Meet Dr. Adam Ehrlich- From Mount Sinai To Temple: Caring For Underserved IBD Patients

What does great IBD care look like when the system won’t make it easy? We sit down with Dr. Adam Ehrlich, Section Chief of Gastroenterology at Temple Health and GI fellowship program director, to explore how he builds patient-centered care in an underserved setting—where insurance denials, missing records, and real-life logistics collide with complex disease.

We talk about health literacy, trust, and the conversations that actually change outcomes. Adam explains how he frames risks and benefits with clarity, why the “risks of doing nothing” deserve equal airtime, and how he balances mode of therapy—IV, subcutaneous, or oral—against lifestyle, trauma history, pregnancy plans, and coverage rules. We dig into prison medicine’s constraints, from medication access to policy barriers around scheduling, and the creative problem-solving required to keep patients safe and informed. He shares why being honest about uncertainty builds credibility, and how an early investment in patient education pays off with better monitoring and shared targets for remission.

The episode also gets practical about personalization. We discuss drug levels with infliximab when severe colitis “loses” medication into the stool, when it’s wise to de-escalate dosing, and how habits from flare days can persist after inflammation settles. Adam offers tools to retrain routines, navigate IBS overlap, and align care with quality of life goals like driving, work travel, and showing up at a kid’s soccer game without anxiety. As a fellowship director, he reveals how he equips new gastroenterologists to handle today’s broader therapy menu, think beyond flowcharts, and advocate through insurance barriers with persistence and purpose.

If this conversation resonates, tap follow, share it with someone who needs it, and leave a quick review. Your support helps more people find practical, human-centered IBD care.

Links and organizations to follow! 

• Color of Gastrointestinal Illness (COGI)- mission to improve quality of life for BIPOC who are affected by IBD and other GI issues. 
• The Stephanie A. Wynn Foundation - mission to eliminate health disparities and improve outcomes for individuals and communities affected by Inflammatory Bowel Diseases through comprehensive support services, with priority given to underserved populations facing the greatest barriers to healthcare.
• Strategic Alliance for Intercultural Advocacy in GI (SAIA)- mission to create culturally sensitive resources, research, and education for patients, caregivers and healthcare providers managing chronic GI conditions in order to minimize delays, dispel stigma, promote early diagnosis, and improve access to treatment for all.

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Chapters

• 0:00 Welcome And Holiday Break Note
• 1:03 Meet Dr. Adam Ehrlich
• 2:10 Why GI And Finding Purpose In IBD
• 5:56 Building An IBD Program At Temple
• 8:53 Treating Underserved Patients And Prison Care
• 13:12 Health Literacy Gaps And Patient Education
• 17:00 Explaining Risks, Benefits, And Tradeoffs
• 20:11 Shared Decision Making Versus Insurance Barriers
• 24:15 Expanding Options: IV, SubQ, And Oral Therapies
• 27:00 Diversity, Trials, And Being Honest About Unknowns
• 31:10 Quality Of Life: Goals Beyond Symptoms
• 35:15 Habits, IBS Overlap, And Retraining Routines
• 38:20 Drug Levels, De‑escalation, And Personalization
• 42:06 Coordinating Care And Absorption Concerns
• 44:06 Training Fellows And Growing IBD Expertise
• 47:05 Travel, Access, And Real-Life Treatment Planning
• 50:05 The One Piece Of Advice For Patients

Transcript

SPEAKER_00: 0:00

Hi, I'm Alicia. And I'm Raymond, and you're listening to Battle Moment. The podcast during real talk about the realities of IVD. This week I was flying solo and I talked to Dr. Adam Ehrlich. Dr. Ehrlich is the chief on the section of gastroenterology at Temple Health. I talked to him about building an IVD center there. I talked to him about his work as a program director of gastroenterology fellowships. We talked about treatment and health literacy and how he works with his patient population at Temple Health. And finally, we talked about the importance of sharing quality of life and what's important to you as a patient with your provider so that you can work together to find the best treatment for you. And just as a note, Robin and I will be off for the holidays. So we're taking a little break. The next episode will come out on January 7th, but we want to say a big happy holidays to all of our friends that listen to the show. You truly make this something that we love doing. Cheers. Hi everybody, this is Alicia and welcome to Bowel Moments. Unfortunately, I am flying solo tonight again. Robin wasn't able to join me, but I am really, really excited to be joined by Dr. Adam Ehrlich. Can I call you Adam? Of course. Adam, thank you. Welcome to the show.

SPEAKER_01: 1:11

Thank you for having me.

SPEAKER_00: 1:12

My first very unprofessional question for you is what are you drinking?

SPEAKER_01: 1:16

Well, when you sent me the info beforehand and I was like, ooh, I get to drink. That's fantastic. So so tonight I am drinking a omegan hennepin. I don't know. Omegang is a brewery in Cooperstown, New York, and it's amazing, small quantity Belgian ales and stuff. So it's really great.

SPEAKER_00: 1:32

Yes. So I used to live in Ithaca, New York, and my husband went to Cornell. And so yes, we have definitely been there and seen it. And it's actually really pretty too. Like it's like it's quite a pretty place to go. As I told you right when you joined, I managed to spill most of my drink tonight, and I'm very, very upset about it. But I have exactly one swallow left of champagne, which is my favorite. So I am gonna savor this tiny amount of champagne that's left in my glass. Okay, Adam, again, so excited to have you on the show. So my next question for you is tell us your IBD story. What brings you into our community? What made you choose gastroenterology and IBD specifically?

SPEAKER_01: 2:05

You know, I think a lot of things in life are like happen by circumstance, right? And so if you had asked me at the beginning of medical school, what was I gonna do? GI was definitely not at the top of my list. I was at Mount Sinai in New York. And at Mount Sinai, you know, I had an amazing GI course in my second year of medical school with some very well-known IBD docs teaching it. And then I happened to be on the GI liver service when I was a third-year medical student. I happened to be put on the colorectal surgery service when I was on the surgery rotation. And, you know, Mount Sinai, for many of the listeners who I'm sure know, is a big IBD place. Dr. Crone was at Mount Sinai in the 1930s. And so it remains sort of a mecca for IBD care. And so I saw a lot of it. I knew then after I decided internal medicine, I wanted to do GI. And for me, I think GI was maybe a little selfish to think that I could, you know, I got the sort of immediate satisfaction of making people feel better in a way that sometimes you don't get it in other specialties, right? So, you know, if you're I use this this analogy a lot for folks that are out of medicine, you know, if you're a cardiologist, obviously very important job. You control people's blood pressure because we know that high blood pressure leads to stroke and leads to heart failure, but you don't necessarily feel bad if your blood pressure is high on any given day. If you come and see me and you're going to the bathroom 20 times a day, and I can do something, and you're then you go twice, you know, or alternatively, you're not going for a week and now I can make you go, you feel better. And like I get that personal satisfaction too to hear about my patients doing better. I like the fact that it's a little bit cerebral and a little bit hands-on, right? Because we're doing some mental stuff and also the hands-on part of endoscopy and colonoscopy. And I think, you know, from an IBD perspective, part of this was certainly shaped by being at Mount Sinai, where I worked with, you know, world world leaders in inflammatory bow disease. I came to Temple, where I did my fellowship in Philadelphia and have stayed on as faculty for a long time now. And they sort of pegged me as, hey, you're from Sinai, are you the IBD guy? And I was sort of thinking about it at the time. I have a number of family members with Crohn's and ulcer colitis. Although my decision to go into GI was before, you know, that some of those things happened, a number of friends as well. And the the circumstance of being at a place, a temple that has a good number of IBD patients but didn't really have a good IBD program, that was a circumstance that was good for me. And I liked helping to sort of grow and build that. And so here we are, you know, 15 years later. And I've had a lot of interactions with the Crows and Clayton's Foundation and also, you know, with family and friends, with my patients. Temple is a very underserved, uh, takes care of a very underserved patient population. And so something that I'm really passionate about is providing care to folks that may not otherwise be able to access it. And I take care of a lot of prisoners, a lot of people who are dealing with homelessness and mental health issues. And it's really super rewarding to really make a difference in people's lives where they don't have a lot of other control.

SPEAKER_00: 5:03

Yeah, I'd love to talk about that because I definitely think there's a lot to unpack, as they say, with that one. But I think, I mean, it's also interesting. A lot of the folks we talk to also talk about how many times the other professions you kind of see people in small windows of their lives. But if you're an IVD doctor, you see people through the entirety of their life, basically. And we don't have a cure yet. So you're gonna keep seeing them, and that it can be really rewarding to see people kind of, you know, grow and change and, you know, go to college, build families, all these things, and you get to see that as an inflammatory bowel disease specialist. I think that's lovely.

SPEAKER_01: 5:34

Yeah, absolutely. I, you know, I started at Temple in 2011, and I have patients that I've had since then when they were in college and now are married with kids, and we talk about our, you know, each other's kids when we see each other and all that kind of stuff. It's really awesome to see sort of the entirety of the life cycle.

SPEAKER_00: 5:51

I think it's interesting that you came from Sinai because you're right, that's you know, it's so well known for inflammatory bowel disease. It must have been really interesting to go to someplace like Temple, like you said, that didn't have an IBD program and that serves a very different population. So talk to me about building the IBD program there, especially with the type of population and resources I would imagine you have. It's probably not the same as Mount Sinai, I would imagine, you know, serving a population that's much more, you know, perhaps dependent on charity care or Medicaid or some of these other things that are just not the same as some of the hospitals that, you know, kind of have private pay patients or patients that are on uh commercial health insurance. So just building a program seems that seems really challenging.

SPEAKER_01: 6:28

Yeah, it is. I mean, it obviously there's a lot of limitations. I mean, Temple is never gonna have a billion dollars to build a new building or or name something after someone or whatever. It's just not gonna be sort of what we're able to do. And I remember one of the Sinai folks came down, I can't remember when this was, and he he gave a talk to my fellows, and we were talking afterwards about the patients. And this is a a person that live that works in the upper east side of Manhattan, takes only self-pay, you know, whatever medicine or whatever tests they want to do is they just do it, right? And and they figure it out afterwards. And then I talk about my patients who I can't get them mesalamine because mesalamine's not covered by their insurance, and I put people on a biologic as a result. I mean, like it's like the real world, you know, do the best you can. I know what the guidelines are, I know what I want to do, but I can't necessarily do that. So we got to be strategic and creative in figuring out the best case scenario for a patient. I have patients who have a history of IV drug abuse and can't or won't give themselves injections because of the PTSD that they have as a result, and then figuring out ways to get a nurse to be able to do it or to come in and do it and things. So, like these are like the real world challenges. You know, building a program, I think by default, then comes just sort of naturally and organically from being there and wanting to do it, right? Because it's not like I can go to people and say, I need a dietitian, three nurses, an APP, a certain, you know, it's it's well, let's scrap and do what we can with what we have and then build a a little bit of a name for yourself and try to, you know, leverage that to grow and give a talk here and do something here. And and it's it's happened slowly. And I think it would be different at other places for sure. But I don't know that it would be better. It would it would just be different.

SPEAKER_00: 8:10

Unfortunately, with the American healthcare system, it's all a difference of what you're dealing with, I think. And it's not always better. I have said multiple times the American healthcare system is just like a bunch of string all knotted together, and when you pull on one string, you're just tightening the knot, you're not necessarily changing anything. And so unfortunately, you're dealing with a few strings over on one side and and perhaps dealt with other strings on the other side.

SPEAKER_01: 8:31

Temple has, and I don't don't quote me on the exact numbers, but the highest percentage of government pay patients in the state, in the country, and I don't know, in some large percentage. And and it means we're always operating on the margins and we have a lot of grit as a result. It sort of fits with a the very filly mentality that we have, and it makes it all the more rewarding when we're, you know, when we're successful and we can we can do make a difference to the patient's life.

SPEAKER_00: 8:53

Love to know more about the healthcare system in the prison. Is this gonna depress me though, if I ask you this question? Do we want to go down this path?

SPEAKER_01: 9:01

Uh we look, I mean, I think the biggest challenge in the system with the prisoners is that you don't have the information you need. You can't just call up someone and say, like, hey, you know, what's their history? You know, the patients don't necessarily know what their medications are, which is not unique to Temple in general, but it even more so they don't bring paperwork with them when they come from the prison often. And I don't really know what they can get at the prison. I've had patients on a lot of the different medicines, but it's not like we can call the insurance company and say, hey, what's the approved IL23? Right? It's we have no idea. And actually, I just saw someone this week and they're not doing well on Humira, and I don't know what my options are to do next for them. And like the logistics of that piece, you know, I've had a patient once who we were putting on Remicaid, and they were gonna come to Temple to get their infusions. And I said to the patient, you know, okay, so we're gonna put you on this medicine, you get it at time zero, two weeks, six weeks, and then every eight weeks. That's sort of the standard dosing. And the prison guards yelled at me and they said, you can't tell the patient when they're coming back, because if the if you tell them that like this is the part of their policy, then they could arrange something or try to break out or this and that, whatever. Right. I said, you know what? Like I have an obligation to explain to a patient what I'm doing for them, you know, and you don't have to study exactly at two weeks and exactly at six weeks. I just have to tell you that this is sort of the general cadence of the medicine you're gonna get. It's things like that that you don't even sort of contemplate when you're, you know, handling, you know, an average run of the middle patient.

SPEAKER_00: 10:34

No, that that's difficult because I'm, you know, when we were chatting before I hit record, you mentioned shared decision making and talking about that. And it's like, you know, just because somebody is in the prison system doesn't take away the fact that they should have shared decision making, you should be able to talk to them about it. And I get it that there's, you know, certain limitations to the available treatments, but that doesn't mean that you should just throw it out the window and just say, okay, I'm gonna paternalistically just tell you what, you know, what's gonna happen. And then you're just gonna go back to your cell and not have any idea what's going on. Like that's cruel to treat somebody that way. You know, it's it's not fair. And you know, and again, this like the prison sentence is supposed to be the punishment, you know, not being treated as a human being that has, you know, questions is is not the punishment.

unknown: 11:14

Totally.

SPEAKER_00: 11:15

I'm a social worker, you can tell.

SPEAKER_01: 11:17

Yeah, no, totally agree. And and and these, but these are the sort of the real world challenges that we're that we have to deal with sometimes. So hopefully we do the best we can, and you know, hopefully most patients do okay.

SPEAKER_00: 11:27

Yeah. You know, I was immediately thinking too, just like of what would be accessible in prison. And you mentioned Humera, because my first thought was like, surely they don't like it must be that they have to do Humera in front of somebody. They can't just like be like, here's your, you know, here's your Humera injection pen that's just loose in the prison. But I was thinking that maybe they just wouldn't even allow it.

SPEAKER_01: 11:45

Yeah, they they have uh they have a hospital ward or hospital wing or something there. And obviously, I've never been to the prison, but I know that because when we do colonoscopy on patients, whether they have IBD or not, if they're in prison, we said we're someone doing colonoscopy, they don't do the bowel prep in their cell. They go for the night to to the hospital ward where they can obviously get to the bathroom and do everything. So, like I know there is a place where medical care happens, and I imagine that's where they're going to get their injections.

SPEAKER_00: 12:11

Okay. Yeah. I was that would be real, that would be real wild to have to do colonoscopy prep with like a cellmate or just like, you know, the way things are set up. That would I would not be great. So I'm glad to hear that one. That is interesting. So I'm also curious about just did you notice a difference in the patients that you saw at Mount Sinai and the ones you're seeing now at Temple, just in their level of health literacy or like how much patient education you're having to do? Is there a difference in the two? I mean, because most people don't know anything about IBD, you know, regardless. Like, I I didn't know anything about IBD until I started working within the chronic disease community. And then I learned about it. But, you know, there's a lot of people that have never heard about this. They get diagnosed, and all of a sudden they're like, what happened? What is this?

SPEAKER_01: 12:48

Yeah, I think there absolutely is a difference in medical knowledge. And I actually now I see patients at Temple and I also see patients at a clinic we have in the burbs. And so even that, like that's a that's a very similar dichotomy that I'm living on a week-to-week basis. When I see the patients in the in the suburbs on one Monday, it's a different demographic than those that we're seeing it at the hospital. And there are pluses and minuses of both, right? So the patients that I see at Temple often not only don't know things about IBD, don't know things about their medical care or about uh health literacy in general. And first few visits are a lot of discussion and teaching and trying to explain what you have, why you have it, and the fact that we often don't know why you have it, what it might mean, what happens if you do nothing, what happens if you do something, what are the potential risks, what are our targets, right? You know, very important, especially in a young person, to talk about, hey, yeah, we want you feeling better, but we also want that inflammation better inside to prevent the long-term complications, right? It's easy to say, oh, I'm feeling better, I'm fine, right? So why I want to do that colonoscopy in six months, or why I want to check your cow protectin in, you know, next visit so that we can monitor things even when you're feeling okay. And then treatment options, obviously, is a conversation. And I think just as important thinking about what happens if you don't go on a medicine or on a treatment. I think we have a lot of conversations about the risks of medicines, right? Oh, this medicine can do this, this medicine can do that. We don't spend a lot of time talking about what happens if you don't go on the therapy or you choose to not do something, which is totally okay if you decide to do that, as long as you understand what those potential risks are, right? And so I find that that time up front, you know, even though it makes me run late, will benefit me and the patient in subsequent visits because then they have a little bit better of an understanding. We still struggle with patients who lose their insurance, who switch their insurances. I mean, that's true everywhere in the healthcare system. You know, Medicaid rules, now they start working and now all of a sudden they don't qualify for Medicaid anymore and now they have a problem, you know, and things like that. But yeah, I think I think education is key trying to bridge that gap.

SPEAKER_00: 14:58

Absolutely. I think the more you can help people understand the disease, the more they are really the a true partner to you as they start to look at what's going to be the best option for them treatment-wise and to make those educated decisions. But it's interesting you talk about talking to people about the risks of the medicines, and you know, the nobody's good at statistics, it seems. I say as somebody who's not good at statistics. And so, you know, when you when you're telling people like there's this risk of cancer, but then you tell them that like what percentage it actually is, it is really quite, quite, quite small. And yet, even just saying the C word out loud, people immediately kind of go, Well, then I don't want to do that. And it's like, well, meanwhile, the high risk of developing colon cancer and go if you're untreated is significantly higher. And so, you know, how do you talk to patients about the risks versus the rewards versus the benefits?

SPEAKER_01: 15:39

I don't know if you talked about it on this podcast, but you know, Corey Siegel at Dartmouth has great sort of patient-facing documents to show someone visually, you know, risk of cancer, a little person that's lit up versus four little people that are lit up. And it puts it in perspective. And I think there's a good argument to be had about telling people about relative risk and absolute risk, right? And you may have four times as likely, oh, four times as likely risk of cancer. That's a lot, four times, you know, but it's one in ten thousand versus four in ten thousand. And so like the absolute risk is still super, super small. I honestly, I don't usually get into the the numbers in that way unless a patient asks, and then of course, happy to talk about it. I'm usually talking about very small risks and slightly increased risks and things along those lines because that's the reality, right? And I and I say for most of these things, you're relatively immunosuppressed, you may be more risk of certain infections. Generally, they're common infections. We, you know, yes, there's risk of serious infections, but those are very rare. I actually often say that I have a lot of patients that are healthcare workers who are on these medicines because they're exposed to potential infections all the time and they are healthy. And so that actually gives people reassurance to know that, you know, even people that are exposed to things can can be on these medicines safely. But every person also is gonna be different, right? The thing that they're gonna focus on, you know, may be different than the person you just spoke to previously, right? And if they have a family member that have lymphoma, the risk of lymphoma is gonna be, you know, higher on their mind than if someone didn't have that risk, right? So that's part of getting to know a patient and and sort of understanding what their fears are, what their uh concerns are.

SPEAKER_00: 17:09

I am curious about the shared decision-making side of things, though, because you know, the as as I said, the health the American healthcare system is its own special treat. And so there is a part of it that I kind of go with like shared decision making is great. But at the end of the day, if you can't get the health insurance to cover what you think is best and what they think is best, it sort of feels moot, right? So I'm curious when you're talking shared decision making with folks, especially when you're talking to people that do have sort of maybe slightly more restrictive plans, like Medicare or, you know, people that are uninsured, how are you talking about that? How do you change your kind of spiel, your shared decision-making conversation with somebody if you have somebody that does have commercial insurance that's perhaps a little more, and I hate to use the sort of a generous, has more plan options versus somebody who doesn't have as many plan options? And how do you kind of coach that decision?

SPEAKER_01: 17:54

So a few things. So, first of all, I actually I'm not sure that folks with commercial insurance have more options. I I there are a lot of parents that are that are very restrictive. But I think what I try very hard to do, and this is very challenging, but if I know I'm gonna have a conversation with a patient about a new medicine or switching medicines, I try to find out ahead of time what my options are within the plan. And it doesn't always work that way. And sometimes we think we know what the options are, and of course it's something different. But I think the worst scenario is you and I sit in a room, we talk about what the options are, we decide together what we think is the right choice, and then we find out we can't get it. Because no matter what we give as the alternative, it's gonna feel like you're getting a second class treatment, right? Even if it's just as good in the data as the drug we chose, uh we originally chose, it's gonna feel like it's not the right choice. So I try very hard to do that. It doesn't always work out. The other thing I say, and I think is really important to acknowledge what we don't know, which is really a lot. Like we don't like to admit that we don't really know a lot of what we're doing. And a lot of what we're doing is based on potentially patients that are not like the patient that's sitting in front of us. And so, you know, I usually start the conversation if it's the new patient who's never been on an advanced therapy before, and I'll say, I wish I could tell you which drug is going to be the right drug for you. We don't really know. None of these drugs, with a few exceptions, have been compared to each other, right? We know they're better than nothing or better than placebo. We don't know which one's better than the other. We make our decision based on a whole host of other factors and we go through mode of injection, obviously insurance, risk factors, you know, other comorbid conditions that might make a drug a good choice or a bad choice, all that stuff. And then I say, even if we pick out of the group that's available, they're gonna work about two-thirds of the time. Approximately, right? Every study is a little bit different, but like on average, the drug is gonna work two thirds of the time. And I can't tell you beforehand which one is gonna work and which one is not. I wish I had a calculator and a method of of assessing, hey, for patient X, because of this factor, this factor, this genetic test, this whatever, you know, we know this is the right choice. We don't have that yet. Obviously, that's one of the sort of whole. Grails of the research world is to try to personalize our medication choice to a particular person. And I think that having that conversation, right? Expressing what we don't know, talking about, you know, how good the medicines are, right? Because that's the other thing. I think people have this impression, we've talked about other diseases. You go into medicine, the medicine works, and you're done, right? Like we don't often have the conversation of, well, it's only going to work in certain people. And if you already own a different medicine, then this medicine's going to work less well. And, you know, what although I we don't really have that when we talk about ARPR, right? Go in a PPI and it's going to work or you know, whatever. So I think that helps the conversation. And it helps when we we ultimately get to, okay, you know, the insurance lets us pick between these two or three choices. Now let's talk about those and which one is going to be good for you. And recognizing that it might not be the final choice because the insurance might not approve it, but also it might not work. And then we got to switch to something anyway. So even if we pick the medicine we think is best, it may not be the right medicine.

SPEAKER_00: 20:53

I mean, shared decision making is a gold standard, right? Like patients, they especially a lot of inflammatory bowel disease patients really know a lot about their disease. They're the experts. I mean, they've been live, they've been living with it. And so gold standard is that they're part of that decision making. I think what I find so frustrating is that you as a doctor have sat down with this person and talked through all of this to say what's going to fit into your life the best, what is going to be probably best for you for lots of reasons. And then you still have to go and somebody else, some you know, pencil pusher behind a desk, is still the one that's going to be like, well, nope, sorry. You know, and so I think the the quality of life and how it fits into somebody's life part of it is what I find frustrating because it gets removed at some point. And I get kind of up in arms about this and on some, you know, about three soapboxes.

SPEAKER_01: 21:33

When I'm on the phone with an insurance company, my office staff knows it because I'm in my office with the door closed and my volume gets louder and louder, and I get a little bit nastier. And I've I've taken to start like asking for their information, right? So, you know, what's your name? What's your specialty? Have you treated patients with inflammatory bowel disease? Before we even like dive into the particular question, because you know, I'll throw right back at them, like you've never treated a patient with Crohn's disease before, and yet you're telling me what to do. Like, I'll say, like, hey, look, if they get admitted to the hospital and they lose their colon because you put you you decided on this drug, like, you know, you guys are making the medical decisions, not me, you know. And and and I would say I win 98% of the time. It's a lot of work, you know, but it's worth it. And I and I think things to your point about like like being on an injection versus an oral versus whatever for lifestyle things, I actually think that does have some have some weight. And and I I've had success, you know, patients who have arthritis and can't use the injector. Or I mentioned to you before, you know, patients that are PTSD, who who have a history of IV drug abuse, who can't inject themselves. And fortunately, uh, some of the medicines that were only IV now have have sub Q options, which is great. And we have some oral options now, which is great. And some new oral options are hopefully coming soon, which is great. And so, you know, as we as we evolve, I think we are we are getting closer to being able to meet patients where they are.

SPEAKER_00: 22:54

It's so exciting to think that, you know, more drugs are coming to the pipeline and they're working in different ways. And some of them seem like more effective for certain types of diseases, but then the matrix gets bigger, right? So then trying to explain to patients, like, okay, here are your, you know, 12 choices, 15 choices, whatever it is, makes it even more difficult for you to be like, okay, so that's why I think maybe this class or this type of drug is going to be better for you. It almost makes it more complicated.

SPEAKER_01: 23:15

Oh, it's it's super complicated. I mean, when I started GI Fellowship, there were two drugs, right? And now we have many. And that's wonderful. And there's good and bad to that, right? Like, like it or not, treating IBD in the mid-2000s was not that hard. It was Remy Kate or nothing. That was it, right? So, you know, you don't need to be an expert to do that. And as the medicines have become more complicated and, you know, more numerous and more nuanced, we've seen this burgeoning field of IBD specialists, which is, I think, necessary for not all patients with IBD, but for many patients with IBD, because I see what happens sometimes in the community where patients are not told the things that we've talked about that I think are important to be told. I often get at the end of a first visit, like, oh my God, like my doctor never told me that before. And I was like, this is basic stuff. Like that never conversation has never come up before. And I think, you know, beyond the reflexively right for drug X that I won't name right now, because it's the easiest one to get, you know, you have to actually put a little bit of thought into it. Maybe that's not the right choice for this particular patient. And so we're seeing, I think, more referrals to subspecialty IBD care, appropriately so, because it's complicated.

SPEAKER_00: 24:22

So, in thinking about your patient population, actually, I'm mid-editing of uh an episode that we did with Stephanie Wynn. Stephanie Wynn runs the Stephanie Wynn Foundation. And she is a woman of color and talked about how, you know, that's really what her focus is is trying to ensure that people of color have the education that they need and the resources they need and putting it in a way that it is very understandable to that community. We got into a conversation about clinical trials. And obviously, you know, there's historic things that definitely make healthcare in general, you know, a little bit scary and challenging. But clinical trials and in particular, you know, sort of research in particular is one of the things we talked about. And her organization is going to be focusing on providing patient education there. So I'm curious when you're bringing this up with patients, like how are you bringing it up with patients? And how are you keeping that lens in place to make sure that, you know, your cultural competency is there as you're explaining research and getting involved in research to patients of color? Yeah.

SPEAKER_01: 25:14

The diversity of patients that I see of all colors, you know, has has taught me a ton because there are different cultural things that I didn't know before I got into this. And there's cultures where they are very paternalistic or they want you to be very paternalistic, right? Just tell me what to do. Like I'll do whatever you say. There's people where, you know, they don't want to make the decisions, they want their kids to make the decision, especially if it's an elderly patient, right? And they're they're sort of everywhere in between, right? And so I think it's just a it's just a question of being open and honest about what we're dealing with. We don't do a lot of clinical research at Temple, largely because of infrastructure questions. We have tried, and some of the things unrelated to the patients have have made it challenging. But the pharma companies like would love to work with me. We talk about it all the time because I can provide them with some patients of a diverse background that they want to get in their studies, and very appropriately so, because we know most of the research trials are not representative of uh of many of the backgrounds that we would like to see. And certainly, you know, I don't know, you know, we talked earlier about, you know, the person sitting in front of you may not be representative of the study or the data that you're using, right? And that that's certainly true all the time in my population, right? That if you have, you know, whatever drug was studied with, you know, 90% Caucasian patients in their study, and I'm sitting in front of an African-American patient, a Hispanic patient, Asian patient, I don't know if that's transferable in the same way. It adds to the many things that we don't know when we when we're caring for a patient. And yeah, I just think it's it's being open. And I really, really, really stressed with my trainees being honest about what you know and what you don't know. And I mentioned that already, but I think it builds credibility with patients for a patient to hear we're sort of in this together. It's not like, oh, this is clearly the right thing and this is clearly the wrong thing. It's like we're gonna do the best we can. And it might not work out the way we all want it to work out, but we're trying our best to get there because that's how patients are too, right? They don't know what's gonna work. And uh, and I don't think I think some people have this perception that that's a sign of weakness or that's a sign of not having the expertise, right? If you don't know what the right thing is, right? But if you ask folks, and I'm sure you have, you know, we don't really know in many cases what the right answer is.

SPEAKER_00: 27:22

No, unfortunately not. I know that, you know, the obviously everybody's striving for the personalized medicine. And I know it feels like we're getting closer, but you're right. There's still so many unknowns because you're right, like a lot of the research has happened on white people, especially white men, to be frank. You know, and so yeah, are we, do we even know whether there's a genetic component that means that somebody's gonna respond differently to certain types of medications? Or is there a genetic component that makes certain races of people, you know, respond differently to having inflammatory bowel disease? I know that's come up, you know, I'm my dad had multiple sclerosis. That's how I got involved in this clearly in the chronic disease community. And I know when they're looking at people living with MS, that like if you're an African-American man who's diagnosed with MS, you tend to have a much more aggressive course. And is that because it's not being diagnosed early enough? And so by the time it gets diagnosed, you know, like there could be some other factors that that play into that. Or what is there a genetic component that just says if you're an African-American man, it's just you, it's going to be different for you than it is for, you know, a 30-year-old white woman. Like there's a lot to understand there still that we just don't know. And I think we're getting there, but it's a long way.

SPEAKER_01: 28:23

And there used to be data, or there, I mean, there is data out there that's older that suggested, for example, that African-American folks with perietal disease had more aggressive courses of their disease. And I'm not so sure that that's real. That may be the biases of being diagnosed later or not getting the right appropriate medications, right? Like if they they are less likely to get a biologic first, then they might do worse, right? And that's not necessarily a more aggressive disease. So there's a lot of things we don't we don't know there, but it stands to reason. We know certain ethnic backgrounds have certain genetic predispositions, right? Celiac disease, I can tell you, is not very common in the African American population. It's very common in, you know, Mediterranean, Northern European, et cetera, right? So it doesn't mean it can't happen, but it's much less common. And we're making sort of our best guess decision making on the trends that we've seen, you know, and and that we know exist in the literature.

SPEAKER_00: 29:14

I agree with you. I think there's just a lot that we can learn about this. And also just thinking about like, you know, more aggressive periental diseases. I think about all the people that we've talked to that were going to just like, and and no offense to these folks, but community GIs who are trying to do every aspect of gastroenterology, right? Not just inflammatory bowel disease, that just don't know as much as you do because you spend every day doing this and you do research and you and you're going out and talking and doing all these things. You know, if you get somebody with perianal disease, you do your best, but you don't know what is the best treatment. And so what that person, you know, gets strung along until eventually they find their way to you, you know, gosh, they've gone a long time without, you know, with under-treated disease. And so then of course they're going to look worse, you know. So and that's what's available to you. One of the things you mentioned before we hit record is just when you're talking to patients about the things that they could be talking to you about that might help. So the quality of life aspects of living with a chronic illness like inflammatory bow disease that could be helpful for doctors to know that may you may not know you should ask it or say it out loud. So talk talk to us about your way what you're thinking there.

SPEAKER_01: 30:11

Yeah. So when I see someone in the office, or when a doctor sees a patient in the office, right? You know it's 10 minutes, 15 minutes. There's things that we have to know, right? Diarrhea, bleeding, pain, weight loss, right? Like all the standard questions that you're gonna get with related to IBD. We have to talk about, you know, what your last test was, when your next test needs to be, right? Like there's so many things to talk about that are sort of standard. And I think what we lose sometimes, and I know I'm guilty of it from sometimes, is who is the patient? What is important to the person sitting in front of you? And I'll I'll give you a great example. I have a patient who has a desk job where he works from home and he's three steps from his bathroom. And he goes to the bathroom all the time. And on one hand, I say, that's not good. Like, right? We gotta fix your inflammation, we gotta do this, whatever. And that's not that important to him because that's not the biggest problem that he has, right? His biggest problem is the rare time he's gotta take a two-hour drive, he's got an issue, right? But 90%, 95% of the time, he's okay, right? Even though he's got, you know, symptoms. If we don't delve into that, right, it limits my ability to pick what the right answer is. Because ultimately I think this particular patient needs surgery. And we've tried a lot of different medicines and it hasn't worked, unfortunately, right? We know that happens sometimes. But the day-to-day is something that we don't often hear about. We don't often hear about, especially, you know, in any patient, but certainly in in young folks, about relationships, right? And and you know, sexual function and dating and and and how that might affect things, right? A lot of times I make a very overt point with patients of childbearing age to talk about interest in pregnancy, you know, soon or or in the distant, you know, future. But a lot of times people don't talk about it. We know there's higher rates of voluntary childlessness in IBD because people are worried or scared. You know, one of the examples we gave or I gave to you earlier before we recorded was, you know, someone who might, what they really want to do is they want to be able to be outside at their kids' soccer game and they can't because, you know, it's not near a bathroom, or they've altered their morning breakfast routine because they know they have to drive to work and things. And if you don't ask those sorts of questions, or you don't ask even just the basic question of like, what's your goal? Like, what's the most important thing to you? Or as we think about this medicine, like what is the thing you hope this medicine helps you with? And sometimes it's normal things, right? It's I don't want to have bleeding, I don't want to have pain, uh, you know, whatever. And then sometimes you'll learn something that you might not have otherwise expected, right? And so I know later on you'll you're gonna ask me sort of my my tip of the day, or I don't know, whatever you want to call it, but like, but to the patients, it's let your doctor know what's important. I would say it's most of the time not what the doctor thinks is important. And that will help me figure out what the right thing is for you, right? And sometimes that means, you know, sort of stepping outside of the guidelines of care, right? Like we don't always have to follow the textbook or the recipe of managing a patient, right? That we have sometimes we step out and we say, you know, okay, you know, normally I would do this, but this is why I'm not in this case, and I want to do X or Y differently.

SPEAKER_00: 33:10

The patient you mentioned that, you know, works three steps away from the bathroom and and thus can go to the bathroom whenever they feel like it brought up in a, you know, kind of a thought. So Robin has talked about how, like, just because she has had active disease for a long time, that and it's almost like a psychological or and or like muscle memory type of a situation where it's like now her body just like she goes to the bathroom at night kind of thing. And it's not that sometimes she maybe really needs to. It's like it's almost like she needs to retrain her body to think you don't have to do this now. So I am curious about that. Like in this person's case, you know, like they're so used to going to the bathroom so often. What aspect of maybe like sort of that idea of like muscle memory goes into this too? Of like, how are you helping people retrain once they are in a state of not flare and inflammation? Is that part of what you talk to people about? Is that even a thing? Did I just, did we just make this up?

SPEAKER_01: 33:59

I think you're you're you you have a very good point that when people get into a routine, it's what they know, right? And we also know, I'll say as an aside, that there's so many other things that go into whether a patient's run into the bathroom, right? And, you know, can common irritable bowel syndrome. You know, we know very well about the brain gut axis and how various, you know, mental stuff can affect the GI tract in all sorts of different ways, right? I've talked before with patients about, you know, the idea of why don't you try to not run to the bathroom as soon as you feel like you've got to go, right? Like maybe you can hold it more than you think you can hold it, right? And you feel that twinge and you're like, oh crap, gotta go to the bathroom, you know, and maybe actually, especially if we're doing something active to change your disease, like maybe it's actually getting better, right? And you just don't quite realize it yet. We've talked about that for sure. I think it depends on the patient, obviously.

SPEAKER_00: 34:51

Uh yeah, obviously. Yeah. I mean, it certainly isn't gonna be everybody, but it does make me curious because I mean, just everybody goes it gets into a certain routine, you know. And so you kind of just go, okay, well, after this, after every Zoom meeting, I go to the bathroom just to make sure because who knows if it's gonna happen in the middle of my Zoom meeting. And so then thus you start this pattern of like, well, after every Zoom meeting, I go to the bathroom.

SPEAKER_01: 35:11

Totally. And and there are many patients with or without IBD where that's a very appropriate mechanism, right? Patients that have incontinence for not inflammatory reasons. Sometimes we talk about, hey, you know what? You should set an alarm and every four hours you should try to go to the bathroom, even if you don't feel like you've got to go, because that might prevent you from having an accident, right? You know, like down the line or something, right? So, like every patient, you got to think about what makes sense for them. But it it might make sense to say, you know what, let's try to break out of your routine a little bit. And I mean, I'm thinking out loud about even saying, like, maybe you work in your house in a different room that's a little bit further from the bathroom, and you just see what happens. You might, it might not change, right? But maybe it does.

SPEAKER_00: 35:52

Yeah. Oh, I like that. Yeah. Okay. This is a question. If one of the things I've been mulling over is when we're talking about patients who are in flares and there's lots of inflammation happening. Like I know people that talk about how like they have stuff goes through them so quickly that they can literally see like whole pills in their stool, right? In the toilet. And so clearly that didn't break down for them. When you're working with patients and you get them past that phase and now they're like, they're not in flare anymore, and things are staying in them long enough to get processed. Do you is there a way to measure like how much drug is actually in their system? Because I'm so curious about like, do we have a bunch of people that are running around potentially over medicated? Because you know, you had to give them so much medication in order to get them out of inflammation and sort of help them feel better when they're in, they have such inflammation going on, that now that they don't have the inflammation, they're perhaps getting more medication than they need because you've had to like set it at this bar when they maybe only needed this bar.

SPEAKER_01: 36:42

The short answer is yes. It's definitely, right? So we know, and the drug we have the best data for is infliximab Remicaid. And we know that in a patient with a very inflamed colon, they lose a lot of that infliximab in the stool. There's studies that have measured the amount of infliximab in the stool. That's not like a commercially available test.

SPEAKER_00: 37:02

So even though it's an infused product.

SPEAKER_01: 37:03

Correct. It because the membrane, you know, between the gut and the, you know, the tissue is so broken down that the infleximab gets into the tissue and then it just leaks into the into the stool. And so we know that for many patients with also with ulcer colitis and influximab, they need a higher level. And there's data out there for someone sick in the hospital, you give them a higher dose to start than the standard dose and things like that. So we can, and we often do with infliximab, measure drug levels to know sometimes we got to increase the dose, right? And sometimes, to your point, we start at a high dose, they get better, and we're probably giving them too much, and we can potentially lower the dose. The challenge is with almost every other medicine, we don't have that data. We can theoretically check levels for some of the other medicines, but we don't really have good data on what the right level is or what a good level is. And we also know that just like we've already been talking about, every patient needs a different amount of drug. And so while we may have a guideline of, hey, we want to target between five and 10, well, patient X needs 12 or else they're gonna have a problem. And patient Y needs three. And so as we are understanding these medicines better, I think we are hopefully knowing sort of where we can tweak things around the edges. And there are patients that may not need infliximab every eight weeks. They can get it every 10 weeks. And there are certainly patients we know that need it more frequently than every eight weeks, right? Six weeks, four weeks, et cetera. But there are some people that are on sort of more extended regimens and that seems to work for them. So we just don't know, especially with the newer ones, what that looks like. I think what we can safely say is that most of the therapies don't have higher risks with higher levels or with higher dosing. And so that's some level of reassurance that maybe people who are on more drug, it may not be necessary, but it's not harmful. So that's that should at least be somewhat reassuring. But we don't do a great job of de-escalating therapy because we're worried about people getting worse, right? We finally got you better, let's not screw with it, right? You know, and there's a lot of validity to that, particularly in someone who's been very difficult to control, right? Like, and patients think similarly, right? Like some patients, they want to be off medicines tomorrow, right? Like if I said tomorrow you could come off, they would stop in two seconds, right? And there's some patients that say, like, don't mess with me. Like, I'm finally feeling good. You know, like I've been on six different things, and we finally figured out something that works, like, don't mess with it. And there's a lot of validity to that, and a lot of very reasonable, that's a very reasonable feeling. And so, yeah, I mean, goes back to that same question personalized medicine. Who is the patient that can manage to have a lower level or who's the patient that needs a higher level? Both at the beginning, right, when you're first starting, but also a year down the line, five years down the line, 10 years down the line.

SPEAKER_00: 39:54

Not to add another layer to it, but I'm going to when you have a patient that has co occurring disorders, like has something else going on with them, like say, You know, they do have to have heart medicine or they do have to have something else. Like when somebody is in a flare and then you go, oh gosh, maybe this means they're like, you know, their heart medicine is fully intact in the toilet. How are you working with the other doctors that this person works with? Like, do you reach out to them and say, hey, this person is, you know, their IBD is flaring. And so we might need to measure drug levels for other things to make sure that this person doesn't suddenly have a heart attack on top of it.

SPEAKER_01: 40:24

That's a really good question. I would say that most medications, and I'm not an expert in the non-GI medications, but most medications are absorbed more proximal in the GI tract than the I where the IBD is, right? Stomach or early, early small intestine. And so we don't think, or I don't think at least, that most of those drugs would have significant issues with absorption. Also, you know, it depends on obviously it depends on the medicine. There are not a lot of drugs out there in general that we can check levels for. Really? Outside of outside of IBD, right? I mean, like there are some for sure, but not a lot. And so I we couldn't do it necessarily even if we wanted to.

SPEAKER_00: 41:07

This is what this is what I don't sleep at night. I go, well, but what about people who have like bipolar disorder or schizophrenia? Like now are we like, especially folks with bipolar disorder, are you medicating them to the point that they've like all swung over to the other side? You know, like I'm just going, gosh, there's got to be some funky stuff going on there. But you know, also you like you said, we can't measure it.

SPEAKER_01: 41:25

So yeah. I mean, the colon does not absorb really any medications. The colon is really just absorbs. For sure. No, for for sure, Crohn's disease. But I think again, most things are absorbed in areas where Crohn's disease is less common and therefore hopefully is less significant. But you're getting me thinking about it too now.

SPEAKER_00: 41:43

So I'm sorry.

SPEAKER_01: 41:44

No, it's okay.

SPEAKER_00: 41:45

Now you're just getting my curiosity questions because I haven't gotten to ask anybody this. Okay. So one of the other things I I put on my list to talk to you about that we haven't necessarily chatted with folks about is that you are the director of the fellows program within your institution. And so when I was looking up your research, you do have a number of things that you are, you know, papers and things that you're you are authored on, you're cited as an author on, talking about fellowship training and and how you're working with people to prepare them to become IBD doctors. So talk to us about that program and just, you know, some of the research that's happened there. What have you found in your experience being the director of this program that is like these are the things that are the most important to teach your fellows?

SPEAKER_01: 42:22

So GI Fellowship is a three-year training program. And they're supposed to become competent gastroenterologists at the end of that time, right? From a endos from a procedure perspective, from a cerebral perspective. And, you know, as we talked about a little bit with community docs, right? You got to know a little bit of everything, right? So we, of course, have to make sure they know hepatology and esophageal diseases and, you know, H. pylori and GERD and all the celiac disease and all the things, plus IBD, right? And we know now that there are a lot of programs in the country that have an extra year to do IBD training. A lot of the major IBD, you know, hospitals that you would think of if you're thinking about where's a good IBD place, have an extra year of training. So I think the the idea behind training people for IBD really depends on where they are doing the training. If you're training at Mount Sinai as a fellow, you don't need extra training. You're gonna see all the things you need to see just as part of your general fellowship. If you're at Temple, like it or not, we don't have the biggest IBD population. And so that's a place where fellows at Temple say, hey, I want to learn more, I want to do more. And so for me, like I'll have them spend some time with me in the office because they can see, you know, IBD patients there. There are programs through the Crohn's Glides Foundation to send them to other institutions for a month to get them to learn. And we've had a number of fellows that have done that. We've had fellows that have gone on to do that extra year of IBD after they finish our three years of fellowship. And so it really is sort of identifying this is true for any subspecialty, not just IBD, right? You know, we want to customize their learning to what they're interested in. Yeah, you got to learn a little bit of everything. But if you want to learn IBD or you want to learn advanced endoscopy, or you want to learn hepatology, or you want to learn whatever those things are, you know, third second and third year of our fellowship, you have some time to sort of customize what you want to do. And, you know, we've established some new lectures in IBD. Like I give, like sort of, for lack of a better term, IBD 101 lecture series at the beginning of the year, where I don't even have slides, we just like talk and I like write things on the board and stuff. And then fellows who have, they'll give some presentations over the course of the year as well. We'll do some case studies. So it really varies depending on who the person is, and it'll depend in general about where you do your training.

SPEAKER_00: 44:27

Got it. It seems like that would be a really rewarding thing to do, just because, you know, if you uh it's very obvious you love patient care. It's very obvious, like, you know, your your passion for this is obvious. And so it must be fun to be able to teach other people, you know, and help them become better doctors as they go forward.

SPEAKER_01: 44:41

The thing I like most about being involved in fellow education is that I feel like my I can impact more people than just the patients that I have time to see in a in a given week, right? And and I now have been doing this for long enough to have a lot of fellows that are in other places now that they've graduated and and are doing other things. And occasionally they'll call me and ask me about a patient, and sometimes I'll see them at a conference and and whatever it is. But like to know that I played a small role in their education and now they are doing the thing that I am passionate about, taking care of patients. And so I feel like my influence has spread a little bit in a hopefully mostly positive way.

SPEAKER_00: 45:20

I'm sure it's positive. This is your wild card question. So go circling back to you know, patients telling you things and quality of life. I am curious what was the most unexpectedly helpful thing somebody told you unsolicited that now you go, I'm gonna ask other people that.

SPEAKER_01: 45:47

But this person, I didn't, I don't know if I sort of realized it beforehand or whatever, but he was from Hungary, the country of Hungary. And he told me that he was planning on going back to Hungary when he finishes school in a year. And I said, Well, crap, I gotta think a little bit differently about what medicine I want to put you on, because I have no idea what I don't even know what's available here in Philadelphia, let alone what's available in Hungary and picking a medium. I don't want to pick you put you on a medicine that now you can't get a year from now. And we did some, I did some research and we sort of figured it out and and we got him on a therapy and there's like a family connection to him also. So like I understand he's still doing well now, like a number of years later. But like I think travel was like one of the first things that I realized is really important. And this is a case of where someone's gonna live in another place, but also, you know, does your job require a lot of travel, you know, where you you might not be able to get the infusions and getting, you know, an injection might be more helpful. And obviously, this was a at a time when a lot of the medicines that are now available by Sub Q were not available, Sub Q. You know, college students I mentioned about you know, study abroad. I've had to get patients' infusions in other countries before, and it is you think this healthcare system is bad? Like navigating that is just insane. We did it, but it was really, really, really hard. And of course, like at the time we made the decision about the drug, we were not thinking about that this kind of travel, whatever. But that's like a thing that has stuck out for me on a number of occasions, thinking about where someone might be. I I now I'm thinking now of a patient who told me they were gonna be do a semester at sea.

SPEAKER_00: 47:14

Oh Lord, what?

SPEAKER_01: 47:15

So so, like, not only would they not be in a place, but they wouldn't even be able to get packages. So, you know, like thinking about getting your drug, you know, said month or whatever, like they weren't gonna have access to that. And so then we had to appeal to the give them six months of drug, which they normally don't do, and like, you know, real life stuff, right?

SPEAKER_00: 47:31

Jeez, yeah, right. Yeah, that would definitely be like that. Wow. Also, just thinking about like if you went into a flare and you're on a boat, like with a bunch of other people, this that is a very brave patient, whoever that was, kudos, because I would have not probably made that. I would have been too scared. I would have been too scared to make that decision.

SPEAKER_01: 47:49

It was a professor.

SPEAKER_00: 47:50

It was not a well, okay. Still choices. It's interesting you say that because one of the things, you know, having again been a social worker, I one of the pieces of my job when I when I was working with patients with inflammatory bowel disease is I would get people that would email in to be like, how what do I do about, you know, I'm going to go study abroad or whatever. And also just the importance of making sure you're getting insurance, extra insurance to take with you. Like your health insurance typically doesn't cover you when you're abroad. So you have to get a special type of health insurance. A lot of times you can get that through a university if you're studying there. But about how, like, I mean, when I studied abroad, I didn't do that. And but I don't live with a chronic illness, and I fortunately didn't need the healthcare system the entire time I was there.

SPEAKER_01: 48:30

And I don't know if it still exists, but at least as of a few years ago, there was an organization or program called IBD Passport that was literally meant for helping people who were traveling abroad to get their IBD medicines in various places. One of the Israeli ducs, I think Shroman Ben Horan was part of it. And there was a nurse from Britain who's, I think her name was Kay something. And they helped me when I needed to get a patient an Elizabeth, an Intivio infusion in London.

SPEAKER_00: 48:58

Last question for you, Dr. Is if you had one piece of advice for the IBD community, what would it be?

SPEAKER_01: 49:02

So I alluded to it earlier, and I would say from a patient perspective, the advice is that your doctor only knows what you tell your doctor. So please, please, please tell your doctor the things that are important to you. Of course, like all of like the usual stuff, but like the things that they might not otherwise know that are going to matter. We don't know we should be asking, but also, you know, you should take, you should be empowered to tell us those, tell us those things that are important.

SPEAKER_00: 49:27

Fabulous advice. Cause I do think, you know, you're right. Not every doctor remembers to ask that. I know everybody's busy. And it's so important to say how are things working, what are your tests, blah, blah, blah, to get that done. But I think spending that time getting to know the thing that is the most important, like you said, sometimes can be surprising and also really help inform how you're you're moving forward with that patient. So great.

SPEAKER_01: 49:45

And and I acknowledge that I don't do it all the time either, right? You know, we're busy and stuff, but like we try, I try to to think about that in the care. And sometimes, you know, sometimes those sort of things come out without overtly asking the question. But if you're not sure, you know, get it, you know, tell us.

SPEAKER_00: 50:00

Yeah. Well, and even just like maybe setting yourself a reminder in your charts to say, like once a year, ask this person, all right, are your goals different now? You know, because you know, we talk about people in their seasons of life. It might be that somebody is going to a place where they're like, I want to go spend a semester at sea, or I want to get pregnant, or I want to move someplace else. And so I need to figure out continuity of care and blah, blah, blah. And so there's lots of things that can change within a person's life. And so, you know, setting a reminder to just kind of check back in. There's lots of things that can come into play there. So Adam, I really, really enjoyed talking to you. I told you, I warned you that we would go down paths that may not be expected. So I appreciate your flexibility and willingness to go down those paths with me. I appreciate you joining us. I appreciate all of our guests for listening. And I'm gonna say cheers. Cheers.

SPEAKER_01: 50:43

Hi, this is Dr. Adam Earling. If you enjoyed this episode, please rate, review, and subscribe, and share it with your friends.