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Ep. 431 Know Better, Do Better: Medicine’s Evolution with Dr. Kwadwo Kyeremanteng


Today, we have an extra-special episode recorded live at an Eudemonia event in West Palm Beach in November 2024. I had the privilege of sitting down with Dr. Kwadwo Kyeremanteng, an ICU-attending physician in Ontario, Canada. Dr. Kyeremanteng is particularly attuned to middle-aged women and is interested in preventative care and metabolic health. Across social media channels, he is known affectionately as Dr. K.


In our discussion, we spoke at length about fear-based decision-making and medicine, looking at the impact of allopathic care models and lifestyle-related diseases, the impact of hospitalizations and big-gun antibiotic therapy, and the trauma of being hospitalized in the ICU. We also dove into the role of the microbiome, exploring lifestyle, the challenges of changing the medical system, and the concept of knowing better and doing better as a clinician. We closed the conversation by discussing the Women's Health Initiative and the subsequent prescribing changes in the wake of that study, the role of advocacy, and end-of-life decisions. 


You will not want to miss this invaluable conversation with the delightfully charming and insightful Dr K.


IN THIS EPISODE YOU WILL LEARN:

  • How fear-based decisions in the ICU can lead to over-testing and misdiagnoses

  • Why it’s essential to be clear and focused when making important decisions in high-stress situations

  • Common lifestyle-related issues that drive many individuals to the ICU

  • How metabolic health links to mental illness

  • Smoking and lung health and other conditions like emphysema and chronic obstructive pulmonary disease

  • Potential long-term effects of antibiotic overuse

  • Why a healthy microbiome is essential for preventing chronic diseases

  • Challenges of changing existing medical practices

  • The long-term impact of the Women's Health Initiative on women's health

  • How HRT can improve women's quality of life

  • Importance of having end-of-life conversations with loved ones


Bio: 

Dr. Kwadwo Kyeremanteng is an ICU physician, productivity expert, and health and wellness advocate. He is the author of "Unapologetic Leadership," which promotes decisive and authentic leadership principles. Dr. Kyeremanteng also hosts the popular podcast "Solving Healthcare," where he discusses innovative solutions to improve healthcare delivery and outcomes. His work is driven by a commitment to equitable access to care and reducing healthcare costs while enhancing quality. Dr. Kyeremanteng is an active social media presence and leverages AI in his work to further his mission of relieving suffering and promoting health.

 

“Most doctors like to think in categories or black and white. They don’t think in the personalization kind of approach.”


-Dr. Kwadwo Kyeremanteng

 

Connect with Cynthia Thurlow  


Connect with Dr. Kwadwo Kyeremanteng


Disclaimer:

This episode was recorded at Eudemonia. The creators retain full rights to use the footage and audio across their platforms, including podcast distribution, YouTube, and social media. With permission, portions of this recording may also appear in Eudemonia's non-commercial catalog behind an email wall, with a link back acknowledging the recording location.


Transcript:


Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.


[00:00:29] Today, is an extra special podcast episode. This was recorded at Eudaimonia in November of 2024, where we spoke at an event in West Palm Beach. I had the distinction and honor of sitting down with Dr. K, Dr. Kwadwo Kyeremanteng. He's affectionately known as Dr. K across social media channels. He is an ICU attending in Ontario, Canada and has a particular interest in preventative care, metabolic health and being particularly attuned to middle aged women. 


[00:01:13] Today, we spoke at length about fear-based decision making in medicine, the impact of allopathic models of care and lifestyle related diseases, the impact of hospitalizations and the trauma of being hospitalized in the ICU as well as big gun antibiotic therapy. 


[00:01:31] We shifted the focus and went on to speak at length about the role of the microbiome and the impact of lifestyle, why it is so hard to change the system in medicine and the concept of know better, do better as a clinician. Lastly, we rounded out the conversation discussing the Women's Health Initiative, and the resultant statistics and prescribing changes that happened in the wake of that particular study and lastly, the role of advocacy and end of life decisions. This is an invaluable conversation with Dr. K. He's so charming, so insightful. I know you will love this conversation. 


[00:02:14] It's such a cool experience to be able to record in front of a live audience, which is something I don't get to do at home. But I would really love to initiate the conversation around how fear-based decision-making influences how we practice in medicine. And obviously, as an ICU intensivist that practiced during the pandemic, how does fear based decision making from a top-down perspective, how does that impact us, not just as clinicians but as human beings? 


Dr. Kwadwo Kyeremanteng: Great question. What drove me to comment on it was we were making most of our decisions out of fear. And for me, it's a bit of a mindset, because when you have fear as your foundation, you're not thinking clearly. You're not thinking your flight. You are thinking of the worst-case scenario that totally integrates into your mindset. And so, for you to think creatively, for you to think of the best solution for the patient in front of you or at the time society, that's getting impacted. I see it clinically as well. So, in the intensive care unit, obviously, there's a lot of high stakes. We were dealing with life-or-death situations, and your calls can impact whether somebody lives or dies.


[00:03:42] The nature of our job, if you make a lot of fear-based decisions, what I typically see is that you order more and more tests, you get more and more diagnostic imaging and it leads you astray, because you get that false positive, you focus on that area that could be significant but truly isn't. And as opposed to seeing the big picture or addressing what is really pushing that patient into a poor outcome, you led astray. 


[00:04:12] So, to me, fear-based decision making at a micro and a macro level leads to an un-optimal decision making. Especially once again, in the intensive care unit, you have to have that clarity. You have to think clearer, because there's so much at stake. People are so vulnerable. Sometimes you have a window of time to making that right decision. 


[00:04:33] Again, I don't mean to go off on a stray, but I'll never forget this one. This was when I was a trainee, my last year of fellowship and we had a patient trying to make this story quick. We thought they had a clot in their leg which was leading them to be very unstable, like on three medications to make sure their blood pressure was adequate. They were on the verge of dying. It was this observation or this instinct when we looked at the leg and it started to blister and we're like, “You know what? This could be necrotizing fasciitis or flesh-eating disease.” Like, “This could be-- Like, “Yeah, we need to pivot.” And if it wasn't for that clarity, that creative thought process of what else could this be, this 30 some year-old woman wouldn't have lived. 


[00:05:24] She went to the OR within the hour, cleared out the infection and is now living with her family. And so, this is long winded answer. But yeah, fear-based decision making to me is something we need to avoid at full cost. And really, when it comes to at least at a high level, focusing on our values is really important. 


Cynthia Thurlow: [00:05:43] Yeah. It's interesting, because my background in traditional allopathic medicine was in cardiology. So, I spent 16 years in the trenches. My feeling has always been cardiology, nephrology, which are kidney doctors. ICU doctors are oftentimes some of the most incredibly talented, decisive individuals. And understanding physiologically, like when we are making decisions, whether it's in a hospital or in our personal lives, when we're making decisions from a place of fear. 


[00:06:14] So, just physiologically, the prefrontal cortex is what drives executive functioning. And if our prefrontal cortex is overridden by our lizard brain, which is the amygdala, we no longer can really think thoughtfully. It's interesting, talking about this before we started recording, how many people I would interact with that were in the ICU, whether it was the MICU, the SICU, the NICU. I mean, wherever we were-- 


[00:06:38] Hopefully, I'm talking about the neuro ICU. I thankfully never saw patients in the NICU, the traditional NICU, the neonatal patients. I would say 90% of those people, they would deal with emergencies and they were calm, cool, collected. But then you would have people, the outliers, whether they were a nurse, a tech or a doctor that would get highly excitable, they would freak out, they would jump to doing more testing, which bought them time to try to figure out what was going on, when what they really needed was just be decisive. 


[00:07:08] And so, I think that in so many ways, I have so much reverence and respect for people that work in those high acuity areas, because you have to be able to think methodically, decisively, quickly and really not be thinking that every single patient needs to be run through the same algorithm. It's just really thinking, as you appropriately and astutely noted, instead of thinking about a deep vein thrombosis, thinking, could this be some other issue that's ongoing and you saved that woman's life? 


[00:07:37] I think that in so many different reasons, why I wanted to start the conversation here, is that this translates into real life. This translates into the traditional allopathic medical model right now that is so focused on medications treating, and for the most part, lifestyle related diseases. I saw so much of it in cardiology. It's why I got to a point I could not write another prescription, because in cardiology, I was sometimes writing 20 to 30 per patient, depending on what was going on coming out of the hospital or into the office. 


[00:08:12] And so, you are able, as the ICU attending, to be able to see with tremendous clarity, I'm sure. What are some of the most common issues that you think are driving the problems that you're seeing in the ICU right now? What are the lifestyle related issues that are creating a wave of problems? Maybe people don't realize that little bit of insulin resistance in your 30s that progresses to diabetes, which progresses to sequelae, really becomes problematic. 


Dr. Kwadwo Kyeremanteng: [00:08:45] I'm really glad you brought this question up, because I just want to put some context to it too. If you land in the ICU for any reason, you are not coming out the same person, most of the time. So, it is like you want to avoid this at all costs. I see 25-year-olds, I see 75-year-olds. And the 25-year-olds, yeah, they'll recover, but it's a long road ahead of them. And so, when I'm talking about this whole prevention side, it's because of the gravity of landing in an ICU. Yes, it's actually hard to die. We're pretty good at maintaining life, but it's the quality of life that results after leaving us. 


[00:09:26] And so, a good proportion-- I couldn't cite to you what proportion of our patients because a lot of ICUs are different, but a lot of them are related to lifestyle choices. And those being type 2 diabetes that we see, it's obesity. We see a lot of hypertension related illnesses, we see a lot of dyslipidemia or cholesterol that that's off. And there's a few layers of how this affects your care in the intensive care unit. So, you land in ICU because of-- 


[00:09:56] Most of the time, it's inflammation related diseases. So, whether it is an infection, whether it is that heart attack, inflammation makes everything worse. The lung infection, even COVID, if we're talking about that, all inflammation, you land in hospital because of inflammation. And so, these conditions, as many of you know, carry a lot of inflammatory processes along with it. And so, that's the one aspect to land you in ICU. 


[00:10:22] And then, the people that come in because they're sarcopenic, so don't have much in the way of lean muscle mass, because there's a lot of obesity, when it comes to the recovery aspect, which is probably one of the most important part-- Because I'm not being facetious when I say it is hard to die in 2024. Like, we're good at keeping the numbers going, but the most important part is the recovery aspect. When you are 40 pounds overweight, when you have no lean muscle mass, when that physio’s come into you and says, “Hey, time to get up and get moving and get strong again.” And you're like, “Mm-hmm, I don't think so.” Now, you get your second infection. Now, you get that clot in the leg. Now, you get that sacral ulcer that is really impairing your mobility. 


[00:11:09] It is so much layers because of people are metabolically unhealthy. So, many layers that land you in ICU and prevent you from being your optimal self. It's remarkable. Then you add the component, which also really excites me. You got to meet my wife just now but from the psychological aspects, like the ties from metabolic health and mental illness to me is so fascinating. Like, the whole Chris Palmer movement and linking metabolic health to mental health-- This is another component that lands a lot of people in the intensive care unit when we see a ton of overdoses, suicide attempts, and so much links to that metabolic syndrome. And this is why I'm, as an ICU doc, passionate about it. 


[00:11:58] If you Google ICU doc, you talk about preventative health, I think it'll be hard pressed to find many of us, if not just one. But it's because, one, as I mentioned coming into ICU is so profound-- It, obviously, can impact your quality of life significantly. But yeah, if we could talk more about ways to reverse this-- To me, it's so exciting to think that, hey, we could create this movement where people are healthier, you're less likely to land in hospital and get all these comorbidities as a result. This is where our conversation needs to go. 


[00:12:36] I don't know. Cynthia, I don't want to speak too big or whatever, but I feel a shift. I feel like people are starting to see it. I think people are starting to see it, because we're able to make more and more ties to metabolic syndrome and other disease states. So, I'm hoping the tide is turning. 


Cynthia Thurlow: [00:13:00] Yeah. Well, and it's interesting to me, having had all that time, 20 years of ER medicine, cardiology, and then the last eight years really nicely niched into honoring women in perimenopause and menopause-- As you're talking about those patients, those were my patients-- Cardiology, there are a million things that could land you in the ICU. But more often than not, my patients were sedentary. We used the term sarcopenic obesity, which means they had such a significant loss of muscle that's been replaced by adipose tissue, and it is slow and insidious. If you're north of 40, I can't say this and I can't emphasize this enough how critically important it is to maintain muscle. It is not just about the physicality of it, although I think for a lot of us, we're appreciative of that. 


[00:13:48] Having said that, other things that I think about that many patients-- It was a bigger issue when I was in Baltimore than it is in Virginia. But so many of my patients-- If you could get your patients not to smoke before the age of 18, they were statistically much less likely to smoke. But the sequelae, the side effects of smoking-- There's always an exception. There's your family member, that's 92 that smoke their entire life. They're this thin and they've never had a problem. But more often than not, those smokers go on to develop lung disease. They develop emphysema. They develop chronic obstructive pulmonary disease. Those are my patients that end up having heart disease, that end up in the ICU because they couldn't breathe. 


[00:14:34] I'm sure you see those patients, you can’t-- We use the term, wean them off the ventilator, which means the breathing tube that's in, the endotracheal tube that's in, you couldn't take them off ventilator because they just had such poor pulmonary function. Then you add on top of it, someone's obese, it makes it even harder. So, smoking is without question, it impairs wound healing, it has so much impact. This vasoconstriction, it ages us. Actually, if you look at the research, if you are a woman, it will age your ovaries faster. Don't know what the research is on men, but I would imagine it's doing much the same. 


[00:15:09] We're so good about treating infections, right? We are so proactive. And in the ICU, it's different. But in the outpatient environment, even in primary care, I feel like the overuse of antibiotics drives a lot of problems. So, let's talk about some of the things that can happen for patients if they are overly prescribed antibiotics. This doesn't just happen in adults. It can happen in kids too. But what are some of the concerns you have as a father, as a husband, as a clinician, about the overuse of antibiotic therapy? 


Dr. Kwadwo Kyeremanteng: [00:15:41] Yeah, I love this question, because it's an important one that at some point will affect us all. I'll go with the most severe or the one that I deal with on a regular basis. So, there's a concept called antibiotic resistance. So, the bacteria eventually get smart. You get them exposed to a wide-ranging amount of antibiotics, they adapt and mutate and tell themselves, “Okay, we are going to create a defense against penicillin, or vancomycin or any of the antibiotics.” And so, what I see, which is-- I'm not exaggerating when I say this. When you have these chronically hospitalized patients that come in for recurrent infections often related to their diabetes, they eventually will have no antibiotic that will treat their infection appropriately, because they've developed that much resistance. 


[00:16:40] In fact, there's resistant-- I'm going to get the acronym wrong now that I'm on the spot. But it's one of our strongest antibiotics, meropenem. When occasionally there's a resistance to that, we will isolate that patient. We will do all measures to avoid the spread of this resistant bug, because if all of us had that level of resistance, the antibiotics essentially wouldn't work. So, this is the fear when it comes to overuse of antibiotics. So, there is a constant-stewardship strategies to promote adequate duration and adequate prescription of antibiotics. So, that's the scary thing. 


[00:17:21] As a father and as somebody that's in the health and wellness space now, I'll say I'm pretty microbiome ignorant, but I've come across a couple of our own clinicians and scientists at our center that have tied antibiotics resulting in changes in microbiome to some chronic diseases. It just making me pause, put it this way, that to the point where with how much we're learning about the microbiome and how it seems to be tied to everything. When it comes to my boys, anyway, it's got to be a good reason to want to prescribe them antibiotics. 


[00:18:05] So, yeah, that's where my head is at currently. Like, most docs I think would agree, you want to only give antibiotics when you had a strong case for it. But to me, that mystery piece, is that microbiome side and I'm curious to hear how that evolves. Maybe you have some insights into that actually. But yeah, that to me is where I really get curious. 


Cynthia Thurlow: [00:18:27] Yeah. I'm knee deep in book number two. And so, for everyone to know, especially people in this room, it is about the microbiome. It's talking specifically about the changes that go on in perimenopause and menopause, which are significant and profound. But from a very basic level, our microbiome is determined by our mother's microbiome. It's determined by whether or not we're delivered vaginally or by C-section. There's no judgment. Both my boys were delivered C-section, because they were both big and breech. So, my kids weren't delivered vaginally. But if you look at the research, it talks about how babies that are born via C-section, obviously you lose out on that opportunity to be exposed to lactobacilli that are in the vaginal canal. 


[00:19:12] There's one research article that I was looking at that was talking about C-section babies. Their microbiome at the time of birth and their first few days of life is more akin to the hospital environment. It's influenced by whether or not we formula feed or we breastfeed. It's influenced by dirt exposure, whether or not you have pets. It ebbs and flows up until puberty. This is where young men and young women, that's where this differentiation in the microbiome that is directly related to the sex hormones. So, obviously, young men have more testosterone, and a little bit of estrogen and then young women have testosterone, estrogen and progesterone. 


[00:19:48] And so, it's really interesting that there's three points in a woman's life. One is puberty, one is pregnancy, one is perimenopause, where the microbiome really takes a significant turn and shift. And so, your colleagues talking about how probably one round of antibiotics may not decimate the microbiome, but if it's like one after another really ups the likelihood that we're going to develop leaky gut, which is a real thing. Our small intestine is one cell layer thick. It's very easy to get those tight junctions to open up. And then, actually, your food particles, they can be exposed into the bloodstream you can drive underlying food sensitivity is why so many people will suddenly start developing sensitivities at that stage of life. 


[00:20:32] But I think about like the long-term implications. We're more likely to get autoimmune disorders because of our XX chromosome. So, I'm knee deep in that nerdy research right now. But what is relevant and timely is that antibiotics are not per se bad, but the rampant overuse of antibiotics. I know when my kids were young, my second child, who I talked about as my special child, had one ear infection after another, till we got ear tubes put in. I remember looking at the research and thinking, oh, my gosh, I've set him up. He's obviously healthy, metabolically healthy, but the net impact on their developing microbiomes can be quite significant. 


[00:21:10] Now, one thing and I can only speak to the United States. Here in the United States, we have a very paternalistic medical acumen. It's hard to make change. There's this rigid dogmatism that people are adverse to change. We don't like change. Change makes us uncomfortable. Do you feel like, is it different in Canada, or does it feel like it's more akin to what we deal with here in the United States? 


Dr. Kwadwo Kyeremanteng: [00:21:35] Yeah, very good question. I would say it's global. I often make fun of docs, because I can and say [Cynthia laughs] like, “We are dinosaurs. We don't like change. We're stubborn.” Let’s look at things at a high level, even when it comes to metabolic health. The idea that reversing type 2 diabetes through diet and exercise, that concept-- If you went to your GP right now and said, “Maybe I don't want to take a Ozempic. I really want to explore this low carb,” or something like that. How many do you think would be comfortable with that? How many do you think if you had the perimenopausal symptoms and we wanted to explore HRT? How many think it would be comfortable with that. 


[00:22:16] We were talking about this on stage. Canadian menopause societies. It sounds like is more up to speed than some of the others. But really, we're dinosaurs. We don't like change. It's the way we learned in medical school. We don't learn much about the gray. We don't learn about-- People have to fit in the box. Once they're in the box, this is a prescription. You know what I'm saying? I don't want to give the impression that I wasn't victim of this. I'm was totally the oppression. 


Cynthia Thurlow: [00:22:42] We all are. 


Dr. Kwadwo Kyeremanteng: [00:22:43] Yeah. I don't know, maybe it was a bit of-- I don't know what it was. During the pandemic, my eyes got a little bit open to a lot, I think, especially, the metabolic side and lifestyle changes and so forth. But the one good thing that the pandemic in the medical community brought was I think we're a little bit more likely to change now, because we had to be. We had to be more adaptable. Otherwise, people's lives wouldn't have been saved. 


[00:23:15] Some quick examples. Early in the pandemic, we were told you're supposed to put them on ventilators early. Apparently, that was going to better off for them. That was clearly not what we were seeing. So, we pivoted away from that. We saw that they were developing clots everywhere. And so, we started to introduce blood thinners. We noticed there was some evidence emerging that maybe steroids would help. So, we started putting everyone on steroids and got better outcome. 


[00:23:41] So, I did see this movement towards agility in healthcare, which is not common. But yeah, that's your question directly. It is not unique to the US. It is what we attract for doctors. Most doctors are like to think in categories or like to think black and white. They don't like to think in the personalization approach. I think that's changing. I see with the youth and the kids that are coming in, they see the big picture I think, but it is global as far as I'm concerned. 


Cynthia Thurlow: [00:24:19] Well, and it's interesting. For the benefit of listeners, it's understanding that it takes about 20 years for research to trickle down into clinical practice. And so, one thing I've spoken out about, because I think it's so important and I take a lot of heat from other nurse practitioners, I'm like, “If you are still practicing the way that you did when you started as a new nurse, a new doctor, a new nurse practitioner, you are not staying current.” And so, I get so frustrated. 


[00:24:46] When I actually had a colleague of mine that will remain nameless that reached out, and I had done a five-part lipid series or earlier this year with Dr. Tom Dayspring. My team was like, “I don't know if your listeners are going to like this.” And I said, I'm going to make it relevant. I'm going to make it relevant so they're interested. And then, that has turned out to be a very popular series, because people are like, “Lipids, that's boring.” I'm like, “No, no, I'm going to make it really relevant for my community.” 


[00:25:11] What was interesting to me was a colleague reached out and said, “You just made my job 100 times harder.” They weren't happy with me. And I just said, well, if you're still treating for LDL and you're not looking at an ApoB and you're not looking at an LP(a) and you're not looking at metabolic health. Shame on you.”


Dr. Kwadwo Kyeremanteng: [00:25:27] 100%


Cynthia Thurlow: [00:25:28] And I was nicer than that. But the point being, is that I have evolved and I hope I will continue to evolve and being a lifelong learner. I think all of us desire to do that. But I think the medical community, as a whole, it's easier to just stay-- You put your blinders on, and this patient falls into this bucket and therefore they will lie in that bucket for the totality of their life. And yet, I think that what makes us dynamic as humans is to entertain the possibility that we might know better now. I tell everyone, I apologize to all the people that I started on XYZ drug, because I didn't know better, but now I do know better and that's why it's so important to amplify the information. 


Dr. Kwadwo Kyeremanteng: [00:26:06] Wouldn't you want that as a clinician? 


Cynthia Thurlow: [00:26:08] Yes. 


Dr. Kwadwo Kyeremanteng: [00:26:09] My doctor said, “I'm willing to pivot and see the light.” Holy cow. Then, that's someone I trust, right? 


Cynthia Thurlow: [00:26:17] Yes. 


Dr. Kwadwo Kyeremanteng: [00:26:19] I don't want to be so pessimistic, but sometimes I think it's a bit ego driven. Sometimes it's like we don't like to be wrong. In medical community, it is a bit shame based like you-- There is a little bit of shame in there and that's changing too. So, being wrong comes with some heat. But oh my God, I value that so much more if you are-- Not just in the healthcare industry. Anything. You don't want to be blockbuster, you don't want to be BlackBerry, you want to be agile. That to me-- Now being in the leadership position in my hospital, when I look for people to bring on, it's that humility, it's that agility, because you know you're going to get the best out of that person and instead of letting ego overwhelm them. 


Cynthia Thurlow: [00:27:05] Well, and it's interesting, because I trained at a big academic center. I think there was a good mix of clinicians that were willing to always be learning and that's how I was raised. But there were just as many people that were just so rigidly dogmatic. This applies to any area of any industry. This is not unique to medicine, but medicine is unique in the aspect that if we aren't evolving as clinicians who ultimately suffers, our patients. I think 99.9% of us really, really care about our patients, and therefore we want to do what's best for them. 


[00:27:39] Now, you touched on something, and obviously our conversation yesterday and the panel we were on, we were talking solely laser focused on women in perimenopause and menopause. I've heard you say that the Women's Health Initiative, so published in 2002, it was a study with 16,608. I actually went to look it up, female study based on researchers from Harvard and Stanford. In your personal estimation, what has the impact been on women? I know that you see it from different sides, but from your perspective, because you see these patients, you see the net impact of many of these women in the ICU, what is your view on the impact of the Women's Health Initiative? 


Dr. Kwadwo Kyeremanteng: [00:28:25] So, I love the question. It's scary that the impact has been so dramatic. So, obviously, the interpretation of this study was that hormone replacement therapy caused breast cancer. So, globally, people everywhere stopped taking HRT essentially. I'm giving the Coles Notes version. And as a result, not only we saw number of women suffer symptomatically from not having treatment, but then you have all the long-term impacts that we see in hospital. So, the osteoporosis. So, you fall break your hip. My number I had, back this was med school about 25% mortality within a year. If you break your hip, it's serious. 


Cynthia Thurlow: [00:29:13] I have all the stats. We're going to go through them. 


Dr. Kwadwo Kyeremanteng: [00:29:15] Oh, you got-- Okay, beautiful. [Cynthia laughs] And then, think about the cardiovascular disease. So, number one killer in women. And you're seeing that increased risk of that without treatment. Some we see all the time, heart attacks, strokes or heart failure. Like, it's very bread and butter common reasons that people land and women land in hospital. And also, the lack of strength, the loss of lean muscle mass and that frailty, because frailty is a true killer when it comes to being in hospital, as I mentioned and trying to rehabilitate. So, this has been huge. 


[00:29:49] And then, there's the other side that's just the justice side. Like, talk a lot about values and this one has always been important to me. Just the idea that number of women suffered is not right. That to me already-- So, I'm a male intensive care physician that's been advocating about perimenopausal menopausal awareness, and you ask yourself why. It is the justice part. When I saw the stats and you'll know better. I don't got them off the top of my head, but the amount of women that are prescribed antidepressants, some antipsychotics, some antianxiety medications, because they weren't treated insane. 


[00:30:29] If you think about 10% of people of women retired early from their profession-- I'll tell you how it tied to me, this is one I learned. So, mid pandemic or I don't know, mid 2022 tons of exodus, tons of healthcare workers left ICU. Healthcare in general. But one of my sites we lost 20% of our nurses. When you have somebody in their mid-50s or early-50s that is seasoned, and could coach up the young-ins and has the resilience and resolve especially in the time of crisis and they're leaving your community, that's huge. It wasn't like one or two. It's like leaving in droves. 


[00:31:08] When you look at the numbers and the impact, it's just wild. It is wild. So, on our platform, on our podcast, on our socials, we went through a little bit of a campaign of saying “Hey, these are the people you could talk to. This is how you learn more.” Like, “Everything else, it’s not black and white if you should be on hormone replacement therapy, but we did a lot of content on the lifestyle changes you should be making.” Like, “Get that muscle mass up, do that resistance training, protein creatine, say no to alcohol,” all these things that I think would was important to put front and center. 


[00:31:40] But what are the indications for hormone replacement therapy? What would you be looking out for? How do you have that conversation with your family doc? Because in my opinion, if it affects your survival and your quality of life, and why did we all get into this field? To help people. When you look at half the population, or I know it's not half but all the women are going to go through perimenopause or menopause, it's crazy. And so, yeah, I long winded answer, but it was something I felt pretty passionate about. 


[00:32:09] One thing I forgot to mention too yesterday that also made it personal is I saw my wife go through it. She was an early perimenopausal patient. I saw the mental fog, I saw the concerns. I saw the lack of sleep. When we came to the conclusion that this is perimenopause, which was also challenging to diagnose, by the way, we got things in the right direction. I saw the 180. I personally saw how much it improved her quality of life and how better she feels. And to me, if we could help women feel the same way, well, let's do this. 


Cynthia Thurlow: [00:32:45] Well, I love that. I've started finding that researchers, physicians that come on as guests on the podcast, they'll start saying it's because my wife went through this. I just had Dr. Bill Campbell, who's an incredible fat loss expert, and he said, “My wife up until menopause was able to utilize all of my strategies. And all of a sudden, they stopped working.” And he said, “Now, my entire lab is focused on women in menopause, because I want to help women understand their physiology, so that they can continue to maintain metabolic health.” 


[00:33:18] And so, I think on a lot of different levels, the thing that I find surprising and I went down a rabbit hole, my mom's generation was impacted by the WHI. And so, I watched my aunts. I have five aunts, all of whom got taken off of HRT. I've watched a lot of their health decline. All giving me permission to talk openly about this, for which I'm appreciative. But after the WHI, 80% of scripts decreased. So, there were still people getting HRT, but really they were an outlier. If a physician or nurse practitioner PA was still prescribing, they were really very unusual. 


[00:33:53] What's interesting is that when I think about from a cardiology perspective, estradiol, which is the predominant form of estrogen our bodies make by the ovaries before we go through menopause, it does a lot of things in the body. It's like we just don't fully appreciate the role of estrogen enough, because if we did, we wouldn't want women. It's like you go from-- your ovaries are producing estrogen, and then our ovaries are the biological clock for our bodies. They drive senescence. So, it's like our pacemaker of aging. 


[00:34:25] And so, now, there's a lot of focus and attention on research to figure this out. Prolonging not necessarily fertility, but prolonging this senescence, where we go into being less healthy. What I think is interesting, is that both as a nurse and nurse practitioner and then all the physicians I've spoken to, no one gets much education. It's almost like the WHI came out and then there was no need to talk about menopause, because women should suffer in silence. That's the aforementioned messaging. 


[00:34:56] What's interesting is I interviewed Dr Avrum Bluming. If you haven't read why Estrogen Matters, please do. It's like just one of those quintessential books. He's an oncologist and he just said, “Cynthia, the reason why women have suffered is because no man would put up with what women have put up with.” He just said it very bluntly and distinctly. And I said, you're absolutely correct. I think about the amount of patients that I've interacted with over the years who were on long-term benzodiazepines, which you and I know is not good. They're prescribed antidepressants, antipsychotics, as you mentioned. They're given everything. But what they need is probably a little bit of progesterone and possibly some estrogen and possibly some testosterone. 


[00:35:38] And so, I'm going to read off some statistics that I think are really relevant. I say this with great reverence. I lost my stepmother last week to Alzheimer's. She didn't have to develop Alzheimer's. Yeah, it's just been a heck of a year. But I share this, because I think about the incredibly dynamic woman that she was. She was fiercely independent. She traveled the world before women were really doing that. One of the favorite things she did was travel with my dad. 


[00:36:06] So, women on estrogen have a 35% lower incidence of Alzheimer's. That's number one. Number two, we appropriately focus on women developing breast cancer. That's without question. But what's interesting is for every one breast cancer diagnosis, there are two Alzheimer's diseases diagnoses. We know that estrogen in particular lowers our risk of fracture by 50% to 60%. That's based on multiple randomized controlled trials, which is considered to be the gold standard. 


[00:36:34] That's in The New England Journal of Medicine, which is considered to be the quintessential. If you get published there, you're a big deal. 40,000 women die of hip fractures every year, and that's equivalent to the amount of women that die from breast cancer. I just have a couple more. 50% reduction in risk of heart disease. if you take estrogen. This is concerning. Those that discontinue hormone replacement therapy have a 26% risk of fatal heart attack in the first year. Now, that was sobering. 


Dr. Kwadwo Kyeremanteng: [00:37:04] Proof is in the numbers, yo. 


Cynthia Thurlow: [00:37:05] Yeah. I read those and I just listed them out. I normally don't necessarily just rattle off statistics, but talk about sobering. 


Dr. Kwadwo Kyeremanteng: [00:37:13] This is what makes it-- So, we were talking earlier about fear based decision making. This ties directly to this. You have a very scary diagnosis, breast cancer, but we don't contextualize it. We don't talk about the whole picture of what else we want to factor into the equation. And as a result, 80% of people were-- Do you say 80% less or 80% were taken off? 


Cynthia Thurlow: [00:37:44] 80% were taken off. 


Dr. Kwadwo Kyeremanteng: [00:37:45] Yeah. 80% were taking off HRT which associated with all the things you mentioned, fractures, heart attacks in the first year, significant amount of heart attacks in our first year, Alzheimer's.


Cynthia Thurlow: [00:37:58] They cried in my office. It broke my heart. As the NP, I was like a very young NP, I couldn't have advocated for them, because I was told to stay in my lane. 


Dr. Kwadwo Kyeremanteng: [00:38:09] Yeah.


Cynthia Thurlow: [00:38:10] Stay in your lane. You focus on the heart. That's your job. 


Dr. Kwadwo Kyeremanteng: [00:38:13] This was also in an era-- I don't want to speak for you, but I'll speak it from my experience. It wasn't the era of as much shared decision making. It was we know better, so we're just going to tell you what to do here as opposed to say like, 2024, “Dr. K, here are the risks, here are the benefits. Knowing what you value, this is what I suggest. How does that feel?” Giving you the opportunity to weigh in and say, I will take the risk, because what's important to me is my quality of life. 


[00:38:48] I was having this conversation. I don't want to bring everything to the pandemic, but I was having this conversation with a colleague the other day. If I was 89 years old and someone told me that yet you could pass away from COVID in your nursing home, but you also got to weigh in the loneliness and being isolated for extended period of time, well, I'll just say personally and what I believe many people would take that risk instead of being isolated, being not never seeing their loved ones. I don't mean to digress, but how heartbreaking it was I get a little weepy thinking about this. How many great people that lived these tremendous lives that contributed to society that were just left alone to—


Cynthia Thurlow: [00:39:33] And die alone.


Dr. Kwadwo Kyeremanteng: [00:39:33] Oh, my God, I hate this. I honestly it was-- 


Cynthia Thurlow: [00:39:36] That's heartbreaking. 


Dr. Kwadwo Kyeremanteng: [00:39:37] Yeah. I don't even know how it got from menopause to nursing homes. But, yeah-- [crosstalk] 


Cynthia Thurlow: [00:39:43] Well, before they do go, some instances, “You live long enough, if you're not in a situation where you can live with loved ones. You may be in assisted living. You may be in a nursing home.” And so, what's interesting to me is, we lost my dad in June, and then my stepmother had progressive Alzheimer's, but my dad wanted to care for her up until the end of his life. And so, when my brother and I were left with the responsibility of caring for her, we got her into an amazing Alzheimer's unit. What broke my heart is of the 10 people in that unit, all of them were women, all of them were women. And so, it just reaffirmed for me. 


[00:40:19] It was like, every time I went to see her, and there were varying degrees of-- Alzheimer's, I don't want to use the term, a spectrum, but there are people that are more high functioning than others, and stepmother at the end of her life was not able to much for herself. It was so reaffirming for why we need to be having these conversations, so that people can be taking the information to their healthcare provider to say, “Listen, I heard this information. I want to advocate for myself. I don't want to end up developing neurocognitive decline is kind of the big fancy way.” But it's not just Alzheimer's. It can be Parkinson's. It can be Lewy body. There is different types of dementias that you can develop. Vascular dementia. 


[00:41:01] And so, I think that the biggest thing is to be having these conversations and especially really relevant, because you're seeing patients. In some instances, it is the very end of their lives. If they are not in a position where they can make that decision for themselves, understanding, like, what can we ensure that the quality of their life is the best at the end of their lives. When we're talking about ICU, we can also, on the other hand, talk about hospice and palliative care, and how does that factor in? I'm curious for you, because I've now dealt with two hospice situations this year personally. Where do the hospice conversations for you start? I would imagine you're proactive about having those discussions when it's appropriate. 


Dr. Kwadwo Kyeremanteng: [00:41:43] Yeah. First of all, I just sorry about this year. 


Cynthia Thurlow: [00:41:46] It's been a hell of a year. 


Dr. Kwadwo Kyeremanteng: [00:41:47] Yeah. I just want to express, especially losing someone so recently. That's hard. But in terms of when we have these conversations-- I didn't bring this up, but my other job that I don't do as much these days as in palliative care. I did part of my training, and so I am a big advocate of having those tough conversations as early as possible. And to give you context, I'm 47. My wife knows if I had a significant traumatic brain injury, if I was close to being brain dead, if I wasn't having a certain level of quality of life, she knows what I would want. And in fact, we've had these conversations even in our 30s. 


[00:42:33] And so, to me, the most important things we could do collectively as a society is to have these conversations of what our values are, because we're going to be in situations where that when I'm at work, I deal with it every day. Mortality rate is anywhere from 15% to 20%. Usually, we have at least a death a day and have these tough conversations. There's nothing worse when a family member feels like they don't know what that loved one would want. One of the most important parts of my job is to make sure that burden isn't on their shoulders. Like, I don't want you to feel that weight of saying, I was responsible for pulling the plug on mom or dad. Like, to me, that's not fair. 


[00:43:20] As clinicians, to frame it that way like, “What do you want us to do?” To me, honestly, it's not right. This is my personal belief, it's not right. It's what would she want, what would he want, knowing what the information that we have in front of us. I often give this visual. I got this from one of my preceptors, was that if you had this devastating injury and your loved one was at the foot of the bed, seeing themselves hearing the information from the doctors, what would they want? Would they say, “Keep going at all costs?” Would they say, “Let me go.” Often that visual can tip the scales either way. 


Cynthia Thurlow: [00:44:00] What's interesting to me, is that I remember back when I was an ER nurse, so I was inner city Baltimore, and so we saw a lot. We would have patients that would come in and they had expressed, do not resuscitate, do not intubate, DNR, DNI. They would come in with that paperwork. And so, we were like, “We're going to honor that because it's what the patient wants.” The patient's in extremis, and family comes in and they're upset. They're upset with what they're seeing. It's sad. And then, there were a couple attendings that would come in and they would say, “I don't want your family member to suffer. If we put a breathing tube in, we're going to be able to make them breathe more easily.” We would be so angry. We're like, “That is not what the patient wanted.”


[00:44:41] Now, the family's put in this awkward position where-- Of course, they don't want their loved one to suffer. I would say the other side of it is because I had so much experience referring patients to hospice, as a clinician-- When my dad got very sick, he had a moment of clarity. He had fallen frailty. So, we talk about frailty, falls. My father had fallen, had a subdural hematoma, which is a head bleed. Was in the neuro intensive care unit. And in a moment of clarity, my dad called and left me a message. I still have the voicemail. And he said, “I told him I don't want to do surgery. Honest to God, I don't want to do surgery.” That night, my dad decompensated. Meaning, he became unstable. 


[00:45:21] And in the middle of the night, my brother and I drove to the hospital. My brother's not in the medical field, and so I was translating what we were being told. They were basically like, “We need to take him to surgery. We need to do a craniotomy,” which means we're going to wrap his head. My dad was 80 years old. He was very frail. And I said, absolutely, positively not. That is not what he wanted. I said, if he made it through surgery, he'd come back. He would kill us. He would literally kill us if he could do it, because he was so clear. I literally played the voicemail for the neurosurgeon and the trauma ICU doc, and they said, “We're so glad you said you don't want to take him to surgery. We didn't want to take him to surgery.” And I said, well, that's not how you framed it.


[00:46:02] So, with that being said, honoring, having those uncomfortable conversations and making it sure-- Sometimes we don't have the opportunity to have those conversations. But if you're in a relationship with someone, let them know. My husband and I are both 100% on the same page. If something ever happens to us, like, what we would want or would not want. But sometimes those conversations are so uncomfortable. Families never have them and you're left guessing. 


[00:46:28] I remember, as an example, my dad had one good day after that night, and then it was a slow progressive decline until his death. I looked at my brother and I said, dad and I, we never talked about what he wanted after he died. Where do you want to be buried? What did he want to do? Do you want to be buried in South Carolina, which is where he was born. I remember saying to my brother, I was like, “Gosh, now we need to have this conversation with mom,” because this is where I hope this conversation leads listeners to think about what would they want for themselves? What would they want for their loved ones? 


[00:47:03] Sometimes it seems like it's premature. But when you have all those things identified ahead of time, it takes the burden off of your loved ones. Because I knew, I felt so strongly when I was in the ICU in the middle of the night saying to the trauma ICU attending, my dad was so clear, he didn't want surgery. So so clear. And I was like, “What a blessing that he called me that night and was so clear.” And then, later had a stroke and was not unable to communicate. But I said that was this little blessing that we got. But so many families don't have that opportunity. 


Dr. Kwadwo Kyeremanteng: [00:47:38] Oh. I've been, unfortunately, lost both parents, and the grieving process too. When you add those layers, those questions, all the things that are left unfinished, as you mentioned, if that can be overwhelming, it could prolong the grieving process. So, that 5 to 10 minute or however long 15-minute conversation that you have with your loved one can be so impactful down the road. What you describe here, go chills too for several reasons. I don't want to digress too much, but patients for-- Empire Care, we see it a lot where patients know for some reason their time is coming or-- I've been in situations where everything looks good and the patient will be like, “I'm going to die tonight.” 


Cynthia Thurlow: [00:48:32] Yup. 


Dr. Kwadwo Kyeremanteng: [00:48:33] And I'm like, “What?” 


Cynthia Thurlow: [00:48:33] They have the premonition you listen to. 


Dr. Kwadwo Kyeremanteng: [00:48:35] Yeah. They're 9 times out of 10 correct. And so, that was entering my head too. It shows that you had that clarity before tough decisions happen, because that's a lot of pressure on you when there isn't that level of clarity. Yeah, so, that 15-minute conversation could take away alleviate so much pain down the road. 


Cynthia Thurlow: [00:48:58] Absolutely. Well, such a pleasure to have you on the podcast. Please let listeners know how to connect with you, how to find your podcast, how to connect with you on social media. 


Dr. Kwadwo Kyeremanteng: [00:49:08] Amazing. Can I just say Cynthia? Monster fan, 400 plus episodes, the talk you gave at eudaimonia without the tech [Cynthia laughs] was amazing. My wife and I were both riveted and learned a lot, actually. So, thank you for all that you do and good luck with the latest book. I know it's going to be amazing. For us, Unapologetic Leadership is our book. You can find us on all social media, @kwadcast, K-W-A-D-C-A-S-T. What else? We got newsletter on Substack. We got a nutrition company that just start launch, Guided Nutrition. And so, yeah, that's where you find us. And the podcast of course, Solving Healthcare, which we're going to have to have you on as well. You're amazing. 


Cynthia Thurlow: [00:49:57] Thank you. Such a pleasure. 


Dr. Kwadwo Kyeremanteng: [00:49:58] Thank you. 


[music]


Cynthia Thurlow: [00:50:01] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend. 



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