In this episode, we are joined by Dr. Nicholas Fogelson and discuss endometriosis, the gynecologic healthcare system, and the world of neuropelveology. Thanks for listening Uterinekind!
In the season of being grateful, we are definitely grateful for you Uterinekind. Thankful for your existence and unwavering determination to make sure we are seen and heard in this nation. In this past midterm election, uterinekind has shown up to the polls unlike ever before and it has made a huge impact. We are letting the world know that we are using our voice and vote to protect our health, wellness, and future. Thank you for getting out and voting!
Pop the champagne, today we are making history with Hello Uterus’s first male guest, Dr. Nicholas Fogelson. Dr. Fogelson is a board-certified and fellowship-trained gynecologist who specializes in endometriosis. He also specializes in the incredible, emerging field of neuropelveology which we’ll dive into! With a passion for digging up clues and getting to the bottom of things Sherlock Holmes style, Dr. Fogelson is dedicated to learning, connecting the dots, and caring about his patients until they are better. Listen in as we chat with Dr. Fogelson about the ways to navigate endo, the hidden truths about the reality of healthcare, the future of gynecology, and the exciting world of neuropelveology.
Lastly, we end on a high note. Our future is bright, thanks to the youth of our generation!
Thanks for listening, learning, and being you. And join us back here every Tuesday for all things uterus, in service to you, uterinekind.
Carol: Those who believe all sexes of the human species are equal. Voted and the uterus won. I'm Carol Johnson and this is Hello Uterus.
On today's show, we are joined by a world class endos surgeon and in a first for Hello Uterus, our expert is a he. His skills are slamming, but it's his thoughtfulness that makes him one of the best. And so Dr. Nicholas Fogelson gets the bulk of our time today.
But first, a quick uterus in the news.
All that needs to be said here is Thank you, Thank you. Thank you to those in the US for voting. Voting to protect the right to healthcare, including abortion care, which is essential for the health and wellbeing of over half of the world's population. It goes without saying that those born with a uterus deserve the same access to healthcare as those born with a penis.
I mean, right. Like , I don't even know what to say about that. The fact that, that's still a conversation that we have to have. It's just so ridiculous. But anyway, that message was delivered at the polls this past week in the United States. So thank you. From the bottom of our reproductive organs.
Thank you. And now allow me to introduce today's guest.
Dr. Nicholas Fogelson is board certified and fellowship trained. Dr. Fogelson went to the Oregon Health and Science University School of Medicine where he received his medical degree, and then he received a fellowship in advanced pelvic surgery from Emory University Division of Gynecologic oncology. Dr. Fogelson is one of the few surgeons in the country to focus nearly exclusively on the area of endometriosis care, including management of super complicated cases that involve bowel resection and urinary tract issues, and thoracic disease.
He's also just one of a handful of people in the United States who have entered into formal training. I guess I would call it an emerging field, , called neuropelveology. It's a field dedicated to a deep neurological understanding of pain and neurosensory dysfunction. And new surgical and non-surgical approaches to the management of pain and chronic pain.
You can connect with him@nwendometriosis.com. So it's like, you know, northwest endometriosis.com. Super easy to remember. He's also on YouTube. His videos are amazing and on Instagram. So let's meet up with Dr. Fogelson.
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Carol: Nicholas, thank you for taking the time to be with us today on Hello Uterus. You are our first male guest ever.
Nick: Woo.
Carol: Woo. Right. We, you should have a sash. We should have sent you a sash and something. I don't know, flowers, I don't know. Something
Nick: I'm like, I'm like the atom of the,
Carol: Yes,
Nick: I couldn't come up with a good
Carol: with a good metaphor. Well, you have, you have like, 20, 25 minutes or so to work on that while we go ahead and talk about some less complicated things, than metaphors.
I wanna point out that the reason why, uh, it wasn't like we just, were like, Oh gosh, we haven't had a guy on the podcast. Let's go ahead and do that. it really was because you have an interesting background, and it's one that we talk about a lot on this podcast. Specifically I'm thinking about the fact that you have a fellowship also.
We're gonna talk about some, Practices or, new disciplines that you are involved in and training in and in general, we saw you as, I think your patients see you as well as someone who has not stopped educating themselves. And, is really thoughtful in in how you look at your role in treating people who are living with these debilitating chronic conditions.
Specifically endo, but I would imagine you see other people, right? you, do you see patients who just come in with bad periods, the so-called
Nick: yeah, absolutely. I mean, many of those patients have endo. I generally have found the niche in taking care of people that other people haven't been successful taking care of. I guess it's my own personality that I'm kind of like interested in the Sherlock Holmes scene, process of trying to figure out what's wrong.
And I don't always succeed by any means, but I definitely succeed at times when others have failed. And often it's not because I'm like so fundamentally smarter or anything, but I just take the time. I think that, that if you, keep your knowledge up and you kind of allow yourself to be open to different possibilities, sometimes the pieces kind of fit together and give you the answer.
And, but it took a lot of time, like some of those cases. It just takes a lot of thinking and a lot of sometimes even like writing it all down and trying to draw lines between things and go, Okay, what, what does this all add up to? And, Developed my own practice in a way that allows me to do that.
And if I were seeing 30 patients a day in some like hospital employed practice, I would never be able to do that. That's kind of why I left that practice. That's the kind of practice I used to be in, and I realized it was limiting me from being the kind of doctor I wanted to be. I think what you said is true, and it's partially me, but partially like structurally how I've chosen to practice medicine allows me to do that a little more.
Carol: That's interesting. That's like the pendulum is swinging in the other direction because starting, I don't know that maybe a decade ago, probably longer, hospitals were buying gynecology practices and bringing them in house what I witnessed was doctors wanting that. Right. wanting to move in that direction.
Or maybe they felt like they had to move in that direction in
Nick: Yeah. They had to.
Carol: They had to. And then you, pivoted and did that, but then you left
Nick: Well, I was in academia, so I was, I practiced for university medicine for 14 years and I, and I was teaching medical students and residence and, that was a wonderful way to practice. Had a lot of really, great things about it. But ultimately I kind of wanted to strike my own path a little bit to trust myself.
And like I had a lot of instincts about how I wanted to practice what kind of doctor I wanted to be. And it kind of clashed a little bit with some of the structural issues that are surrounding being part of a really large corporate organization. And, um, I just decided to kind of trust myself and say, You know what?
I think what I wanna do is probably gonna work out and go do it. And I have to credit my wife for that, to be honest. I mean, she, she's very much a person that is out of the box thinker as far as careers. And I think if I hadn't married her, I'd probably still be working at Emory as the drone, you know,
Carol: Interesting. So what, what did she say that had you consider this alternate path or this change?
Nick: So much what she said is what she did in her own life. I mean, she's definitely done, her, done a variety of, taken a bunch of kind of jig jags in her own career that many people would've said like, it's not the stable path, you know, just not the secure path. so in some sense that kind of gave me like, Huh, okay, you can try something else.
And it's worked out great. Like, I'm really happy with my practice. I'm happy with what I'm able to provide for our patients. I'm happy with how I'm able to support my family doing what I wanna do. I'm happy about a lot of things. I largely don't have people telling me what to do cause I work for myself.
it fits my personality and it, and it's turned out good for the people I, I serve.
Carol: Absolutely. I was just gonna say from a patient perspective, and we'll get into this a little bit more, um, as we continue to talk, but from a patient perspective, It's like, finding, pot of gold at the end of the rainbow when you find a physician who is a specialist rather than a generalist.
And, and it's kind of weird because we think about gynecologists as being specialists, but I think it's safe to say that there are generalist gynecologists and then there are specialist gynecologists.
Nick: I mean, there are, of course, there are literally general gynecologists, and then there's known specialties which are like maternal fetal of medicine, urogynecology, gynecologic oncology genetics. These are all like boarded specialties. And then endometriosis surgery is not a recognized specialty, like this is a made up nonsense specialty that, but, but it's not like there's a certification on the wall.
but nonetheless, I think I can rightfully say that's my special.
Carol: for sure.
Nick: but people that are in general, ob gyn sometimes will say, What is this endometriosis specialist that's not, that's made up, They're just selling some nonsense. And I'm like, Yeah, you don't know what you don't know. There's the Dunning Kruger effect right there.
Like you, you had mentioned before we came on that someone that doesn't actually recognize what it means to be an endometriosis specialist doesn't understand enough to realize what they dunno.
Carol: And that, that's a perfect segue. One of the pieces that you wrote online involves the Dunning Kruger theory, and it was about your recognition of it and then applying that theory to your own life and looking at, you know, where you may have, been under the, the fog of Dunning Kruger. Can you talk to us a little bit about
Nick: Yeah. So Donny Krueger were, psychologists, I know, I'm not sure. Maybe they were economics people, but in any event, their theory is basically that, the more you know, The more you realize what you don't know and what that leads, because basically you have to understand that there is knowledge out there that you lack to come to realize that you don't know something.
And like if you're unaware of an entire concept or a field of medicine and then you don't like you, you're not even wearing it exists, and then you don't know it, then it's not like a gap in your knowledge. have the, the total amount of knowledge you're aware of, which is like the ceiling of what you can know.
And then you know what you know. And if you, if you have a really wide perception of what is knowable in the universe, then you're gonna think that you don't know very much
Carol: All
Nick: because you certainly don't know everything that is existing in the universe. But if you're not very well read and you're not very widely read and you don't read, you know, maybe you don't read books or you don't, do things that kind of expand your horizon about what is there to know in the universe.
Then you may get the perception that you know more than you do. and what Dunn Kruger showed through a lot of like self assessment followed by objective testing is that by and large, people that know a lot generally underestimate what they know. And people that know very little generally overestimate what they know.
And then when they, they broke it into quartiles, the people that knew nothing usually thought they were in the third quartile of the smartest believ, that they were the next to the smartest. The people that know the mo most usually thought they were the second meaning the, 25th to 50th percentile and kind of mixed in from there.
And so effectively, again, it's just that it breaks down to you don't know what you don't know. And I'll give you the, the Southernism, which was taught to me by Bubba Carter was one of my attendings when I was a resident. And it was, the eyes don't see what the mind don't, No.
Carol: It is spot on. It's so true. You know, it's like, I mean, I often refer to our human body as an exquisite system, but there are some things that happen and maybe it's conditioning, that really suggest that there are also other aspects of our human system that are completely haywire. Because it would be cool if it was just built in that it was clear what we don't know.
Nick: I was really happy with my medical education in medical school and it was very interesting that like one of the things that was on every single course in medical school, they had an evaluation at the end of every course. And there was a question on there that said, what did this course do for your comfort with medical uncertainty?
And I swear that they were planting that as a suggestion that you should be comfortable with medical uncertainty. Like, I don't think it was there to really ask you. It's not like, what, what are they gonna change about a course to make you more comfortable with medical uncertainty? I honestly think that they wanted you to see that question 30 times over four years
Carol: conditioning
Nick: to make you go, Oh, it's okay that, I don't know, something.
one of the struggle. And I, if somebody actually wrote that, that survey with the intention of conditioning a doctor to be comfortable with medical uncertainty, I'm gonna give 'em a Nobel prize for, for education or something because it works. Um, you're like, Huh, they keep asking me this.
Maybe this is important. one of the things that I think that sometimes people struggle with, doctors are sort of expected to have the answers. , particularly in, in some cultures and a little bit more in the past than now, but doctors were supposed to be like a higher level of, being or something where you're like, Oh, you know everything.
I'm gonna come to the doctor and they're gonna, they're gonna wave their wand and cure me. and so if you buy into that too much as a doctor, you start to think, Well, I have to have the answers. And then when, when a patient comes to you with something that you're not sure about and you're, you're, you have a gap in your knowledge of even understanding like what it could possibly be.
And you're left with, I don't know what's wrong with this person. And as far as I know, it's unknowable. What's wrong with this person? Then that leads doctors down the wrong road of blaming the patient. They start to say that the patient is crazy or the patient is making it up. I mean, there's an entire thought process about patients in pain being drug seekers, that it was pounded into me in medical school.
Carol: Really?
Nick: that come to the ER wanting narcotics, cuz they're in pain are drug addicts and they will make up anything to get their fix. Like, do you know how often that was told me, you know, how many er docs told me that, that basically that these patients were the ban of their existence and they're all just drug seekers that, that want to do this rather than buying heroin on the street.
Like I think it's bullshit. Like I, I'm not sure that that's ever happened. I, in my, in my entire career, I can honestly tell you that I don't think I've ever interacted with a patient that made up a symptom. Like what, what real motivation to someone have to make something up like they want help and when they explain symptoms to you that you can't understand and the only answer you have is to give them narcotics because they're in terrible pain.
if it's not in your wheel, wheel house to actually figure it out. For me, I am okay with people. Getting some pain relief until we can figure out what's wrong. and maybe we don't figure out what's wrong, but hopefully we do. like that was something that was just hammered into me and I that patients are lying to you, patients are making it up.
Patients just want narcotics. And I'm just like, Wow. That's a very adversarial way to think about your, your clients
Carol: so when you were in medical school and you're fielding this kind of, dialogue around people, like, are you questioning,
Nick: at the time I didn't. but I, I did later, I mean, it's not a savvy, I, I learned a tremendous number of wonderful things in medical school, of course. And I had a lot of great professors and they were not like, not horrible people, but this was something that was, that was sort of common, particularly in the ER that was a certain, uh, a certain amount of like us versus them.
Carol: Wow, that's wild. And that now with some, you know, hindsight, having treated so many Endo patients, you know, it would be great if you could go back and give, give a class to the educators about what it's like to pass out from Endo Paine. And also I think it's amazing, the amount of credit that they give people to be such fabulous actors and to be able to like effective.
Nick: right, right, right, right. I agree. and then also sometimes people will say, Oh, you don't look like you're in that much pain. It's like, you know what? At a certain point, if you're in pain all the time, you stop making a scene about it because like, what's the point? Especially if no one's listening to you.
you know, saying you don't look like you're in that much pain is pretty condescending, shitty thing to say,
Carol: Yeah, for sure. so it's interesting that the Dunning Kruger, the way that you've described it is like super clear to understand and it, makes me wonder if there's a projection style of Dunning Kruger and perhaps they, they got into this because interviewed hundreds of patients where they've said they've been undiagnosed, they've been dealing with chronic condition and, you know, a lot of pain or a lot of bleeding or what have you, and they still say, I a hundred percent trust my gynecologist.
and it's typically followed by, delivered me, um, he was my mom's gynecologist, you know, I'm picturing like this 175 year old person. and so is that like projection style Dunning Kruger where
Nick: I don't know exactly what that means, but I think, that's common. There is a certain interesting emotional connection between the, the obstetrical care and the gynecologic care. Like, these things shouldn't really be linked, in my opinion, like being a sleuth about unusual pain syndromes.
And for that matter, just being good at complex surgery has no reason, real reason to be connected to delivering babies. Like people develop a real emotional connection with the person that delivered their babies. Cuz they, saw them 12 times and then they were potentially in the room with them for a very emotional moment in their life.
It creates a connection. I, I experienced that connection many times. I used to love doing it. I love doing obstetrics for, for a while. I used to really enjoy that. but it doesn't necessarily mean that , you still only know what you know. You know, And, I think it's getting better though.
I mean, I get a lot of referrals from general gynecologists that are happy to know that there's someone that's interested in taking care of this patient that they don't know how to help, you know? And. To some extent when they think I can't help you and no one can help you, when it's, I can't help you, but I actually know somebody who is actually doesn't hate taking care of people like you,
Carol: Right,
Nick: and,
Carol: There's a little behind the curtain,
Nick: and, and, uh, then they will then refer them.
So, and, and not, I'm not the only, even in my own community, I think there's five or six people who have a good skill set and are interested in taking care of, uh, endometriosis patients and pelvic pain patients. But it's a challenge. I mean, you have to, honestly, like, I've had to work with my own therapist, unlike how do I be compassionate and empathetic without getting, or either being compassionate and sympathetic without being too empathetic, Meaning that I can't feel everyone else's pain for myself.
I have to try to help and to be okay with be, excited about succeeding and being okay with failing sometimes. and not let that be too destroying of my own psyche. Because when you take care of, and I, this would go along with people that are like taking care of cancer patients, uh, many of whom are not going to do well, to be be proud of what you're doing and try to do it as good as you can and celebrate the successes and be okay with the fact that you're not always gonna succeed.
Because unfortunately, like pain issues, particularly when they've been going on for a long, long time, have very, are very complex. and by complex I mean sometimes unsolvable, there, there can be neurologic reasons why people continue to feel pain. And having studied this neuropelveology that you and I were gonna discuss a little bit, I think I understand a little bit more about the nerve function or at least have re-familiarize myself with things that everyone learned in medical school There are, you know, reasons why people may continue to feel pain that can't fully be addressed surgically and may not be fully addressable at all. and that's, that's difficult. And so what, what I tell my patients is that like, I'm really happy if they're 75% better. Like that's a really success story.
and to not chase after a hundred percent better because it may not be achievable if you've been in pain for 15 years in your spinal cord and brain or just been completely accustomed to that. It, you can take off, take out the thing that started it all, but it's difficult to completely, turn back the clock on that, sort of sensation that they're having.
And, and there's some people that don't believe that. Like there's some people that believe that every person with recurrent endometriosis pain must need another surgery. And my own experience has been that that's probably not the case. That that we have to look at a lot of different modalities and try to help and also accept that Better is better and complete a hundred percent root resolution of everything may not be worthwhile to pursue.
Carol: Right, but getting to 75% for so many would be amazing. And then also, you know, having the, education that can carry them, forward from a surgical procedure so that they can start to understand their bodies better. And, perhaps there are things that we're discovering now that would help with, descending into the body, you know, imagining yourself in the body and just communicating better with your own system.
Um, I think they call it pain, pain imagery or something like that. I don't
Nick: well, I'm not a psychologist, you know, but I mean, there are definitely people that, that spend time in that kind of area, and I think it's worthwhile, um, at least for some subset of patients, I think that. I'm very positive about my patients using a wide variety of, of modalities to try to improve the quality of their life.
You know, I, I think all these things can be synergistic. I mean, I think that surgery for people that endometriosis, I think surgery is quite helpful. Medical therapy can be helpful too. And there's no reason to like have some sort of like crucifix in front of you holding you against medical therapy. I, I think that there are some people that feel that medical therapy is somehow, I don't know, like it's some sort of scam or something.
And it's not, I mean, the endometriosis is a, when it comes to endometriosis specifically, I mean, endometriosis is a hormonally sensitive, biologic process. And there are things that you can do to manipulate the hormonal system in the body that will make endometriosis less painful and less problematic.
There are certain characteristics of endometriosis that may make that work better than some patients and less in others. I mean, in some cases like endometriosis, it is an estrogen sensitive condition. If you, if you generally have higher estrogen, you're generally gonna have more inflammation and more pain.
So things that will decrease estrogen will generally be helpful. I, I hear sometimes people say, Well, gosh, endometriosis makes its own estrogen, so why would it matter if you reduce the amount of estrogen in the body? And it's such a theoretical idea. What I can tell you is that if you reduce the amount of estrogen in the body, people have less pain.
So I, I think what it means is that nothing is a hundred percent or 0%. Like some people will do well on medical therapy and there's no reason for them not to take advantage of that. If they're gonna do well, other people will not. It's a very genetically diverse disease, which means that it's not the same disease.
Like I don't think anybody, if you were to say that every cancer were the same disease, I think even in lay population, people would say, Well, that's crazy. Lung cancer's not leukemia. Like, these are two different things. Like everybody knows that. But I think that a lot of people want to say that endometriosis is all one disease, but if you look at it genetically, it's very much like cancer.
Like there are hundreds of genes that are coding for the condition of endometriosis. And many of these genes have been published, but there are also lots that are unpublished. And I used to work with a genetics company that was on the forefront of looking for this stuff. And they had a lot of gene signatures that if you had this gene, particular gene mutation, you were almost certainly gonna have endometriosis.
And what was characteristic was that these genes were very different. It wasn't like all, like there's lots of genes in the body that kind of code for the same thing, more or less. So it's not like all the genes. Cell membrane signalers, or all the genes were mitochondria, whatever. They were all over the body.
Like there were lots of different functions that could go wrong, that would lead you to have endometriosis. And that's just like, there's lots of reasons people can get cancer. Like there's a lot of different mutations that can predispose one to get cancer. and I think that, that, you gotta think of endo the same way.
So it entirely makes sense that some people will respond very well to surgery and some people won't. It entirely makes sense that some people will respond beautifully to birth control pills or progesterone, or even Lupron and others won't. It entirely makes sense that some people have widespread endometriosis and they have no pain at all, their only problem is they can't get pregnant.
Anybody that wants to have a very simplistic view of endometriosis as being just one thing that will respond the same in all patients. I, I think they're wrong. Like, and I, and I think that that will not be as effective as a way to address the disease state, because no one thing's gonna work for everyone.
it makes sense any more than one chemotherapy is gonna cure all cancers. Like we know that some chemotherapies are like murder to cancer, one cancer, and they don't do anything to another cancer because they're different diseases. So, I think that that's why there is no logical or rational reason to like, have some strong feeling against any particular therapy.
there's no reason to say that that Lupron is evil. I don't care if the company made up some data to get it on the market. Like that may or may not be true. There's people that believe that, but, and it may be, it is true. What the reality is is that some people do well on that drug. Not everyone, but some people do.
So some people do well in Alyssa. Like I don't write those things very often because most people have sort of tried it before they got to me. but these are options on how to take care of this condition, and it's, it's okay to consider them.
Carol: I'm glad that you brought that up in advance of me asking my totally not objective question around that because, , as you're describing it, I'm like tapping into my own bias here and going, also going back in time, to when I was dealing with some situations like this. And it feels to me like when we come to appointment three or appointment four and we're trying to address something that's super problematic, the, the prior appointments shape how we meet those next level appointments.
and I, it feels like what's happening is those first appointments, those first, general problem appointments, we are offered birth control pills to manage the symptoms.
And it's, it's not just that exchange. I mean, cuz that exchange is a unique exchange. The person could be just really having a bad day and, not explaining anything to you or whatever.
But that exchange happens, multiple times around the world. and then people come together and talk about their experiences. You know, like, yeah, I went in and, I just get offered birth control pills. And then it's repeated over time that, this is something that happens.
And so we kind of put up like a wall against it and it feels like the wall is our way of saying, I deserve a diagnosis.
Nick: Yeah, and that's very understandable. I think that people want to know what's going on. Like unfortunately, like ACOG's criteria is sort of like not about making a diagnosis, it's about treating symptoms, and they're saying that the, the standard pathway should be just focused on treating symptoms. Don't worry if they actually have endometriosis.
so kind of like throw a wide net, put people on hormonal therapy and they don't get better. Maybe, so maybe do surgery, maybe don't. , and probably ratchet up to every possible medical therapy before you consider surgery. again, like, I think it's a little done in Kruger because by and large, ACOG is ruled by general ob GYNs that don't know very much about endometriosis.
Like ACOG is the, the labor union of general OB GYNs, you know, at least they used to be, in a lot of ways that's, they're kind of like trying to protect the interests of general OB GYNs. Like realistically, General OBGYNs they probably. Try to operate on complex endometriosis.
I mean, maybe really simple cases, but they're not gonna do very well because they don't have the skillset. And again, it's not being critical of them. It's the reality is like the training that a general OB two gets, does not prepare one to be good at operating on complex endometriosis. Just doesn't.
Carol: Right.
Nick: And so when you have the big organization of the gatekeepers is made up of general ob GYNs, all of which haven't had too much deep experience in endometriosis. It's sort of a self, you know, it's an, a Boris sort of a self eating snake of like, well they don't think surgery works very well because they're not very good at surgery cuz they don't have very good results with surgery cuz they're not good at it.
And so then they think, well, surgery doesn't work, so we shouldn't be. pushing hard for surgery. Let's just treat everybody with medical therapy. but to be fair, I gotta be fair about something which is that being good at endometriosis surgery takes a long time. It took me probably like from the time that I decided that, hey, I think I wanna be an endometriosis surgeon.
I think I went and did a fellowship, I did it. I did a year of cancer training at Emory. I'm not a gynecologic oncologist, but basically like I did a year of cancer fellowship effectively. and then I continued to hone those skills for another four years in academia, working with other really good surgeons, But I worked with urologists and I worked with colorectal surgeons and I did a lot of stuff that people wouldn't do. Like if I had an afternoon off, I didn't have anything to do, I wander down to the operating room and like go into some urologic cancer surgeon and say, Hey, can I come scrub in and watch what you're doing?
Because I'm just like that geeky surgeon that does that. Like who does that? But. , they got to know me, I got to know them, They'd help me on their cases. So I get to see, Oh wow, look at that, vena cava resection, that's crazy. Like these little experiences just grow you as a surgeon.
So, and then I spent another five or six years after leaving academia, just continuing to get good at it. And even when I sort of had put myself out out as an endometriosis surgeon, I'm much better now than I was five years ago. And I was, I had a reputation in endometriosis surgery five years ago.
and I'll probably be better five years from now than I am now. So my point of that is that if surgery is the answer, it's not scalable. It's not like you can make enough good endometriosis surgeons to operate on everybody with endometriosis. it takes too long. And actually, from a structural point of view, they don't also don't pay surgeons well enough to make it worthwhile, like, , I've chosen a practice style that allows me to get rewarded for what I do, has its own pluses and minuses.
Unfortunately, like the pricing of endometriosis surgery is based on ineffective spending 20 minutes and buzzing some lesions. Like if you're gonna spend four hours and really thoroughly, thoroughly remove endometriosis, they won't pay you enough money to make that profitable.
Carol: It's so interesting. I kind of, I'm not sure if you were hesitating sharing that or not,
Nick: no, I'm open about everything, you know.
Carol: But it is something that people don't realize, cuz I think we think, oh, you know, that they're gonna be either be paid by the hour. There's just some sort of like, large package
Nick: Oh, no,
Carol: happening.
And it's the way that it happens is Yeah. . Some governing body determines this is the price that we're gonna put on this procedure. But they don't, change that price if the procedure is one hour or if it's 10
Nick: Well, you can put like a modifier on it and say, I spent more time. But I mean, you're asking for months of records review and then if you succeed, they'll pay you like another 20% or something. Like, it's not worth it. Like you delay getting paid by six months in order to make an extra $200. So nobody wants to do that.
it's unfortunately is the case. Like there are certain conditions that have kind of been like relegated to a place that makes it uninteresting to physicians, like physicians wanna support their families too. And, physicians are altruistic in general, but at the same time, if you say, Well, I want you to really focus yourself on a specialty that you're gonna spend five to 10 years being good at, and when you're done, you're gonna make much less money than you made when you started.
Carol: Right,
Nick: Like, how many people are gonna say yes.
Carol: Right. like you described, yourself at the top of our conversation, you need to have some sort of like inner quest to connect dots and to solve mysteries and things like that, to pursue it. And a
Nick: Right. And I have people ask me, So I mean, I'm an out of network doctor, which means I don't contract the insurance companies. Cause again, they don't want to pay not only what I think my services are worth, but like what I think I would have a career that I would enjoy being in.
Like, I want to enjoy my work. I want to feel like, yeah, I, I like what I do. I work hard and I feel like I get adequately rewarded for it. I don't want to do that and go home and, feel like I'm not being rewarded is a bit of almost like an institutional sexism to be honest, because you can be a really, really good cardiothoracic surgeon and you're gonna make a lot of money. But you can be a really, really good gynecologic surgeon and you're gonna make like a quarter of what the cardiothoracic surgeon made.
the cardiothoracic surgeon's almost always male. Not always anymore, but . Now it's probably like 90%. it's kind of like a big macho job. It's like the, it's the neurosurgeons and cardio surgeons are like the top of the feeding the totem pole of surgeons, And they spent more time in training. I mean, they, they spent eight, seven, or eight years in residency. It's like a leverage thing that the more time you spend in training, the more potentially you can grow it later, but it ends up being very imbalanced nonetheless. Like a lot of what I've learned was not in my formal training, It was me deciding to teach myself and me deciding to study and so forth. And yet that is not rewarded in any way by the typical system. And it is a real, uh, sexism let's just go with pelvic surgeons. A urologist who is largely focused on male pelvises.
Is going to be paid more for their time than a gynecologist who's focused on female pelvises. Why, I don't know, is just the way it is. I mean there actually is a story on why that is, and it has to do with, it is, it has to do with the fact that obstetrics and gynecology or linked.
And in the eighties when HMO started coming in and they started putting the, , I'll be fully admitting, like generations ago, doctors were pillaging the system by and making obscene amounts of money. And this is where people got the societal idea that doctors were way too wealthy.
And it was that at a certain time when insurance came out, a doctor could turn in a bill and insurance would just pay the bill. And doctors found out that if I wrote $2,000 on the bill, I got $2,000. Well, let's try writing 3000. Let's try, let's try writing 10,000. Hey, let's try writing 20,000. Well, they just keep sending me the checks.
So not surprisingly people just started fighting their charges cuz they just made more money. So eventually, and it took a pretty high number before people thought, Hmm, maybe this is too much. and so HMOs came in and started, basically the modern insurance system came in and sort of forced.
This idea that we're gonna put prices on what people do, and we're gonna stop paying them more than these prices. so what happened is when that kind of came in, ACOG got together and said, What are we gonna do to protect the reimbursements of our doctors? And they decided that predominantly what OB Gys were, were people that deliver babies.
And so we're going to protect the money in delivering babies, and we're gonna let the money in doing gynecologic surgery get slashed. Because we, we feel like, I mean, this has been pretty clear, well documented. We feel like if we try to protect both, we're gonna lose both. So let's just protect one. And so what happened was that, by and large, the fundamental payment system for gynecologic surgery got slashed while obstetrics got protected.
And it made gynecology into kind of like a subspecies of doctors that didn't get paid to operate And so it became unprofitable to be a really good gynecologic surgeon. And in fact, if you, if you do a fellowship in minimally invasive gynecologic surgery, when you come out of that, you'll make less money than you would've made by not doing the fellowship.
Carol: Yeah, we've heard that before on this show. It's remarkable. ,
Nick: these are incentives. You know, people say that physicians are all altruistic and not about money. It's like people, everybody wants to get paid for what they do, and everyone wants to feel like their hard work will be rewarded in one way or another.
Carol: Yeah. It's what, It's what we deserve and it's, and it's also, it's healthy,
Nick: Right. And so people, and so people that, that folk, again, like that kind of weird political thing never happened in urology. It never happened in
Carol: right?
Nick: whole rectal surgery or whatever. So we've kind of developed this system where, Gynecologic surgeons, by and large, are paid less than other surgeons. And it's also, you see a weird thing like pediatricians are paid less than internal medicine doctors.
It's like, well, the babies, the kids half the size, you should make less money. It's like insane, right? But that, that is, that is actually real. That, that an internal medicine physician who's trained very similarly to a pediatrician, like the pediatrician's kind of an internist for children, literally is paid maybe 30% more.
It makes no sense at all.
Carol: Absolutely. And it's more difficult to, to work with, kids and in the process of trying to
Nick: In any event, it doesn't, it doesn't make any sense. Unfortunately these systems have bias., you can get really deep into stuff and I don't know how much we wanna talk about this, but like you were mentioning that, you know, people are hospital employed.
What, That's why people then go work for the hospital because the hospital is willing to underwrite them because they bring the surgeries into the operating room. And the operating room is where the hospital makes the money. So, by working for the hospital, the hospital is willing to potentially underwrite the physician at a, at a greater rate than they can really justify on their own.
And so it makes it very difficult for physicians to be totally in private practice.
Carol: we walk around like, especially when you consider chronic conditions and there's, they're, engaging with the healthcare system multiple times, but they're not, progressing. And so to understand what's happening, that works against them, that is behind the curtain is really wonderful because it helps us address gaslighting, , So for instance, the way that you described the history of, OB and GY and, and how, you one was protected and one was sort of sacrificed, that really helps clear up the experience that many people have in their early problem appointments when they go to a gynecologist that is not a trained surgeon.
Nick: they're all trained surgeons that just have not as much experience as some others,
Carol: Maybe not a minimally invasive trained or, or a specialist. And then that ends up the, a lot of those people freeze their, quest to get better at that time.
Nick: Yeah. I mean, obviously I think a lot of people would love to hear about that kinda stuff. you know, one thing I tell, people is try to, if you have a complex problem, try to find, no matter what the problem is, whether it's endometriosis or, or your elbows broken, it needs to be pinned or something.
Like find somebody that does a lot of that.
I think some people perceive that if you were to, to gauge sort of the experience level and the quality of the kind of care you're gonna get, as if it's a, big hill and most of it's, piled down on the side of the, everyone's about as good as you can be.
Well, it turns out it's not true. it's just like everything else's a bell curve, like the average physicians are average and there's a small percentage that are pretty inexperienced and maybe call not very good. And then again, there's a small percentage that are really very experienced.
It's not all slanted to one side. And so You will get better results working with someone who does a lot of it. and I mean, me personally as a, as a physician, I would be very selective about who I let operate on.
Me. And also depending on what you have access to, you know, if you have, if you're working with Medicaid insurance, you're probably gonna have to take what you can get to some extent.
Like, maybe, maybe not,
Carol: What are the red flags that someone, can, pick up on, or just the signs that they're with a, with the wrong doctor?
Nick: Yeah, great question. I, I think. Are they listening to you? Are they having a real dialogue about various options? if you ask one, ask one question, if someone's talking about doing a surgery on you, how many times they do that surgery in a year? if someone asks me how many endometriosis surgeries I do in a year, I'll say two to 300.
You know, How many have you done in your life? Five or 10,000. most doctors general ob gys say, how often do you operate in endometriosis? A year they go 10, 20, something like that. like those aren't enough numbers, for a condition like that to be really good at it. or even a hysterectomy, Let's just say you're just bleeding and you need a hysterectomy.
How many hysterectomies do, do you do in a year? Your, if they say 10 they should probably do zero. that's not enough to be really good.
Carol: right?
Nick: so that's a pretty simple question, but I will say on the converse, I'm all for physicians trying to work with the best person they can work with, but at that point, give that person the benefit of the doubt that they actually know something.
there are times when patients can't let go of, this idea that they have to protect themselves from the doctor. And even people that go on to, work with me, and I'm like, you know, I'm arguably pretty good at what I do still. It's like a, a lot, there's a lot of barriers of like not trusting certain things and I'm like, actually, I do know what I'm talking about.
So, I would,
Carol: PTSD or abuse.
Nick: No, I think it is, the line that I, I use is, I find the physician you trust and then trust them,
Carol: Yeah. It's a great point to talk about sort of how to put the experiences that you've had behind and I also believe, not a doctor, right? So the stuff that I believe in is like . I believe in, being fully present for that doctor as a patient to show up in as informed and calm a state as possible so that you can take in information and so that you can heal well and so that you can leave these things behind.
one question on that, and then I know we only have a few minutes and I really wanna ask you
Nick: me,, let, let me,
Carol: is it accurate to say that if a physician says, I'm going to ablate your endometriosis, should you run,
Nick: Well, I think you probably should choose another physician.
Carol: Okay, so maybe a, a light jog , a casual stroll
Nick: Well, I, I would say that one thing I can tell you, see again, like you have a lot of kind of really monolithic truths that are out there about endometriosis that I think actually can be subtle. Like does ablation of endometriosis, is it ever acceptable? The answer is yes. Like there are situations where ablation is okay.
The problem is, is that you don't know that going in. Like you better be prepared to do everything that anybody can do. Like, if all you know how to do is ablation while you're not gonna be successful in plenty of cases, for example, if there's endometriosis on the outside of the uterus, you have to abl it.
You can't just like cut a big chunk out of the uterus cuz it doesn't have a parietal peritoneum. Like There's no skin on the outside of the uterus that you can remove. so if you're gonna treat that, you have to ablate it. but even then, there are ways to set your electrical system that allows you to ablate it more effectively.
Like you can almost vaporize tissue. Like I basically never ablate, but I vaporize sometimes. And you can literally set your, monopolar electrode in a way that it doesn't burn it. Like it literally like destroys it and it's gone. And when it's gone, it pretty much looks like you excised it.
Like you have a hole there, so it looks like you excised it. but again, like it's good if your surgeon has all the tools necessary to handle any situation. And if they sit instead, they say, Well, I played, I don't really have a lot of experience with excision. Well, there's a good chance they're gonna not be able to fully treat the disease state.
Carol: Right. Well, so let's move over to this interesting discipline that you are, pursuing now called neuropelveology and what is it and why have you chosen to go in this direction? Because you could just focus on being a worldclass excision surgeon, endometriosis, specialist. But you're, bringing this into the mix now.
How come.
Nick: The answer is, is because I don't think of myself as like an endometriosis surgeon like I am that, but like, what is my career? It's try to help people with complicated issues that other people haven't helped them with in the realm of pelvic pain. Mostly female, but I even take care of some males too.
Like I operate on men sometimes. And, neuropelveology does really fit into that. Like there are certain patients who have done poorly, with just endometriosis, excision. And when you operate on them and they don't get better, you're like, Huh? Like, what am I gonna do? Am I gonna go back and just reoperate them, try to excise again?
Sometimes what happens to those patients is they bounce from surgeon to surgeon cuz everybody thinks they can do a better job than the last one, which is often not true. Like if I operate on somebody that had surgery with some general surgeon, that general o gyn, I'm like, Yeah, I probably gonna be more effective than they were.
But if somebody had surgery by another really good endometriosis surgeon who I know of, it's like, well, they probably do it about as good as I do it. So like, what neuropelveology y is, is a thought process of really trying to think about neurologically, what is going on in allowing a pain signal to get from wherever it's starting all the way up to the brain trying to map that out.
And usually it's mapped out purely by what the patient is telling you. And being able to ask the right questions is kind of that Sherlock Holmes process of really being able to very be very specific about what a patient is feeling. . and sometimes it all adds up through your kind of like, you know, your web of suspects and you come up with it, you know, it was, it was Julie with the hammer in the library, you know, and then you go, Oh, well this is where the problem must be.
Like, I don't have an MRI that tells me it must be there, but it must be like the symptoms that they are having only have one intersection and it is that they have a compression at their S two nerve root on the right side. Well, neuropelveology was getting all of that knowledge that allowed me to try to make those connections.
And it's extremely complicated and I'm not perfect at it. Like it's complicated. I have my own charts that sometimes I, patients will tell me stuff and then I have to go back and look at my notes and go like, Okay, how does this go together? You know? and the second part of neuropelveology is the surgical techniques that would be required to actually do something about it, like, If you're operating in those areas, it's very deep, dark parts of the pelvis.
It's arguably dangerous if you don't, if you don't understand how to do it safely. So I would say the biggest part of it is, the knowledge. And the second part of it is how do you actually operate safely to try to address those problems? So sometimes there's actually vascular compressions of nerves in the pelvis.
in fact, I think that when people have cyclic sciatica, it is more common that there is a vein that is wrapped around the sciatic nerve that during menstruation that vein is picking up more blood flow and compressing the nerve that is more common than they're actually being endometriosis on the c sciatic nerve.
a lot of people say, Well, I have sciatic endometriosis. I'm like, you know how rare that is? Like it's really rare. That being said, the treatment is the same, which is to actually expose the c sciatic nerve surgically and look, and what I'll tell you is that when you go look more commonly, you find a vein kind of trapped around the nerve than you find endometriosis.
But either way, you're gonna have to look, I'll tell you the veins, a lot easier to remove in the endo two. Endo down in that area. Very challenging. And you're operating next to really, really big blood vessels. And there's a real kind of fear that you could injure the patient or kill the patient, to be honest, because these are large, large blood vessels down at the dark bottom of a deep, dark hole.
And you better be really confident in your ability to manage those spaces and also rescue yourself from potential bleeding. Cause it's very scary if you didn't. And so most people, most doctors have absolutely no interest in doing that because it, like when I looked at the videos of those kinds of surgeries that Mark Passover, who was kind of the father of neuropelveology, when I first looked at the videos of him doing like cyac nerve decompressions, I said, Oh, I would assume you would kill someone doing that.
Like it never occurred to me that you could do that safely,
Carol: That it was even possible,
Nick: it was even possible and then you watch it and you go, Oh, okay, well I can see that you just, it's like the person that walked across the fire swamp with the alligators and the piranas, and they managed to walk across every single stone and never get in the water.
You're like, the alligators. And the paras were there. They just got really good at walking across the stones. So it takes a, an interest in a very complicated intellectual process. B, a willingness to really focus on the surgical technique, operate on a lot of cadavers that you can't kill, and then being willing to try it with patients and c actually having the, sort of personality that says that I'm actually okay doing something that feels really dangerous and I'm confident that I won't screw it up.
it's a little bit like the person that's willing to walk across the canyon on the high wire you know, where they're like, I'm a really good high wire, high wire walker. And I'm pretty sure I'm not gonna fall, but if I screw up, I'm gonna die. And most people don't have that in their personality.
It's a particular kind of surgical thing,
so I've definitely been able to help some patients with neuropelveology type techniques that I otherwise would never have been able to help.
It is a set of tools for thinking about problems differently, and it opens up a possibility of helping some people that otherwise weren't helped. But it isn't the answer to every problem that ever existed. And there are still lots of pat. Not a lot, but there are still some patients that I was like, I don't know why you're in pain.
Like, I totally believe you. I know how it's getting to your brain, but I don't know how to fix it. And neuropelveology helped me to understand like how it got to your brain, but it, it didn't really help me to fix it,
Carol: Yeah, it's like, the Donner Pass in California. It's like seeing the Donner Pass and knowing. to get over the Donner Pass means that you're gonna survive. But then you're like, Yeah, but there's a really good chance I'm gonna die on the Donner Pass. So I don't know if I wanna go do that.
And, and you, you
Nick: it involve eating your, eating your colleagues or
Carol: right, and, in one of your talks about, , discipline, you mentioned that in order to really progress and become an expert at it, that you would need to shut your practice for six months and leave the country and go study elsewhere. And, so
Nick: may still do that.
Carol: which I, I wanna just say that you have to, right.
Because we, we are so desperate for people that will break through these walls and, be the one, if
Nick: Well, it's interesting, I just got an email. I, I was gonna go to Zurich, the end of this month, and I, and then I got to do this more training. it's funny, as we were talking, an email just came across that saying that I was on the waiting list and saying that actually now I can go. I'm not sure I gotta, I gotta make, see if I'm gonna be able to go or not. So, so late. But yeah, I mean, listen, again, it's these structural issues. Like if you are an employed physician, are you gonna be able to, I mean, first of all, you gotta spend like 2000 euro just for the ison course.
So people are spending that of their own money. Probably a lot of people don't wanna do that. It's not that much money. But anyway, it's a barrier. The other thing is you're not gonna be rewarded for it. Like you have to be really interested in it, and hopefully you have some mechanism to be sort of rewarded for it in some way or another.
You know, I'm all about becoming as good as I possibly can be, and, and finding, trying to understand things that I didn't understand, like to me that that's what's fun about being a doctor, you know? but you don't wanna do it for no reason. But also, like, personally, I don't have that high needs for, for rewards to be honest, but higher than the insurance wants to pay me.
again, it's like one of these things, people in academia often are very interested in these very niche areas because the reward is different. The reward is academic promotion and writing papers and like that is something that certain people are interested in. But even there, it's difficult.
Like if I had been at Emory and I said, I want to go to Zurich for three months and do a fellowship with Mark pos over, they'd be like, uh, they probably wouldn't pay you. You'd probably have to go and do it and not get paid for three months. So you better be able to have some money in the bank or something.
Carol: and then they might want you to sign a contract that like
Nick: Oh, and then when you get back, they're not gonna want you to do the surgers cuz they're gonna say they're experimental and their lawyers are gonna freak out that their surgeon's doing something that's experimental. And so, do you have privileges to do a Cy neuro dissection? Only neurosurgeons have privileges to do c sciatic neuro dissects.
Do neurosurgeons know how to do laparoscopy? No. so,
Carol: Sometimes that Dunning Kruger effect is like a blessing because you're opening my eyes to some things that I wasn't aware of and it's like, Oh, no. Now we have another, another issue to
Nick: but it comes up to that. Like part of why, one of the things I like in private practice is I have a little bit wider latitude on like what I'm allowed to do. Like I do things with bowel, I do things with urinary. I still call in colleagues when there are things that I feel like they could do better, but like when it comes to like cutting out a piece of the bow wall and suturing it up, I'm probably better at that than a lot of general surgeons because they don't do that a whole lot.
So, in a large institution, someone would say, You don't have privileges to do that. You should probably call the general surgeon. And then the general surgeon's like, Well, I don't do that either. but they're gonna try to do it even though like, I'm the one that watched 10 videos on how to do this and went to a course and stuff.
So,
Carol: lots to
Nick: yeah, neurobiology is funny. Like I've operated on men before. The American Board of OB gyn for some reason says that you should never operate on men if you're a gynecologist. It's like, uh, I don't know why necessarily, but again, this like neuropelveology kind of falls into this niche, like men have pelvic nerve problems.
Does anyone else know how to operate on them? No. So I've done. Like Tator nerve neurolysis for men. I've done pal nerve surgery for men, the anatomy's the same. Once you're in there, I, I notice that all the muscles are big and fat compared to the women, but, not a lot, but it is noticeable.
I'm like, Oh, wow, that's a lot bigger.
So I mean, that would never fly if I'd been in Emory, me operating on a male in the Department of Gynecology, I just never would've happened. You know, they would've said, Well, a urologist has to do it.
I'm like, Well, how's a urologist? Spent years trying to figure out this particular area. Probably not
Carol: Yeah, so it's all of these, um, it really does. It's so funny that we started with Dunning Kruger, and it, and everything that you've talked about goes back to that. It's like the questions that a health system would ask a doctor, they illuminate what the person at the health system doesn't know just by the nature of the question that they're asking or the demand that they're placing on that person.
Nick: Sometimes, Yeah, that's part of why I left. You know, those systems are really good for a lot of stuff. I mean, they produce a lot of academic research. They, they do a lot of good things. not, I'm not being globally critical of it, but it didn't fit quite with what I wanted to do. It would've been
Carol: all of that. We need, we need specialists, We need, people who deliver babies. We need specialists who, understand a wide variety of chronic conditions where the root cause is unknown. And there's so much learning that's going on as we're treating this. just one last thought about sort of where we're at in time.
I often think about if we had funding and, and the, proper equal attention to the female system, that over the next 10 years we could be looking at an explosion in technologies that could be brought to bear on some of these conditions. and in order for that to be effectively rolled out and scaled across the millions of people who are living with these conditions, we need to have.
Structure in place , and funding in place, and we need
Nick: Well, there is, I think, I think that people under underestimate how much money is going into solving these problems. You could make a, a good treatment for endometriosis, I mean, you'd make billions of dollars trillion. I mean, it'd be insane. So believe me, pharma, Pharma is very interested in finding good treatments for endometriosis.
And I'm not just talking about making, like hormonal modulators. , better treatments than that. There's a certain amount of like NIH funding and so forth, and there was a recent bill with, I can't remember previous presidential candidate. a couple of people, but I was actually across the aisle between some Republicans and Democrats trying to improve NIH funding for endometriosis.
And they did that. but the amount of funding in the private sector for endometriosis is a lot. I mean, they're, they're really working on it and. They'll get somewhere. You know, I think that there are very significant frontiers in genetic treatment for endometriosis. Like as we better understand what are the genetic origins of endo.
I think that we're going to get to a place where we sequence women's DNA or people with endometriosis dna and we will find a subset of them that we all have genetic targets to treat. And I don't know if you notice, but like every television ad now is for some recombinant antibody like, or halts or, revi.
And what are all these drugs, right, that you see when you watch Jeopardy? Like nobody advertises for the $30 a month antihypertensive anymore. Like they're not selling ads for that. They're selling ads for $50,000 a year of recombinant antibodies that are gonna magically cure something. And believe it or not, these drugs really work.
Like if you have eczema, there are a variety of drugs that will make you not have eczema. Pretty much. And they're amazing they're expensive to make, they're expensive to research. Part of why healthcare costs keep going up. Cause people keep coming up with expensive things to do, they're useful.
and so that technology will come into endometriosis also. In fact, some of those drugs that are even being used for like Crohn's disease or being used for even eczema or something, might have use in endometriosis because they're all profoundly anti-inflammatory. They like their i i l six modulators or TNF alpha modulators.
And these things have impact on like uc or, uh, Crohn's disease, like those things might work in endometriosis. I don't think they've been trialed. . But they may be, and there may be other , either recombinant, antibody type things or possibly even direct DNA type treatments.
The technology is a really, is a really open field there of interesting things people are doing. I mean, we are just on the, edge of starting to be able to actually modify people's somatic DNA they can modify the DNA of an embryo now so that it will be born differently than it was destined to be born.
And that DNA change will be persistent throughout that person's life. Um, of course it's all been, it's not in people that are born its own embryo research, but. There's a future where if you have a gene, like a mother has endometriosis, and, and we can tell what gene she has, and you could even maybe just do IVF and select the embryos that didn't get the gene.
Like those things are on the horizon. They'll probably exist in my lifetime, like I'm 47 now. I wouldn't be surprised by the time I'm 60 that those kinds of things are either on the market or very much in heavy research.
Carol: And that is, so thrilling. the person who today had to call out from work, you know, isn't gonna be excited, about something that's happening 10 years from now. But, but I think it's really important that we, just in general, we non-clinician pay attention to what's happening in the research
Nick: people say, Oh, there's no much money being put in endometriosis. I'm like, Well, there's not that much money being put in by the nih, but there's a lot of money going in endometriosis, believe me. the, the genetics lab that I used to work with called Genome Biosciences it's also predictive laboratories in Genome Biosciences in Utah.
They spend more money on endometriosis research than the entire NIH budget for endometriosis research.
Carol: What is the name of the lab again?
Nick: called Juno Biosciences. So,
Carol: good to know because, Because what NIH is spending is, pathetic.
Nick: yeah, it's not, endometriosis is getting a little bit more sexy. Like people are willing to spend a little more on it now. Like breast cancer is very sexy. Like breast cancer's very common and, it's terrible of course. there's a disproportionate amount of money spent on breast cancer compared to the number of diseases that exist in the universe.
Carol: Yeah. Well that, and the breasts don't have the ick factor, , there's, that I factor and who knows how much of our subconscious, um,
Nick: breast cancer's largely curable, like most people with breast cancer survive it.
Carol: Yeah. And as you said, there's different kinds of breast cancers, so there, there are some that are less aggressive and more aggressive. Well, we could go on all day, but I am sure that you have an appointment in a
Nick: Well, I think I've already missed another thing, but That's okay. I
Carol: Oh, no. So, I, I hope that you will come back on because
Nick: be happy to. I, I'm, I'm, No one has ever accused me of not having something to say so.
Carol: Excellent. And I also want people in the interim to be able to find you physically, but also where can they hear more of you? Because you do show up and talk about topics on Instagram and YouTube.
Nick: Sure. I, I'm on Instagram, uh, Nicholas Fogelson. Um, you can friend me on Facebook. if you want, if you friend me on Facebook, it's Nicholas Fogelson physician. Send me a little DM saying that you actually want to be on there, because I have like a million like pending friend requests and I don't always go through it all.
, my Practice Northwest Endometriosis and pelvic surgery in Portland, Oregon.
We have some blog posts and stuff, but it doesn't get very much traffic. Like I mostly put stuff on Facebook and I. . but you can friend us on Facebook, the practice too, and that gets, uh, usually things copied over to there.
I talk on a variety of different things, and so you can catch me in various places. also if you're interested in seeing surgeries themselves, if you go to a, Northwest Endometriosis and Pelvic surgery is a channel on YouTube, and we have a lot of surgical videos and also some educational pieces of me just talking, going blathering on about something.
So there's occasionally I just talk for 15 minutes into the camera and post it on YouTube. So I'm always interested too, like, what do people want to hear about? If someone sends me an email through the website, something they'd like to hear about, you know, sometimes I'll, pick something out like that and talk about it.
Carol: Excellent. Well, we can't thank you enough. I hope that that other physicians in training are looking to you as an example, as to how to, create a career that is not just, satisfying and rewarding, but also fits a real significant need that we have right now, which is the need for experienced, surgeons that can tackle some of these incredibly complex conditions.
So thank
Nick: they, if any of those doctors are listening, my one piece of advice is be yourself. There's no doctor persona and personal persona. There's only one person, and the more you are that one person with your patients, the better a doctor you'll be, it just works out that way.
Carol: Yeah, it's so true.
Nick: not everyone does.
Carol: Yeah, I, I agree. It's interesting. I hadn't thought about that before, but it's very true. You, put on the, the white jacket and then you put on some errors with that
Nick: I don't even have one. I used to, We get dirty, man. I'll tell you a funny story. This is just a funny story to go out. So as a resident, I wore around a white jacket all the time. I also was, you know, as a resident, you're just like a stinky, disgusting person. You don't take enough showers, you're working 110 hours a week.
It's, it's horrible. But I mean, I didn't launder my white jacket very often, and eventually it became like yellow, brown jacket, right? And, and, and so I'm doing a rotation at, , in, at reproductive endocrinology, which is infertility medicine. And they're like the, she, she fancy people, right? And so I show up at their office in my disgusting white coat, and they look at me and they say, Hey, you know what?
You can throw your coat into our laundry. They'll launder it for you.
Carol: Oh, no. . Oh no.
Nick: And, and, and that was like the, the Southernism way of saying, Your coat's gross man. But what was funny is that after that I was like, Oh, wow, that's really nice. Like the white, the coats like bleached and, and crisp. And I became completely, uh, from there on out, I was like, Oh man, yeah, this is much better.
And then I'd throw my coat into their laundry for years.
Carol: Oh.
Nick: And, even when I went on their rotation, I just like go throw my coat in their laundry and then come back to their rack of coats and take my coat.
Carol: That's
Nick: so they said I could throw my coat in their laundry. Said I did.
Carol: Yeah. So you, you took that up at, at that early stage were you thinking, Gosh, I should have become an REI doctor?
Nick: Uh, at one point I was very interested in it, but I actually, I found that it was very, very, Very repetitive. it's all IVF really. And it's just like ivf, ivf, ivf, ivf, ivf, ivf. And again, like IVF is by far the money maker of infertility. And so there's always a push and it's, it's also the most effective way to get someone to get pregnant.
And so everything funnels to ivf and it just felt like you, you're just like this IVF monkey. And I don't mean that as an insult to some, If someone hears me saying that, I don't mean that. Obviously there's a lot of science to it. There's a lot to know. And I'm not saying that there isn't, but, it seemed to me to be fairly repetitive and it, it ultimately, like, it didn't seem as interesting to me as I thought it would be
Carol: Yeah, well that just goes to show that, first of all, doctors are human too, and they need to be inspired by the work that they're doing. And quite honestly, not everything that a doctor does is inspiring. So, you know, it's following that path is,
Nick: too. But I remember when I was younger and making those decisions in my life, Ari I felt very transactional to me. Like, you're buying IVF or you're buying it, trying to buy a baby. And at that time, my idealistic doctor who thought that was bad, I don't feel that way now actually. But, but I remember at that time feeling that way.
, it's interesting now what I do is kind of transactional while also, although I'm absolutely doing my best to help patients, but in the end I charge for it. So, , it's interesting, like we evolve as people, we start to see different sides of things , you're a different person when you're 47 than when you're 30
Carol: If you're paying attention,
Nick: Yeah,
Carol: , this has been amazing. Thank you so much. I really appreciate your time today.
Nick: All right. Thank you.
Carol: We'll be right back with ending on a high note.
Our future is bright. Our future is bright. Can you feel it? I feel it. It's like there are, there are people who care out there in the world. So that's cool. That's super important. People got up and voted in massive numbers to protect the lives of those who have a uterus. Super great. And then we've got people like Dr.
Fogelson who are, who could like, you know, have their practice and then kick off the rest of the time. In the Pacific Northwest there's hiking, there's fishing, there's eating, there's wineries, there's all sorts of stuff. But instead is pursuing things like neuropathology. I mean, it is just so exciting.
And so now ending on a high note on this super long but hopefully chalk full of information podcast. We are going to meet Leanne Fan. So Leanne fan developed Fin Sen headphones and as a result, she was named the Grand Prize winner of this year's 3M Young Scientist Challenge at. The age of 14. Now if you see her talk, you are just like, what?
I feel so incompetent. Amazing intellect. , super creative, obviously. And came up with this amazing low cost headphone device that uses machine learning to detect whether or not there's a mid-year infection, and then if there is, uses blue light therapy to treat it, potentially preventing up to 60% of hearing loss in children.
These infections, these mid-year infections, as we know are very. like, , how does it, how does somebody come up with that F 14? Like, you're, you're that brain. I wanna study that brain. I would like to have a clone of that brain. Please. Could somebody get me that brain? So she's also thoughtful and compassionate and empathic because she made sure that the device was super easy for kids to wear and they could even listen to music while they're being trade.
It's just brilliant. I'm here for the next generations creative problem solving, especially when you consider that, that they can weave that problem solving with new technologies and use the outcomes to diagnose and treat conditions and prevent further harm for all. And Wow. The only thing we need to do now is to just kind.
Really make sure that we're treating everyone equally. And that, I watched a video that Leon, put out on her invention, and she says it too, that everybody, regardless of where you live, of who you are, of what you look like, of what organs you have and how much money you have, everybody, every human being on this planet deserves the right to access healthcare like we have to.
cooler with each other , and, be more empathic and inclusive and considerate and, all of that good stuff. So the cool thing is that there, there are people out there that are, already there and we're gonna drag everybody else with. Absolutely. It's an exciting time and we're so glad that you're here with us.
So thank you for listening to today's show. Thank you, Angel and Maryelle for producing Hello Uterus. Our guest, Nicholas Fogelson and the team back at Uterine Kind and all our partners who are busting butt to build an app that will shrink the time from symptom onset to diagnosis for those living with chronically bad periods, which.
Possibly undiagnosed chronic conditions. So more on the app in the next few weeks as we get ready to launch. Till then, be well, be cool, be kind.
Angel: The Hello Uterus podcast is for informational use only. The content shared here is to not be used to diagnose or treat any medical condition. Please speak with a physician about your health conditions and call 911 if it's an emergency. And thank you, Uterine kind for listening.