existed to begin with is the only way the Affordable Care Act works is if we treat it, the way the VAs work. VA is a universal coverage. Medicare is universal coverage. These are not foreign to our country. And the way it works is that everyone pays into it so that when they need it, there is money there. That is why you need a mandate and making it like, should we give it? Should we not give it? The whole the soon as the mandate was removed. The system started to collapse and the prices started going up because it cannot function. Now, when we talk about direct primary care, we're not really solving something. We're giving the illusion of access, and this old school neighborhood feel. But as soon as something happens, you need to fall back on your insurance. If you need a lab test you're not paying out of pocket. If you need an x-ray, you're not paying outta pocket. And we created an illusion of this old school farmer house, kind of doctor. But it's not true because at the end of the day, you are still for the most expensive parts, utilizing the system, which just further breaks it. to cover everyone. You need to make it mandatory so that the 20 year olds, the 30 year olds, and 40 year olds. Who don't need it, will eventually, because guess what? Everyone gets older. So your time will come where you will need it. but that's how a system works. That's how the financial model works. And every attempt to create some hybrid opt out is not real. Medicine, they'll take you$5,000 a year or whatever to talk to you, but as soon as you need a CAT scan, your insurance. what have we really done with this?

Dr. Ken Sharlin: 49:55

Sounds like we gotta come back full circle and question the decision of the Supreme Court to get rid of the mandate, right?

Dr. Efrat Lamandre: 50:04

It was politicizing what's a known financial model, and they politicized it.'cause it's very easy to talk about why do I have to pay$300 and it was a great political strategy. Genius political strategy. Did not have the patient in mind at all.

Dr. Ken Sharlin: 50:16

No. This is a great conversation. I hope folks who are listening or watching him enjoyed it. Dr. Efrat LaMandre, thank you for being a healthcare disruptor and thank you for promoting the role of the nurse practitioner and our health system. It's so important and I hope these critical practitioners continue to wave this flag of inclusiveness, listening, understanding the patient, understanding that we all have a unique story, and I think that nurse practitioners truly champion that. Yes, they fill a critical economic role, but so much more than that.

Dr. Efrat Lamandre: 50:57

Thank you for the opportunity to have this conversation. It was a lot of fun and we didn't battle.

COMMERCIAL BREAK: 51:01

Hi everyone. Dr. Ken Sharlin here with the Healthy Brain Toolbox. I'd love to hear from you. If you have general questions about brain health, neurology, or the science of keeping your brain sharp. Send them to questions@healthybraintoolbox.com. I'll be reading your questions on the upcoming episodes. Please remember, these need to be general questions, can't answer personal medical questions, or provide individual medical advice. So if you've ever wondered about brain health strategies, lifestyle tips, new research, or the future of neuroscience, send those questions in. I look forward to hearing from you and who knows? You might even hear your question featured on the show. Thank you for tuning into the Healthy Brain Toolbox podcast. I hope today's conversation gave you new insights to protect and nourish your brain. Be sure to subscribe, leave a review and share this episode with anyone looking to take control of their health. Until next time, stay sharp and keep learning.