Transforming Diabetes Care with Dr. Sandra Indacochea-Sobel
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🎙 Episode 3 | Endocrine Matters Podcast
In this episode, we sit down with Dr. Sandra Sobel, a board-certified endocrinologist, lifestyle medicine specialist, and obesity expert based in Pittsburgh. Dr. Sobel shares her journey from practicing in traditional clinical settings to founding her direct care practice, Summon Health, where she delivers comprehensive, patient-centered care.
We discuss the limitations of conventional endocrinology, the importance of lifestyle medicine, and how direct care can provide more personalized and effective treatments. Dr. Sobel also highlights the need for cultural and systemic change in the medical field, encouraging physicians to explore innovative models to better serve their patients.
If you are a patient struggling with diabetes management or a physician looking for ways to transform your practice, this is a must-listen!
Listen to the Full Episode
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Key Topics & Timestamps
Skip to specific parts of the episode:
06:30 Challenges in Traditional Practice: How administrative pressures hinder patient care.
12:45 Lifestyle Medicine in Endocrinology: The importance of addressing nutrition, sleep, and exercise.
20:15 Moving Beyond Diabetes Management: Why focusing on root causes can lead to diabetes remission.
27:00 Direct Care Benefits: How personalized care improves patient outcomes.
33:45 Barriers in Insurance-Based Systems: Why lifestyle medicine struggles in traditional models.
40:10 Personal Health Transformation: Dr. Sobel’s own experience with lifestyle changes.
47:15 Advice for Physicians: Encouraging exploration of nontraditional practice models.
54:00 Closing Reflections: The critical need for systemic change in healthcare.
Episode Highlights
Key Takeaways:
The limitations of traditional endocrinology practices, including time constraints and administrative pressures.
The role of lifestyle medicine and nutrition in improving metabolic health, diabetes care, and overall patient outcomes.
The lack of formal nutrition training in medical education and its impact on endocrinology practice.
How direct care enables deeper patient relationships, personalized care, and the flexibility to address root causes rather than merely managing symptoms.
The challenges and rewards of transitioning to an alternative practice model, focusing on aligning patient care with professional values.
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Arti: Absolutely thrilled to have the one and only Dr. Sandra Sobel and endocrinologist Lifestyle Medicine Specialist and Obesity Expert as [00:01:00] my guest today. Dr. Sobel was my attending during fellowship and little did she know I aspired to be just like her when I grew up. Her patients adored her, trainees loved working with her, and even consultants admired her.
She always seemed effortlessly put together, gorgeous, smiling, and radiating positivity. You could tell how much she loves her two kids. And how much her husband adores her. And honestly, who wouldn't? She's a goddess. Dr. Sobel is the kind of person who is genuinely kind, compassionate, and relentlessly dedicated to going the extra mile for her patients.
She's brilliant, humble, and everything you would want in both a physician and a friend. So when Dr. Sobel reached out to me after I started my direct care practice, curious about how she might start her own. I was floored. As a young physician doing something completely out of the box, I faced quite a bit of skepticism and even outright criticism from within the [00:02:00] medical community, particularly in my specialty.
Many people told me my practice model would fail, that no one would ever want to see me, and that the whole idea was doomed from the start. Before Dr. Sobel, only one person believed in me, my sister in law, the best. So when someone Not only supported my work but wanted to emulate it, it was a major OMG moment for me.
It was validation on a level I'll never forget. And for that, I'm forever grateful. Dr. Sobel shares my passion for lifestyle and nutrition in endocrinology. She geeks out over continuous glucose monitoring just as much as I do. And she treasures her relationships with her patients. But let's be clear, direct care isn't all roses.
While it's easy to assume direct care is just a way for physicians to make more money, the reality is far more nuanced and risky. In an insurance based endocrinology practice, the patient pool is guaranteed because there is such a shortage of [00:03:00] endocrinologists, and most patients are accustomed to using their insurance without fully understanding the actual cost of their care.
In contrast, starting an out of network practice with transparent upfront pricing can make patients uncomfortable. Healthcare is one of the only industries where people are oddly okay with a bill me later approach, which makes the direct care model a huge financial, emotional, and spiritual risk. What sets Dr.
Sobel apart is her belief that nothing is more important than treating her patients thoroughly, compassionately, and supportively. She shares my faith that if we stay focused on those values and are smart and adaptable when challenges arise, everything else will work itself out. In this episode, we talk about the critical role of nutrition and lifestyle medicine in endocrinology, the glaring lack of formal nutrition training in traditional medical education, even in endocrinology, and how this gap impacts patients living with diabetes and metabolic diseases.
[00:04:00] We also discuss the challenges of patient education in traditional practices, why these barriers exist, and how we've worked to overcome them in our direct care practices. I hope you enjoy this episode as much as I enjoyed recording it. If you're looking for Dr. Sobel or links to anything we discussed, check out the show notes.
Let's dive in.
Today, I'm so excited to have Dr. Sandra Sobel, who is an endocrinologist in Pittsburgh. And more importantly, she was my attending and fellowship. So we did get to know each other. Um. Well, even before we entered this new space of direct care endocrinology, and it has been such a joy to get to know her better over the past few years.
But during fellowship, she was like the dream, you know, she was. put together, beautiful, happy, always smiling, took [00:05:00] amazing care of her patients. And I remember thinking, I want to be like her when I grow up. So I am so excited to introduce Sandra Sobel to you guys. And we're going to be talking about nutrition and lifestyle medicine
and the health care education in our current system. Um, the things that we miss and how she has kind of gotten to a different type of practice that incorporates a lot of the things that are very important, but we aren't traditionally taught. So, Sandra. And we'd love for you to introduce yourself and tell us a little bit about what you do and you're passionate about.
Sandra: Thank you so much for inviting me to be on the podcast and, um, I have fond memories of us working together. It's crazy for me to really go back and think about how long ago was that? Even though it seems like it was just [00:06:00] yesterday, um, but it wasn't, I remember seeing you as a fellow and, um, Asking really poignant questions and really not shying away from curiosities.
Cause sometimes in training, we can be a little bit timid. We, as like medical trainees, stay timid about, um, not knowing certain things or also knowing something about themselves and advocating for that. And I remember that being something that was very. Different about you and I admired a lot and it doesn't surprise me that that trait has continued and has taken you to where you are today.
So, um, I love to also be in your space and you've heard me say this to you before, but I'm going to I think it's worth saying again that this is just a classic example. Of where the teacher suddenly becomes the student, right? You mentioned before that I was your attending and we work together. We did research together, clinical [00:07:00] research together.
Um, and then when I was looking to explore direct here, I reached out to you and you taught me so much and supported me so much. So this is, um, this is just the back and forth that I love about me. I, as you mentioned, I'm a medical doctor. I'm a board certified endocrinologist, and I also have board certifications in lifestyle medicine, as well as obesity medicine.
And so my passion within the field of endocrinology has always been metabolic health. So conditions associated with insulin resistance, like pre diabetes type one diet. This is time type two diabetes, metabolic dysfunction, associated liver disease, um, dyslipidemia, as well as polycystic ovarian syndrome, perimenopause, menopause, and obesity management.
And for me, it's really taking this comprehensive approach to metabolic disease. I'm sure we'll get this further, [00:08:00] but what I explained to individuals is what I mean by comprehensive care is really digging down and addressing nutrition, quality of nutrition, talking about exercise and getting specific about it.
You know, when we, many people have had the experience going to a doctor and they're told, Oh, you should eat healthier and exercise more. Well, like that's 0 percent helpful, right? Because in theory, everybody understands, yes, that is what we should all be doing, but what does that even mean, right? What does eating healthier mean?
What does exercise mean? So taking the time to really personalize it and address what that means. And I also talk about stress and sleep. Because those have profound impacts on our health, and we really need to talk about what those impacts are and how to optimize those aspects. And then obviously, as a scientist, as a physician, you know, really critically ordering appropriate labs to understand what's going on, interpreting them and making recommendations off of them.
[00:09:00] So, and leveraging the use of medication. It's in ways to really find that, um, that optimal health that people are looking for, right? With lifestyle medicine, we want to, we want to flex that lifestyle medicine muscle as much as possible to minimize the number of medicines we use or minimize the doses of medicines we have to use.
And so that's, that's what I do. But in order to do that, I needed time. I needed time, Artie, right? And so that's, I get to do that in my direct care practice. And, um, so my direct care practice is called Summon Health. And as you mentioned, I'm based out of Pittsburgh. I see patients in person in Pittsburgh.
I do have medical licenses in other states. Um, But I have to spend that time with individuals talk about these different aspects. Um, I have a teaching kitchen, so I cook with patients. And when we talk, like I said, it's important to be specific about what it means to eat healthier. So I get to do that in real time with individuals.
I also have a meditation room. When we're talking about different [00:10:00] ways of, um, to manage stress and so leveraging meditation as a way to do that. And, um, one of my most fun things to do is scheduling a meditation visit with patients. So that's the type of comprehensive care I do. And I've been doing that now since July, 2021.
And it's been so fulfilling that, um, yeah, I could just go on and on about it forever.
Arti: It's the best. And I think that when you called me to tell me that you were interested in direct care and I'd been in it for a couple of years, I nearly passed out because I was like, she wants to do what I'm doing, but it also kind of goes towards that gut feeling.
Like when you vibe with somebody, um, you just do. And I think that's important in all realms, even in the doctor patient relationship, which, um, is really much more supported in a [00:11:00] direct care model. And I love how you talked about, first of all, everybody who listens to this is going to want you to be their doctor, because you're clearly so passionate and compassionate and really.
Are here to see people and hear people and help them navigate this complicated challenge of health, especially in the world of a lot of information overload and a lot of disease and a lot of competing factors and in a high, fast paced lifestyle that many people are living. And so I think, um, that comprehensive approach is what people really need.
Um, I think that's why we are both in this space and I think it's so important to highlight that that is a reason that physicians like us are leaving the traditional practice models, but tell me a little bit more about what it was like before you made the change. And [00:12:00] why did you feel like you weren't able to give your patients what they needed in a different setup?
Sandra: Yeah. And that really is at the crux of. Making that shift from the traditional way in which we were trained in medicine and, um, and we're practicing medicine to what, you know, we're doing now and, um. You know, just I did a combination of clinical care and hospital care, so, you know, we would make rounds in the hospital on call, um, and taking call on average every 5 weeks, um, going to multiple hospitals to run on inpatients, and then we had our clinic visits.
It became very clear, especially, um, in. Five, six years of my clinical practice after having graduated fellowship, that the [00:13:00] focus and the pressures coming from administration were to achieve a quantity of care. And you have to see x number of patients and, and meet these metrics. And you know, in theory I can under, I, I, I can understand certain metrics being important, but then you, I, I important for me to just step back and be like.
But who is this important for, right? Is this important for the patient? Is this important for me? Or is this important for, you know, those above? And, and do they understand what's going on in the visit when I'm sitting down and my patient's sitting down across from me? They don't know the complexities.
That go on in their health and it also became clear, you know, now we have these, um, advanced practice practitioners who are being introduced into our clinic space, [00:14:00] lovely individuals, right? And, and the. The specialty did not have a good outline as to how to best utilize their support. And a lot of times they were being put into, um, the clinic and, and they felt unsupported and had to leverage us and ask us really important questions because they're also caring for patients.
And. There was a part of me that felt that that was unfair to them, unfair for patients, unfair for me and my time as well, as I'm also trying to care for my patients. And then it also, when I felt that I no longer had the ability to have control over my schedule. If I wanted, you know, to, um, see a patient for follow up because we started a new treatment plan and it was important to check in on [00:15:00] them in a couple of weeks and I said, okay, I want you to follow up with me.
Well, good luck. Your next follow up appointment, Dr. Sobel isn't for eight months. How, how am I being their doctor then? Right. How am I going to radically change a treatment plan or make recommendations for lifestyle changes and have them wait eight months to talk to me about those changes? Of course, people are going to be feel defeated and feel removed from this relationship from their physician.
I. Truly believe that the vast majority of us wanted some medicine because of this deep down desire to wanting to want to help people help people feel better. But when we have that relationship fractured because of these external, um, pressures. that are imposed upon us, that relationship just can't flourish.
And, and then it becomes really fragmented. And that fragmentation of care [00:16:00] can lead to worse outcomes for patients, distrust in the medical system, and frustration for the patient, frustration for the physician. So, um, that was a big part of it. And then patients Really salient questions when they would come in, you would ask me really important questions.
And, um, so, for example, with nutrition, they would ask me questions that honestly, at that time. I didn't know the answer to, and so I would make the recommendation, Hey, why don't you see the dietitian in our division? And at that time too, there was only one dietitian for a faculty of 20 plus endocrinologists.
Imagine this sweet dietitian trying to see the patients of 20 clinical. faculty at an academic institution. And so, of course, this person was pressured for time. And when pressured for time, you try to find the most efficient way, right, to, to [00:17:00] give medical advice. And so it just became the same sheet of paper that was handed to each patient about nutrition without any personalization.
But again, like recognizing. Due to the inability to have the time to personalize it, this is what I recommend. And so I recognize not everybody can follow the same nutrition plan. And if this person is overwhelmed and also has a wait list as far as, you know, giving nutrition advice, I need to learn it myself.
And I need to have these discussions in the office. And in order to have those discussions, I need time. And guess what? I didn't have much of. I didn't have much time. And so it really was just right. This almost the last straw that broke the camel's back was there is so much that we need to talk about that.
We don't have the ability to do in our very short clinic visit [00:18:00] in which we can actually empower patients to take this knowledge and apply it and heal. And get better and we will start to see that these other complications improve or we can start de escalating pharmacotherapy and if I stayed in that system, then I was being complacent with this fractured nature of healthcare that did not sit well with me and I, I, something had to change and.
That's why I left and reached out to you and I was like, please help.
Arti: Well, that's the thing. It's when the veil is lifted and You have a sensitive heart like you just cannot like it's so awful for for patients and I think there's this, you know, insurance companies and hospital admins and the people who are running the show are essentially [00:19:00] faceless, right?
Nobody knows who those people are. They're separated from from the people who their decisions are are impacting. And so there's this narrative around, um, My doctor charged this much. My doctor only spent this amount of time with me. And I know that, you know, when you have a conversation with somebody outside of the clinic setting, when you have time to discuss it, they, they sort of understand that the doctor is, is pressed.
But I think that since we are the face of healthcare, but we're not driving the decisions that are. negatively impacting our patients, oftentimes the patient blames us because we're the only face that they see. And all of a sudden, there has become this adversarial relationship with between endocrinologists and our patients, because many people, especially the type one diabetes world is very [00:20:00] vocal on social media, have this experience of feeling unsupported, unheard, have really fast Visits, long wait times, can't get in, and the immediate response, which I completely understand is they feel my doctor doesn't care enough about me to treat me how I deserve to be treated or to see me in a reasonable amount of time.
But really, we are on the same team with our patients. We Yeah. And I think it's very important, especially in our specialty, to, to recognize that and come up with solutions that gets us back on the same team, because without that relationship, that relationship is healing the relationship is the team. key to creating a plan that actually takes a patient one step further in their health.
And I think you, you put that passion so, so [00:21:00] beautifully, but I think it's important for us to, to identify what's really going on out there with. with our endocrinology colleagues in the traditional, traditional space, the insurance based space, um, and how their patients are perceiving their experiences with them, because I think it's been very damaging for our specialty.
You know, I think also endocrinology is a cerebral specialty. We don't fix broken bones. We don't We don't cut. We don't operate. We don't do procedures. We don't do lasers. We don't do all of these things. We don't do things to patients. In fact, we're here so they don't have to have those things done to them.
We're here to prevent the hip fracture, to prevent the diabetic retinopathy, so they don't have the laser. And I think with that, that makes it even All the more difficult to demonstrate our value in a five minute [00:22:00] window because you just, you cannot support a patient like they need to be supported in, in that type of space.
What was your nutrition training like in, in medical school residency fellowship? Did you have any nutrition training? What was it like?
Sandra: I don't have the statistics on the very, um, top of my brain and you, um, know better than I do, but you know, there it's the statistics for nutrition training and medical school is quite abysmal.
Right. And I remember going through the lifestyle medicine training and reading about that and thinking, Oh, I was really fortunate to have nutrition training in medical school. And so, so that's number one. I was like, Oh, yeah. But let, let me also put that in perspective. Um, when, because. Sometimes it's not even mentioned at all in medical school.
My nutrition training was, I remember, um, [00:23:00] a wonderful primary care physician talking to us about nutrition. And she also asked all of us to keep a food log. Um, and that's what we did. And then we kept a food log. I forget for how many days, if it was just one day or, um, if it was a week, those details escaped me.
And then she just went over, you know, Like what macronutrients are and, and that's all I remember. So it was one class, the classes were probably an hour and then a followup class where she like went over how to interpret it. So I guess that was two hours of nutrition training in medical school. And then in my internal medicine residency, nutrition was not something that was part of the curriculum.
So there was no nutrition training in the curriculum and as part of my fellowship, there was no dedicated curriculum to nutrition, [00:24:00] which is kind of wild. Um, I know that's changed now in the program, but when I was training, that was not part of the curriculum. And so, um, I learned about nutrition. Uh, it was all self driven when I had patients coming to me, asking me questions and recognizing I couldn't refer to my dietician anymore because she was swamped and she wasn't able to personalize or answer some of the, you know, questions people had about the Mediterranean diet or keto or vegan or, you know, gluten free and, and all these nuances and I'm like, okay.
I need to, I need to learn about this myself. And so, you know, that's exactly what I did. I got a nutrition science certificate out of Stanford, um, you know, and, um, taught by Christopher Garner. And I also, then that's what sort of planted the seed. And [00:25:00] then having been keeping up with you and seeing what you were doing.
And you were the one that exposed me to lifestyle medicine. And that's when I was like, Is this and jumping into that and sort of being like, Whoa, and then I got the plant based nutrition certificate through Cornell and then really feeling armed with that knowledge and applying it to myself too, right?
Like I'm someone also that is a firm believer that if you are going to be giving Advice or recommendations, it's helpful to have some experience with that. And so I was like, okay, I hear what these people are saying, you see what this is about doing it. And by feeling so much better myself, I was like, why, why are we not having these conversations with our patients?
What is going on? And that's, that [00:26:00] further reinforced the need to just say, hold on here. I know it's much easier to just look at labs and say, here's a medicine you need and I'll see you in six months because it's quick. And is it effective? Sure. That medicine, if it's, if it's taken the majority of the time, it will be effective.
Have I empowered my patient or educated them as to what's going on? Absolutely not. I also find that the majority of patients are interested in understanding what is going on. Do I have any control over this? If I have some control, what are my options? Let me try these options out and see if they work.
So let's do that. And that's what this is. This type of space has been done, but you know, going back to the question, my actual training, medical training, best two hours. And I learned all of my nutrition.
Arti: It's so like horrifying now for now being where we [00:27:00] are to think back on that. And I remember the same thing being in clinic and kind of like my patients would ask questions.
And I, you know, I could tell you, you know, how a GLP what the mechanism of action was or. all kinds of things, but some very basic questions that were relevant to my patient's lives related to nutrition. I didn't have that foundational background from, I didn't have, I don't think I had anything in medical school, none in residency.
I think I spent 30 minutes with our dietitian during fellowship and I, You know, once CGM came out, I started tracking people's blood glucose more intensively, and that came, that became more popular right as I, as I finished training, and I started noticing patterns with diet, and [00:28:00] it started to become very visually obvious that this was very important.
And then I started thinking about it and I was like, how am I telling people that I am a diabetes expert? I am the expert for Caring for your diabetes, but I don't know about nutrition, which is quintessential to understanding your diabetes and your health and what we can change to help you. And some people need medications, some people don't, but if we're not intervening on the cause of what What is going on, then we certainly aren't going to be able to, to have the impact that we can if, if we are, and I hope that endocrinology fellowship training has changed in a lot of spaces because I think now with social media, there's so much, so many more eyeballs on nutrition, and there's so many [00:29:00] people talking about blood sugar.
And actually, endocrinology is like the sexiest topic on social media. But like, Hormones and blood glucose, but, but our specialty hasn't been uplifted to the same level outside of the direct care spaces. But tell me a little bit more about that personal experience, because I think that is so important.
And the reason I bring it up for many reasons, but one is that In training, we're often taught to kind of have this cold relationship with our patients. Like, don't, don't give too much of yourself. Terms of endearment, definitely off the table. But this, this kind of wall between our patients. And I think that that is a flaw in our medical training.
And I think that The relationship [00:30:00] between any two people, including a doctor and a patient, has to be mutual. Like they can't be spilling their guts to me and they don't know who I am. It doesn't work that way. So I would love to kind of hear your personal story and how that has impacted your relationship with your patients.
Sandra: Yeah. Oh my gosh. I agree with everything you just said. And I, I tell people, um, and even friends, right, who aren't physicians as physicians, we are in an extremely privileged position where we walk into a clinic room, it to a complete stranger, someone we have never met before. And they will, they're ready.
In the majority of cases to just divulge everything about themselves to us. There's this inherent or has been for many years, you know, sometimes with the fractured relationships going on now, but this [00:31:00] inherent trust, I mean, that is huge that these individuals are coming during a time of vulnerability and.
We can ask them anything, and they will be giving us honest answers, right, talking about their social relationships and, and nutrition or, you know, nutrition eating behaviors that they may have held in and nobody else knows about, but we are asking them and they give us the answers. That is wild. There is not many other professions where that happens, but we are in one of those privileged.
Um, positions. And so to your point, to have that just be a one way street. Doesn't does not connect for me and I feel also, I don't know, maybe it's also being Latina, but I, I, I overshare maybe sometimes, but like they need to see the humanity, you know, people, I think it's important for them to understand that.[00:32:00]
We are human too, and we have their best interest in mind, and if we can, whatever we can do to establish that rapport and that trusting relationship will only help engage the patient, and also it allows them to have Ownership in their health care too, because if I'm just standing there and I don't even take the time to sit down, I'm just standing there.
I'm like, well, this is what this shows. This is what this shows. Um, do a cursory exam and, oh, do this and, and, and, you know, see you later and walk out, you know, the person who's an adult, you know, I'm an adult endocrinologist just feels talked to didn't have, you know, any questions about how they felt about things.
Doesn't have any more clarity about what's going on than they did before they came in. And if they also feel, how often have you heard this too? How they'll say, you know, the doctors really didn't show that they care. So why should I [00:33:00] care? Uh, good point. Right. So, um, so that was something to me. I, I have never been able not to show.
Or, or, or express understanding of just the difficulties of some of the things I'm asking them to do, you know, and, and saying, I understand this is challenging and I also know it's not impossible and we're here and we'll work on this and, and try to tweak things and, and work it out. And over the time to, you know, coming back to my story.
I think patients have become really comfortable in, um, asking questions when they don't know the answer and sometimes too in, in one of those challenges, like, oh, you know, exercise and finding the time to exercise and. Several years ago, this must have been like seven years ago, a patient asked me and she was like, you know, doctor, I find it really hard.
You know, I'm working and I have young kids at home. I know you do too. Like, when do you find time to exercise? And [00:34:00] it was almost like a record scratch. And I'm like, Oh, wow. Yeah. When do I find time to exercise? And it was that type of accountability where it was like, yeah, how can I be making these recommendations to my patients if I myself am not even listening to my own advice?
Right. And so that's, you know, I, since then, especially with activity, I'm like, yes, this is really important. And the way to demonstrate that is to do it myself so that when patients are asking me. Questions I can express to them. Like, yeah, there are several days. I don't feel like going to exercise. Why do I do it?
How do I find the motivation? This is how I find the motivation to do it because I know how important it is. Um, and then with the nutrition, you know, so when I was doing the nutrition, um, training and I was hearing about all the benefits of fiber and making sure you hydrate well and the whole food eating and, [00:35:00] and then it gets like revolutionary, right?
But also like it's simple yet it takes time to try to apply that and like, okay, let's, let's do this. My energy levels immediately improved. Um, just like how I've beyond like the energy levels, how I felt, I felt, you know, like my hair was getting thicker and just clarity of thought. And when I looked at my husband, right.
Cause I just feel like with men. I'm totally jumper stereotyping, but men, they like, I'm like, here's my benefit. And he's like, oh yeah, here's my benefit times 100. And I'm like, ah, jerk. Okay. But like he too. And I was like, okay, so it's not just a me thing. Him too. And then my parents caught wind and then they started participating and their health, you know, improved as well.
And so I'm like, okay, these are really important conversations to have. So. Really, my story is in listening to my [00:36:00] patients, having them hold me accountable and also doing it myself. Like, I would not be giving advice to people that I myself don't find valuable and don't find value in and important and, and have seen, you know, one thing is the subjective feeling of feeling great, um, but then the objective.
Seeing on blood work, right, what improvements patients have, seeing the blood pressure come down, deescalating pharmacotherapy, seeing the body composition changes. Those are objective measures. I cannot make up those numbers, right? It's not just a feeling. It's right there in black and white paper. And I tell, I just had this conversation this morning with a patient who did a nutrition intervention.
Her cholesterol numbers, you know, total cholesterol and just two weeks time dropped 40 points for LDL dropped 25 points. And she was like, Oh my gosh, that is so motivating. I'm like, yeah, but everybody has this, like, I'd say superpower that you didn't [00:37:00] know. But you do. And so you just need to understand the quality and the importance of nourishing yourself in a way that benefits your health.
It's like I said, it's not anything that's revolutionary or groundbreaking, but it's something that. If we just take that time and have these conversations so that the health improvements that people have are really astounding and continue to inspire me. And so that's what motivates me to just keep going and keep doing this and keep talking about it.
Arti: Yeah, and I think that whole idea of do as I say, not as I do, it just doesn't work, right? It's. That old paternalistic view of medicine and how medicine is practiced. I think we know enough now. We have enough personal experience, enough research to know that that doesn't work as well. You know, there's data to show that doctors who exercise are more likely to counsel their patients on exercise.
[00:38:00] And also that day to day troubleshooting. You know, with my patients, same thing. If they're struggling with, well, how do I get more protein? Well, here's, this is how I do it. Or, you know, how do you find the time to do this? Or how do you meal prep? How do you batch cook? All of these things are so much easier to counsel your patients on when you're really living it.
And I love how you mentioned how health was kind of contagious. You know, I had a similar experience with that. I started, um, A plant based diet in 2019 and my son was about six months old. I was leaving my old practice. It was very stressful time and I was I was 32 and I felt like I was 80 like my joints hurt.
I was not sleeping. Well, I was getting migraines all the time and we had an au pair who came from Brazil and she was. A [00:39:00] nutritionist and she lived a whole food plant based lifestyle. So I literally had it right in front of my face in my home with somebody who could support me in doing it. And I thought, well, I have, there's nothing else I can do at this point.
So let me just try this thing that she's talking about. And same thing within a couple of weeks, like all the joint pains went away. Felt so much better. And my husband, of course, same thing, got a lot healthier, too, and my parents did, too. And just like disease is contagious, so is health. And I think that when we can help one individual, that ripple effect goes out to the whole community and the people that they Interact with and and their loved ones.
So I think that is just such a cool thing to be a part of and, and to really promote. [00:40:00] And the other thing is, I would love to hear your take on this term that I personally abhor and it is diabetes management. Because I think that in training, that's the term that everybody uses. It's like, Diabetes management, diabetes management, there's never talk of like diabetes improvement, you know, diabetes remission, diabetes getting better.
It's always like, Oh yeah, refill those medications, A1C stable, blah, blah, blah, blah, blah, you know, like moving right along, continue to manage and. What I saw when I started focusing on more lifestyle interventions is you can remove medications very quickly, especially insulin in our patients living with type 2 diabetes, very quickly by intervening on their diet and lifestyle.
But we don't even have that concept ingrained in us in training. [00:41:00] The idea of getting a patient off of their insulin, I don't even think it crossed my mind when I was in training. Um, but yeah, I would love to kind of hear your take on that concept of diabetes management and how your thoughts about that have evolved over time.
Sandra: Yeah, I mean, we trained at the same fellowship and that was It too, right? There was never a discussion that, Oh, by the way, did you know that there is a possibility that, um, people's diabetes can be pushed into remission. And even if it can't be pushed fully into remission, by trying to, it improves without having to augment medications or doses of medications.
And, and especially when we're honing in on the nutrition aspect. I think one of the things that I became really enlightened by, and this speaks to just like health improvement in general, and especially in diabetes, is we really need to focus on [00:42:00] the quality of food, um, more so than the quantity. And you know, and that can be controversial too, because I remember when we were talking about, Oh, you know, I'm trying to lose weight a lot of times.
And, and what I was taught was, Oh, a calorie target, right? And if you're below the calorie target, you're in a calorie deficit. And that's just part of the necessary, you know, quote unquote prescription. And I'm not disagreeing that a calorie deficit is frequently required, but if we can focus the nutrition on the conversation, excuse me, more on quality of nutrition.
and say, okay, what does whole food mean? And it doesn't need to break the bank. You know, I have an Aldi from my office just a block and a half away that has an amazing selection of whole foods there for very reasonable prices. So it's accessible. Right. And, um, and that [00:43:00] when individuals understand. Oh, you know, when I talk about carbohydrates, we're looking for complex carbohydrates, not the crappy carbs, right?
Cause if we just make a blanket statement, like low carb, that is also not helpful, right? We're just like simplifying it. We really want to promote this complex carbohydrate intake, minimize the refined. Carbohydrate intake. When we're talking about protein, let's really opt for those lean proteins and really reduce the high fat.
Um, when we're talking about fat, we want to definitely stay away from trans fat, you know, minimize the saturated fat, but the polyunsaturated and monounsaturated fats and, and give examples of what those are. Because when, when individuals then start to learn that And then we can go over nutrition labels and say like, these are the important things on the nutrition label.
Like look for the fiber, look for added sugar, look at the saturated fat on it. Instead of just looking at the quantity of calories they're consuming, then they under, they start to look at [00:44:00] food as food. What a concept, right? Instead of just a number, look at food, ask me so that when they go to a restaurant, they don't feel like they're sort of, you know, floundering in an ocean, like barely able to tread water.
They can understand by reading the ingredients. I understand what this food is and, and make a decision off of the menu of how I want to nourish myself. Cause I know I feel good with this type of combination of foods that I want to put in versus this other. Right. And so. For me. Um, it has been the biggest flex that I can teach patients in really understanding the quality of how they choose to nourish their body and by doing so, they are treating, you know, like treating their diabetes instead of managing, right?
Managing is just keeping things like, to me, it sounds like status quo and here's the medication here. It's more and more and more. But if we [00:45:00] really want to treat and like you said, get to the roots. Let's address what, where did that even come from in the first place? And one of the places we can make the biggest and quickest impact in on is in their nutrition knowledge and how they apply healthy eating.
Yeah. And
Arti: I also think that. Um, helping them move their mindset from this restrictive mindset, because I think people with diabetes are spoken to in such a punitive way because there's a massive cultural bias against diabetes, obesity, many patients of ours live with both, and they are essentially told culturally and oftentimes by their People medical providers, even their endocrinologists sometimes, that this is your fault.
And even if they don't use those exact words, they're made to feel that way. And frankly, I don't believe that that's true. And I [00:46:00] don't think that anybody chooses to be sick. And I also know that people are doing their best and life is challenging. And, um, When we put these people who are already scared, they're already vulnerable, they already have this disease that perhaps they've had family members have complications from in, in our, both of our communities, we've, we experienced that a lot, people are already vulnerable and scared, and then we come back and say, Hey, This is your fault because you're not eating fewer calories and moving more it it feel and stop eating bananas and stop eating white foods like all these nonsensical claims that people tell to patients it makes them feel very restricted and I think All of us rebel a little when it comes to restriction.
Nobody wants to feel restricted. Nobody wants to be told they can't do the things that they're accustomed to doing or that they like [00:47:00] to do. But if we can shift that mindset to a world of abundance, look at all of these wonderful, beautiful things that you can eat and look at these recipes. I tried this one.
It was great. You know, look at that, what you gain from. from shifting how you eat and what you gain as far as your risk of complications from diabetes, as far as how you feel, how, how you're able to impact the lives of your children and your family with, with eating in this way. I think that becomes a much more palatable way for people to really engage in the changes.
Also, not expecting people to be perfect, right? Because none of us are. And there's always gonna be a challenging time or a challenging time of year and it's different for everybody and Recognizing that you can't have like having an all or nothing mindset doesn't serve [00:48:00] us. It's It's not, oh, I messed up this time, so thus I'm a failure, thus I should give up.
It's, okay, I had a bad day, and moving right along and re re establishing those tools and goals that, that we set, and getting, getting back on track. Life happens. It's okay. Um, I think that Those two pieces of the puzzle are just so, so valuable. Um, so I know we have a lot of colleagues who are, are practicing in the traditional setting or, um, who are fellows about to graduate.
And I would love to talk with you about, um, is there a way to do this in a traditional endocrinology clinic? And [00:49:00] regardless of what you say, kind of the why, like why, why do you feel that it can or can't be done? Um, and then, yeah, we can just kind of see where we go from there. That's a really
Sandra: excellent question.
And so, um, I think the first answer is that it has to be right. It has to be done because it's clear that. If our lifestyle is so integral in health, um, health maintenance, or when health is starting to, you know, show that it's not, um, going in the direction we want it to. We need to make sure that the physicians or training understand what lifestyle medicine is and how we can empower patients and support our patients in, um, being motivated to, um, [00:50:00] do what they can from their perspective.
So it has to be done. And I, and I do think, and I heard that there are programs that are starting to integrate lifestyle medicine into their curriculum. And I think that is phenomenal. Okay. I think that's, it's a necessary thing. And I think it's a wonderful thing. And I do hope that that is something that is, uh, adopted widespread and where the complication comes is the time aspect, right?
Like, so how, how can we do this? And it's gonna be challenging because, um, so first of all, learning about lifestyle medicine, it was so incredibly thrilling and just reading about it and then experimenting on myself and being like, oh my gosh, this is amazing. And, and then I'm like, I can't wait to share this with my patients.
And, and so it's so fun. To learn about it. Um, and then when you also apply it to your patients, let's see them improve. And you're like, what's like, you almost feel like you have this like magic wand. And you're like, I don't, you [00:51:00] get better and you get better and you get better. Um, I have the luxury now in my direct care practice where I get to sit down with my patients and have these conversations.
And it's a conversation, right? It's not me just talking to them. It's me saying something asking, do you have any questions? They're like, actually, yes, here's my question. Great question. Let me answer your question. And it's a back and forth cause it has to be a conversation and that helps with their buying.
Um, you know, I think it would be wonderful, for example, in an endocrinology fellowship at the fellows, it's part of their, um, you know, they graduate with a lifestyle medicine certificate too. You know, they take the board for lifestyle medicine. Now here you have that because it's going to, it is such an important part of endocrinology.
And so is there an opportunity where the fellows could be the ones do it in, in clinic, you know, have a lifestyle medicine clinic and they rotate in and out of the lifestyle medicine clinic. That would be great. But I know, you know, Now, all endocrinology fellowship programs aren't they were as big as ours, right?
And sometimes it's [00:52:00] just one or two fellows per year. So that can be unrealistic. And then we come back to the insurance based system, right? And the compensation. And it is so unfortunate, so unfortunate. That's Um, time spent talking about disease prevention and health improvement isn't compensated. And so no surprise that there isn't any motivation to take that up in a clinic when you know you are, you have, you know, five patients waiting for you.
So how to do that is tricky if we're looking specifically in an insurance based system. And I'm, you know, and I know that direct care isn't the answer for everyone. It's important to have options, and I feel fortunate to be in this space, and to be able to help the patients in the way that I am, and I see how they thrive.
I do a lot more de escalation of care than I do add on medications, [00:53:00] but how that can integrate into an insurance based system is going to be a really big challenge, and so I don't know. I, I feel like of all the people that have really good ideas and answers, you would be that person.
Arti: I,
Sandra: um,
Arti: I think it would be extremely challenging as well to, to introduce this type of care into a traditional insurance based system.
And, and I think we talk about compensation in, um, A way that doesn't really allow people to understand it because nobody feels bad for doctors and their multi six figure salary and nobody should frankly, like, no matter what, that is still a very high income. Compared to the general population, we can get into the weeds about whether it's fair or not, but our patients don't have to [00:54:00] care about that and and they shouldn't.
And it is an extreme place of privilege for us to feel like we can complain about that. So I don't think that complaining about compensation from our own salary perspective is going to win us any friends or get us any sympathy. So I really think that. Physicians do themselves a disservice when they talk about it in that way.
What is important, though, is what your insurance will pay for. Because, yes, we're physicians, we want to go above and beyond for our patients as much as we possibly can. But also we are working for systems that are trying to make a profit off of our work when we are employed by a hospital system. And also clinics need money to keep their lights on, frankly.
And so if, if your insurance is only willing to pay for a five to 10 minute visit with your [00:55:00] doctor and not willing to pay that clinic. Anything for for counseling you are spending time with you are building that relationship with you because they don't value it. In fact, they profit when patients get sicker, right?
Like they when the insurance company is also the hospital system, they because there's a lot of vertical integration. There's a lot of consolidation where hospitals are buying up all the clinical, the The practices in, in that area and beyond, um, they profit when you come in through their ER and get admitted.
And so I think the incentives are misaligned at that point. And when you are working for a system that is incentivized for your patients to be sicker and coming through the ER and getting admitted for the complications you morally and you are trained to [00:56:00] prevent, is some clear friction, right? Your, your, your incentives are not aligned.
And, um, Unless you change your own incentive structure or you work in a system that incentives are aligned with providing lifestyle medicine and patient centered care and all of these lovely things that we're able to do in direct care, I just don't see how it could work because nobody who is writing the book and making the rules wants you to even do that.
And in fact, you'll probably get reprimanded, you know, Productivity is everything in those types of settings, so they would much rather you see 50 patients and write a prescription and for them to get sicker than for you to see 15 patients and take the best care of them possible and get them to their best health and prevent [00:57:00] them from coming through the ER.
So I think that, you know, a lot of people think that doctors leave the insurance model. As a financial grab right as you know to make more money and I think you would agree with this Sandra like it takes a it's a huge risk to go start something that's not customary and
tell me this and I think I think I know the answer but like was your practice profitable in the first year like were you making as much as you were making employed?
Sandra: No. No. And neither was I.
Arti: Definitely not. Definitely not. And the reason for doing this had, you know, my hope was that it would become financially viable and it eventually did, but that was not the primary goal.
The primary goal was to deliver care in a way that I [00:58:00] believe I am able to. I've been given the gift to. A lot of people have supported me in becoming a doctor. And. I have been very privileged to be where I am with a gift to help humanity and individual patients and hopefully at a larger scale as well and, um, that, that was, that was a motivation for leaving and doing all of these things.
And so, uh, when we talk about physician compensation, the narrative just needs to be. Different. And we need to remember that when we're talking about reimbursement by insurance companies, that reimbursement is not just going to the doctor's salary. Most of that reimbursement is going to keep the lights on in the clinic to pay the staff to provide you a level of care that, frankly, now is inadequate, [00:59:00] right?
That's why we're here. The care is inadequate. And, um. And I don't see really, in the short term, a path forward in a traditional setting. And I know, like, I don't mean to put down any of our colleagues who are in that setting because we've all been there. And. We know how challenging it is in that setting and I am confident that The majority of our colleagues are doing their very very best for their patients with the the resources that they do have But I do think that perhaps normalizing alternative practice models for endocrinology Is a better path forward.
Sandra: No, I mean everything that you said is really spot on. And, um, I didn't even realize that there were different ways to practice endocrinology. I didn't even realize that, you know, [01:00:00] outside of the academic setting and private practice, um, insurance based private practice, that there was other options because that's also not taught to us, right?
In our medical training, it is. It's crazy to me too that we're not taught just business medicine, um, or finances in general. And, you know, um, whether that's intentional or, you know, whatever it is, it just doesn't happen. And, um, and so again, it was, Oh, direct care. Oh, what is this? And then, you know, it was my husband actually that told me he saw like how miserable I was.
Practicing the way I was practicing. And I was desperate. I was about to go interview at another academic center in a different States and then COVID shut down the airports. And that's why I didn't fly for that interview because of COVID. And my husband at that time was like, Oh, you were really about to leave to a different [01:01:00] state.
And, and, and if you liked it, like we were going to uproot our whole family. I have two kids to go because of how miserable you are. He's like, we have a really great social circle here in Pittsburgh. Would you really want to do that? And he's like, I guess you are really miserable. And, and the answer wasn't going to somewhere else where it was the same design, right?
You know, the grass is greener in a different, you know, similar setting. And he's like, you need something radically different. And I can see how passionate you are with your patients. And he's like, there's this thing, direct care. And he's like Googling it. He's like, Oh wait, this name seems familiar. Do you know this person?
And he's like, Dr. Arthitangulu. What are you talking about? And he's like, yeah, she's doing direct care. She's like one of the only doing direct care in the United States. And this was four years ago, three years ago, no more than three years ago, obviously. And that's when I reached out and I was like, okay.[01:02:00]
And doing this deep dive and being able to have. The guts, I guess, or insanity to leave, right? Um, I told people it was like three, three main ingredients to do this jump of ship. One was desperation. That was one. Um, because I wasn't happy. Um, number two was definitely insanity to be like, That's it. I'm just going.
And let's hope it works. Right. Um, because it is a huge financial risk. You know, we had to really like my husband was still working. Um, but I, here I am trying to build a practice. And so really, you know, tightening our belts and, and being like, okay, let's just be very mindful about what we're doing. So, um, desperation, insanity, and a little bit of grandiosity, like, oh, of course I could do this.
Um, but you know, just being like. I have to believe it. And when you believe so much in something, you have to make it work. And you [01:03:00] do. And I, and I think also the sincerity of, of your story comes across to patients too. And when you're offering the possibility to prevent, you know, like I have patients that come to me all the time with this.
With this insane family history of cardiometabolic disease, and they just started to have an impaired fasting glucose. Um, or, you know, they, they, um, on their cholesterol profile, right, have been told like, Oh, we might need to start statin therapy if nothing changes. And then they come and they're like, Okay, how can we make this not get worse?
And you talk about it with them and they, they see that they have a lot of control over their health destiny, then they're like, they're, they're just yours. Right? Like you become a team instantly and it's just takes off from there. So yeah, but, but this alternate model of care is what [01:04:00] facilitates that. I wouldn't, what I'm doing now, there is just no way, there is no way I would have been able to do this in that insurance based system.
Arti: Yeah, yeah, I, I love that, that sentiment, I share that sentiment of like, this insane confidence that my every action will somehow impact the world, and so I better make those actions good and right. Otherwise, bad things will happen. I certainly feel that in little and big. So I love that. Well, Sondra, it was so, so, so nice to have you today.
Is there anything that you would like to leave our listeners with, especially those who might be budding endocrinologists or, um, endocrinologists who are already practicing?
Sandra: I just want to share how, um, we, we chose this profession out of [01:05:00] our, you know, fascination with the physiology and the complexities and.
You know, how cool is it that we can investigate and identify, you know, either an overabundance or an underabundance of hormone production and then make some recommendations or, you know, um, or to, to help get those hormone levels, um, back in target range and people genuinely feel better and we get to.
Get input from like what's going on in life to also help guide those recommendations and when it seems like we're just, here's another patient through the revolving door revolving door, I think it's important to just go back and be like, okay. This I need to like dig deep down inside and also recognize what the possibilities are because we don't have to just stay [01:06:00] or do what we've been told like, Oh, well, you train in an academic center.
You should do academic research because otherwise you're not doing anything great for the profession and you have to stay in academia. And that's like what I've had been told. Um. And, and I, and thank God we have our academics who do the research and come out with the papers because they inform my clinical practice.
But there's also multiple ways we can practice within the field of endocrinology. Um, and exploring those options are important, reaching out to people who you see doing that, identifying mentors that you, um, really admire and love. And even if the mentors you identify were once mentees to you, your mentee, like, but that's, that's, I think.
Just part of the necessary evolution of medicine is, is understanding that we don't have to just stay within the mold. And, uh, and that there are many ways in which we can, um, try to [01:07:00] practice medicine in the way that we had envisioned it for ourselves. And that's not, and I'm not saying like, Oh, everybody can do it however they want to know there's challenges and there's, you know, restrictions everywhere, but it's, it's always worth.
Sort of like putting your feelers out and seeing what's there and assembling a supportive team.
Arti: Yeah, and just because it's customary doesn't mean it's right and certainly not right for you. So I think absolutely stay curious and explore and Try to understand the intangibles that are valuable to you.
So, well, thank you so, so very much. I will be talking with you again very soon, but it was such a pleasure having you and I look forward to future conversations. Thank you so much for having me. [01:08:00] Likewise.
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