Eva Sheie (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person because you're making a life-changing decision and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There is no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Sheie, and you're listening to Meet the Doctor. Today on Meet the Doctor, you're in for a treat. And my guest is Heather Richardson, who's a board certified general surgeon and breast specialist now in Beverly Hills, California. Welcome to the podcast.

Dr. Richardson (00:43):
Thank you. I'm so happy to be here. I practice at Bedford Breast Center in Beverly Hills. We're kind of a unicorn. We're kind of a super interesting special place, and every day I pinch myself and think, how did I get a lottery ticket? How did I win this lottery? I don't even remember buying a ticket.

Eva Sheie (01:00):
How did you end up there?

Dr. Richardson (01:03):
I practiced for years in another fabulous practice called Atlanta Breast Care. It was started by a guy named Bill Barber who I just have nothing but wonderful things to say about. He was a very much a pioneer. He was one of the very first breast only practices. He left a very robust general surgery practice where he was doing appendixes and gallbladders and all that other stuff, and he was like, you know what? This is a thing now, people are really centering in just on breast care only, and I think I'm going to do it. And everybody thought he was nuts and he was up to his eyeballs in patients within just a very short amount of time. And I was a resident at Emory and was working with some of the plastic surgery folks thinking maybe that would be the direction I would go in.

(01:48):
And this wonderful plastic surgeon saw Bill needing to grow, and knew me as a person and said, I really think you need to talk to this guy Bill Barber. He's really got this great concept about doing a breast only practice. And I talked with him and he talked about his concepts for life, his concepts for practice, his concepts for patient care and family, and integrating all of that. And it was just sort of like one of those light bulb moments. How did I not think of this and best decision I ever made. So Bill Barber and I joined together. We founded that practice together and then grew it to four support clinicians, so nurse practitioners and PAs, and there were four surgeons practicing. And just life happens, so after 11 years in Atlanta, I felt like I just needed new sky and everyone was lovely and supportive, and as much as I love everyone in Atlanta and everybody that I worked with there and have wonderful things to say about there, I decided I needed new space.

(02:46):
So I came out to Los Angeles and met this amazing plastic surgeon who I am so fortunate to get to work alongside, Dr. Lisa Cassileth. And she's a real visionary and she said, I really want this to be everything superior about breast care. I want the best technology. I want to do everything ourselves. I want to be able to offer immediate imaging for women and then work seamlessly together. And I thought, yeah, right. How is this going to work? And she under promises and over delivers, and we just have this amazing center with these amazing, I don't know how we found all these amazing people that we get to work with, but they're really dedicated and talented and sincere and really caring. And the thing I love best about it is that the training that we did with at Emory, there's a fabulous surgeon by the name of Grace Rozycki, and she's sort of like the mother of ultrasound in the world of surgery.

(03:44):
And she made sure all of us had really robust training in ultrasound and pretty much everything that we did, we had to do an ultrasound with it. So she was the mother of what's called the fast exam and trauma. So for trauma patients, if they had a traumatic blunt injury and we were worried about maybe an organ rupturing inside their abdomen for years, all we could do is take 'em up and open up their abdomen, cut them from stem to stern and take a look and see, well, was anything busted? Oh, it's not. Oh, whoops. We'll nevermind, let's just sew 'em back up. So she said, how about we look with ultrasound first, how we really get comfortable with what kind of things we usually see if something is ruptured inside the abdomen with ultrasound and maybe, maybe, call me crazy, not do a huge operation to find nothing. So she was sort of the mother of that concept of the fast exam.

Eva Sheie (04:33):
It's kind like what we watched on TV growing up where they'd be like, he needs an exploratory surgery.

Dr. Richardson (04:39):
Yeah, exactly. So that's kind of done now. We kind of don't do this anymore.

Eva Sheie (04:43):
They don't cut you open to look anymore.

Dr. Richardson (04:44):
Not to look, not just for funsies, not just for heck, not just for the heck of it. It's like, oh, there's something that we know we need to fix, therefore now we need to go up. And it becomes more of a better use of time and money and

Eva Sheie (04:58):
Well, the time aspect, I think in trauma, that's sort of obvious, but then breast cancer care.

Dr. Richardson (05:03):
It's huge, and to heal a giant incision. But anyway, the bottom line being we were really, really comfortable with ultrasound. So to move into this breast only practice where you had this immediate tool where I have in my hand the power to look into your breast and tell you exactly what we're feeling, exactly what we're looking at, I just think it is super important for anybody who is assessing people for breast disease to have that power. I can't imagine a lot of my colleagues don't do ultrasound. A lot of surgeons who practice breast care don't do ultrasound. And the way a lot of systems are set up in very large institutions is you've got the radiology department and a patient goes and has a scan with the radiologist, they have an ultrasound or a mammogram, and then the radiologist writes things down and there are pictures you can click on and look at a screen.

(05:48):
And the surgeon reads those reports and says, well, the radiologist has told me that your cancer is approximately this position, approximately this size, and they think, they think, they think. I feel like it's so important as a surgeon to have the understanding and the spatial awareness of exactly what's going on with the patient, and more importantly just to have somebody examine you with their hands and say, oh, well I think that this is what this is. Go into another department and I'm going to let somebody else tell me what it actually is and I'm going to get that report in two weeks when I've long forgotten what I felt and what this even is. So I just think it's super important to just have that power in the hand of the person that's actually going to be responsible for removing it and assessing it. I just think it's really important for surgeons not to have that taken away from them.

(06:34):
And there's just more and more of a move in healthcare to separate everything out, make it as complicated as possible, to put it in as many steps as possible with the idea that, oh, oh, there, there's a concept in breast care where if someone has a biopsy, the radiologist, whose job is to just know if it's cancer or not, I got to define this as is this cancer? Is this not? That's kind of their job. And the most important thing they do is reaching in and taking a biopsy. So that's a very big deal. A biopsy is a very big deal for a radiologist, cuz that's the most important thing that they can do, the most dangerous thing that they can do is reach in with a needle. So there's this concept that like, oh, if I have to do a biopsy, it's very serious and this could be very dangerous, and this gets very suspicious. And patients are given this playing the organ in the background for the soap opera music like dun, dun, dun, dun, we see something, ahhh, and patients are left with this feeling like I have cancer, I'm going to die. Now, in all fairness, most of us, when we look at something, we have a pretty good idea that it is or isn't cancer. And most things that we can look at and see and quantify with imaging usually are not cancer. And we can usually take a look at those and say, that really doesn't have features of cancer, but let's make sure and the ways we can make sure to either recheck it in time and make sure it stays safe looking and it's not changing or growing or we can reach in and take a pinch. Well, that is not communicated very well to patients, I think in this day and age. And patients are often under the impression that if we see something and we're going to watch it, then oh my gosh, they see a cancer, they're just going to let it grow. And then, oh no, are they doing a little experiment on me to see how big it gets before they decide to biopsy on it? When the reality is we don't think it's cancer, we don't think there's any way that this is cancer, but we just want to make sure. And it's just not really worth making a person go through a biopsy.

Eva Sheie (08:24):
But it still sits there lurking until you decide to look at it again. It's not like it's not on your mind.

Dr. Richardson (08:30):
Well, and it's true, but that needs to be a communication issue for patients and doctors. I think patients need to be told what I've just said, we see something, we don't think it's cancer at all. I would quote you a less than one to 2% chance that this is cancer at all, and let's say I'm wrong. And we checked this in six months and it is a tiny cancer right now it's measuring five millimeters, which is this tiny, tiny little thing. If I am wrong and I don't think I am, but let's say 1% chance I am wrong, and you come back and that five millimeter thing is now seven millimeters, or maybe it's still five millimeters, but it looks a little different, we decide to sample it then, what are the chances are that discovering that in six months from now is going to change your life or go from a curable to incurable cancer or change your treatment options for prognosis?

(09:12):
It's almost zero, which is what allows us to check things. If something was going to grow like wildfire and go from curable on January 1st and incurable on August 1st, then we wouldn't do that. We would biopsy everything. And that's just not fortunately the way that things break down as far as breast cancer diagnosis and treatment is concerned. So things that we see, so that kind of brings us to the BI-RADS, the BI-RADS score. So when we look at something with imaging, we kind of give it a score of zero to six of how concerning or not concerning we think something is. A zero score means we don't think there's, a zero score means we don't have enough information to really say what we want to say yet. We either need old films to compare or we need some additional piece of information that we're missing right now.

(09:57):
So we're just not going to say anything just yet. BI-RADS one means we see totally normal tissue. There's nothing here that's abnormal, everything is safe, we'll see you in a year for regular screening if that's what you need to do, if you're in that age range. A BI-RADS two means we see something, it's not cancerous, we're not worried about it at all, but it's something, and it could be something like an implant or something like a safe calcium deposit pattern that has zero features of cancer, or a safe growth that's been there for years and hasn't changed. So that could be BI-RADS two, it's a see you next year sort of situation, you're all good. BI-RADS three means we see something, and that's that 98 2% that I just mentioned. We see something, we don't think it's cancer, it has zero features of cancer, but rather than go through the trouble of biopsying it, we think a better idea would be just to check it again in six months and make sure it stays safe, stays stable. And again, less than one to 2% chance that we're wrong.

(10:49):
If we are wrong, we don't think anything will change as far as treatment prognosis or options would be concerned. So it's safe to recheck it in six months. The next level is four, BI-RADS four and BI-RADS four, they sometimes break it up into four A, four B, four C. So kind of a spectrum of how concerned they really are. For BI-RADS four means we think this is safe, 80% chance it's safe, 20% chance it might be something we want to know about a cancer. And so we're going to do something to figure it out. We're either going to do some more imaging with specialty imaging like an MRI, we're going to take a tissue sample and four A would be like, we really don't think this is cancer. We really don't. Four B is like, I don't know, it kind of looks a little weird.

(11:31):
And four C is like, it's not bad enough for me to say, oh, this is a cancer, but I'm kind of worried and I want to sample. So that's kind of how that works out. And then BI-RADS five is, oh, this is cancer. We think this is cancer. This has every feature of a cancer. We're worried about this being cancer. And that would be 80% chance of being cancer, 20% chance of being not cancer. And then the very last category, BI-RADS six is we've already diagnosed you with cancer. We know there's a cancer there, but now we're looking at other things. We're looking at the other breast or whatever. So BI-RADS six is, we already know you have cancer, we know that, but we're looking at other things too. That's how that kind of breaks down. A lot of people are giving those BI-RADS three readings or even a BI-RADS four reading and they're automatically thinking, oh, I have cancer.

(12:15):
When in reality, most of us that are doing the imaging kind of already know like, nah, you're probably okay. Probably going to be just fine. So the ability to be a surgeon and to have that sort of junior radiology badge, junior radiologist badge is a huge, huge advantage.

Eva Sheie (12:33):
Deputy radiologist?

Dr. Richardson (12:33):
I think. So vice president radiologist, runner up in the radiology pageant, something like that. If the radiologist can't do their job, I might be able to step in to a degree in certain situations.

Eva Sheie (12:43):
You're not a radiologist, but you play one on TV?

Dr. Richardson (12:46):
Absolutely, on the radio. On radio for sure.

Eva Sheie (12:48):
On the radio, okay.

Dr. Richardson (12:49):
Yeah. But I love my radiologists and I bless them and I am so grateful for them and the work they do, and they are so fabulous, especially at doing things like reading mammograms and looking at calcium deposit patterns. I don't have the gland for that.

(13:04):
I don't have the strength for that. But as far as ultrasound, anything, the word of ultrasound, I'm such a happy fish swimming in that water. It's a really great place to be and to be a surgeon and to have that skillset and also to be able to carry it into the operating room for instance. It's such a huge benefit for patients. So I was kind of speaking earlier how a lot of centers set things up the way they've made it more complicated and spread it out with the idea that, oh, we're improving things and making things easier on the system and the patient really is not. So the way most centers work it is that if they see something on imaging, they'll take a tiny sample. It's pretty typical to put a clip marker in, to put a little tiny tag inside. And a lot of centers just put any old kind of clip marker in.

(13:46):
You can always see a clip marker on a mammogram, all the time. You can always appreciate clip marker on a mammogram, but you can't always see every kind of clip marker on an ultrasound. So if they choose to put an ultrasound visible clip at the time of their procedure, well then that means it's so much easier for the patient to undergo another ultrasound to assess that area to either point it out for surgical removal or whatever. So sometimes we can see things on ultrasound because that's how we're biopsying it, so it's visible on ultrasound. But if it's things like calcium deposit patterns on a mammogram or things seen on an MRI or other imaging, it's really, really helpful if they can put in a clip type that is visible on ultrasound because that way those of us with the ability to do ultrasound, we can now take the patient to the operating room and let them get nice and sleepy, go under anesthesia, and without them having to go through any additional procedure, any additional pain or discomfort, we can point out that area and just remove it.

(14:43):
But the way the systems are set up is most surgeons can't do that. Most surgeons are like, I don't know where this is. The radiologist is going to have to point it out for me. The radiologist is going to have to tell me where your cancer is. No way I could possibly know. So the way most systems work is the patient then has to go for another procedure back to the radiology center where they've already been poked once and now they need another poke where they put in a special clip marker or a special device that allows the surgeon to then, usually has sort of this magic wands type of seismic counter or beep, beep, beep, that there's so many different types of clip markers on the market that allow surgeons to find them and they use either magnetic technology or radio frequency or what to find it. And then the surgeon will then take out the second clip that the radiologist put in. So now that the patient has had to go through two procedures and it's very expensive, these clips are incredibly expensive, and then that's a second procedure for the radiologist to have to do, and it's the surgeon kind of being powerless at and not really, they're just at the whim of the radiologist and they may or may not really have an appreciation for exactly spatially what's going on inside the cancer or inside the patient's breast where the cancer is, so.

Eva Sheie (15:55):
This is more detail than I've heard maybe ever about this process and it's remarkable. But can you anchor us in the logistics of this for a minute? Because most breast cancer treatment is done in these large institutions.

Dr. Richardson (16:11):
Exactly.

Eva Sheie (16:12):
And you are put in the system and you are contained in this system, which is very rigorous and has a ton of structure around it where you move from this specialist to this one and they do talk to each other. I think I was sort of pleasantly surprised at how, well, at least in the stories I've heard that they did communicate and coordinate and get results to the patient fast. But I think part of what I'm hearing you say is that you've brought a lot of this under one roof and are not doing that. So I think what I'm most curious about is how are patients switching from these big giant systems and that kind of treatment that comes with a Scripps or what is it in Los Angeles? Is it Kaiser?

Dr. Richardson (16:56):
Oh, there's multiple, yeah, there's a lot of big centers in LA there. There's one called UCLA, have you've ever heard of that? There's one called Cedars. It's like a big tree.

Eva Sheie (17:03):
I have heard of those.

Dr. Richardson (17:04):
They're great. I mean, they're great centers. They take great care of patients. They find cancers and people leave without cancer and live long and happy lives, and they're all fabulous systems that have great reputations and very well deserved. My issue as a physician, and one of the reasons why I'm glad I don't work with them is just I have autonomy and I'm really, really happy with being able to, if a patient comes in and has a lump, I can myself do a biopsy there in the moment, just myself like, Hey,

Eva Sheie (17:34):
How do they get to you in the first place?

Dr. Richardson (17:39):
A lot of it's internet. People Google us. A lot of people are having a really hard time getting, like I feel a lump, I call my major medical center close to me and they tell me that they can see me in seven months and I'm not happy with that, or my doctor thinks that's not going to work, or I've had a study at some other center and they say, yeah, we're really worried about you. We want you to come back in three months so that we can check this out. We don't have any appointments available until three months from now. And they're like, it's not going to work. Or we have a great referral network of some really amazing doctors that are very high touch with their patients and they're like, no, I really want you to go see this one doctor. You're going to see her.

(18:17):
She's going to talk to you. She's going to do an ultrasound in real time right in front of you, and you're going to look at the screen and she's going to tell you what we're seeing. And then talking about, well, what are the options? What are the ways we can make sure that this is something safe? How can we make the patient feel comfortable that we've done everything that we need you to prove to them that it's not cancer? Or if we're kind of concerned about something, how do we make things flow really smoothly so that we can get to the bottom what it is and get them to treatment?

Eva Sheie (18:40):
How quickly are you able to get people in to do this once they find you?

Dr. Richardson (18:43):
Yeah, I mean, just same days appointments. We have people that call and we try to keep spaces through the day. We try to keep a few spaces through the day, and if people call in the morning and say, I feel a lump, and okay, well, we've got time at two, come on in. Or a lot of times we also deal with a lot of benign disease, which major medical centers really have a hard time dealing with. They're more cancer focused. They're really focused on the cancer patients, and a lot of my colleagues in major medical centers just don't know what to do with a breastfeeding patient that has a problem or don't know what to do with a patient who doesn't have cancer but has a lot of pain. What do we offer them? Or someone who has a lot of growths in their breasts that aren't cancer.

(19:20):
We have a minimally invasive removal technique where we can remove growths from the breast without surgery. So we've been doing that for 17 years and just have a lot of success with people who have things in their breasts that they don't want watched. They've been told, oh, you have to have an ultrasound every six months for the rest of your life by these centers. And they're a little, people get frustrated or they feel it and they're told, oh, well, you can't have that out. It's not cancer. We don't have time in our schedule to remove this non-cancerous lump. And it's like, oh, come on, we'll take it out. It'll take about 30 minutes. We do it with local in the office and there's no scar, and we just remove the lumps with minimally invasive technique, which takes it out in a piecemeal fashion. I don't recommend this for anything that's cancer.

(20:03):
I don't recommend this for anything that has a high probability of being cancer if we don't already know what it is. I only recommend this for things that are either biopsy proven to be safe or things that have been watched for years or things that were just discovered but have zero features of cancer. But it's a great option for people to be able to have just something people ask all the time, hey, can we just biopsy this gone? Can we just remove it? And the answer is yes. Yeah, the answer is absolutely yes, and I'd love it if more people did it, but I'm one of the very few who does.

Eva Sheie (20:32):
So much common sense, I almost can't stand it.

Dr. Richardson (20:35):
Yeah. Most radiologists will not do this procedure. They're very worried that if they remove these things, their surgery colleagues will be very angry that they weren't passed off to the surgeon to be brought to the operating room and put under anesthesia with a big cut. And also radiologists, a lot of radiologists don't want to go through the trouble of having to deal with removing something. It takes more time, things bleed, they don't really like that. They just want to be in and out. They want to sample. They want to know if it's cancer or not. They don't really want to, I mean, I think there are a lot of radiologists who'd be very interested in moving forward, and there are definitely some out there who do this, and there are definitely some surgeons that do this. I'm not the only one in America by a long shot.

(21:12):
There are lots of people that do this. I did not make this up, but it's really big, this minimally invasive removal concept is really big in Europe. It's really big in Asia. America just doesn't really appreciate the value of it right now. So you have this middle ground where there are definitely things that could be removed and probably should be removed that we just don't have time to do it in the OR. We used to cut all these things out. Now you have all these centers that used to years ago, tell someone, oh, yeah, we need to take out that papilloma or that radial scar or that fibro epithelial lesion that should come out in the operating room. And now it's like, well, it's really not cancer. We really don't have time. We got this long list of cancer patients that we're having a hard time dealing with, so we're just going to watch that.

(21:52):
So they've kind of changed their tune, a lot of centers have changed their tune. So the things that we used to say we're kind of concerning, we should cut them out, now that's like, well, there's this family of gray zone things that aren't cancer that we're just going to watch. And I feel like, well, that's a really great opportunity for radiologists and surgeons who do a lot of ultrasound to say, you know what? We can remove these safely and easily, not take up time in the OR and yet get patients more clear information and do a procedure and remove things that patients don't want in their bodies safely and easily. So I think that's something that really should be investigated and looked into. Some people call it a vacuum assisted biopsy or vacuum assisted, vacuum assisted excision, a VAE. That's kind of terminology that some people use.

(22:35):
I am not a fan of that because I think it really confuses people. I think if you call it a vacuum assisted biopsy or a vacuum assisted excision, a lot of people are like, oh, you're just having, it's just a biopsy. It would be like saying a laparoscopic cholecystectomy when you have a lap coley to take your gallbladder out, it's like, oh, that's the same as an open coley where they just cut you from stent to stern and just rip your gallbladder out with their hands. It's like, no, they're two very different things. I mean, the end goal is to get your gallbladder out, but what you go through as a patient and what you experience and what training and equipment the doctor needs for both of those things are two very different things. So in the same sense, if we're removing these lesions, that's a really big deal. It takes expertise and training and specialized equipment, and it's not the same as just taking a tiny pinch and leaving it there. And it's something that a lot of people and a lot of practitioners don't appreciate that there's value in it. It's a huge advantage to a patient to not have to have a surgery and not have to go under general anesthesia, but yet have something removed. It's, it's a great thing to be able to offer to patients, and I love doing it. They're so much fun.

Eva Sheie (23:39):
There's really, I think two landscapes of breast cancer patients. There's women who think they have breast cancer and they may be coming to you to say, what is this? They don't have any idea what the process of going through breast cancer treatment looks like. Are you also seeing women in the other landscape who have already gone through it and are dealing with other questions? Is this a recurrence or what is happening for

Dr. Richardson (24:03):
Oh, for sure, for sure.

Eva Sheie (24:05):
So what does that look like?

Dr. Richardson (24:07):
Broad spectrum of patients. Patients who are what we call the worried well, who they're just there for screening and maybe they're not worried at all, or maybe they've had a personal experience with someone in their life with breast cancer or they're just health anxiety and they're worried about everything. However, every woman who has anything and every woman who has breasts at some point in time probably has felt some inevitable moment where like, oh, well, that's it. That's the breast cancer. And that's just something that I think any woman with breasts has at one point in time felt like, oh, well, this thing that I'm feeling, this sensation or this texture that I'm feeling, it must be a cancer. And then usually they get more information and hopefully that thought changes. But most people don't have breast cancer, but the people that do, I get a lot of people saying things like, oh, you must have the saddest job ever.

(24:51):
It must be terrible to do your job. And I'm like, no, I love my job. My job is fabulous, because even if we see something that I might recognize as something with more of a likelihood, the characteristics on imaging or examination that, okay, this is more likely to be a cancer than not be a cancer, I still don't get worried, so to speak, because we have amazing treatments. It's like the things that have changed in the last 21 years that I've been doing this. When did I start this? 2004, 2005. So yeah, 20 so odd years that I've been doing this job, things have changed exponentially. The people that I would see and diagnose and think, oh wow, I don't know if she's going to be alive in five years. Now. It's like she's 90% chance of being cured and not having, and probably give us never having any cancer or sign of cancer again.

Eva Sheie (25:38):
You have to give us the five biggest things that have changed.

Dr. Richardson (25:41):
Oh, well, like my own mother, she passed away of breast cancer, and of course that was very sad and very terrible, but it gave me, and I'd rather have my mom around and be, can I say a curse word?

Eva Sheie (25:53):
Yeah, sure.

Dr. Richardson (25:54):
I would rather be a slightly shittier doctor and have my mom around. But I feel like I definitely learned so much from that experience as a human, as a human humaning and as someone who has to take care of people that are in that very scared and anxious place. I learned a lot from that experience with my mom. And I can stand on two feet and with absolute confidence, say if my mom was in that situation today, she would've been cured. My mother would not have died had she was in the position she was in when she brought her situation to the attention of her doctor in, was it 1993? 1992? When she brought her situation to the attention of her doctor did that, if that woman came to my office today, she'd be cured. She would not have died. And things have changed so significantly with our diagnosis. My mother was in the situation where she had a lump, she was told repeatedly, it's probably a cyst, it's nothing and no other. It was like, oh, and that's it. And then a couple months later, it's bigger. It's now hurting. Then it was, oh, well, we're going to take you to the operating room if we were going to test it while you're asleep. If you wake up without a breast, it's cancer. That was her experience.

Eva Sheie (27:07):
Oh that's so nice.

Dr. Richardson (27:08):
There wasn't even a biopsy. It was if you wake up without a breast, well, guess what? It was a cancer. So she woke up without a breast. There was no reconstruction, there was no options for reconstruction. She just woke up and that's how she found out she had cancer. She looked down and there was nothing there. So I mean, that is a horrible, horrible thing for anyone to go through. And that in this day and age in what we have to offer for the most part in Western society, and certainly at our center, that's not going to happen to anyone that I know. And that the types of treatments that are available and the type of treatment my mother would've had, would've cured her. She would not have died of breast cancer. She'd still be alive.

Eva Sheie (27:46):
The treatments are definitely better. Are there two or three other things you can think of that are huge advancements that have changed the way that these patients are cared for?

Dr. Richardson (27:58):
Genetic testing, genetic testing, giving people with fear, with family patterns, a little bit more information to say, yes, you share this genetic component that took your mother and your aunt, your grandmother and gave them ovarian in breast cancer. You do share that with them. This is what we can do to try to head that off at the pass versus, Hey, your mother and your sister and your aunt had this genetic component, but guess what? You didn't get it. You got the good copy, so you're free. Doesn't mean you can't get a breast cancer. It just means you wouldn't get it for that reason, and it would be as if genetically it would be like you would be the stepdaughter or the adopted daughter. You just don't have that fear. So that piece of information to give to families and people with patterns in the family to be able to give them that information about genetics is huge too.

(28:43):
I also think there's a big movement in medicine that I'm really, really happy to see of backing away from treatment. So figuring, it used to be like, oh, we're going to add, add, add, add, add. We're going to add all of these treatments. We're going to do all of this stuff to people. And there's been a big pendulum swing and a big movement to say, well, what don't we need? Who are these people that maybe don't need all these extra treatments? What can we back away from? And I love that about medicine, and I love that there's a really big movement to try to pick out people who we can deescalate. There's a big movement to deescalate treatment.

Eva Sheie (29:14):
I think you posted on your Instagram about the People magazine article saying, we don't have to amputate both breasts anymore.

Dr. Richardson (29:21):
That's absolutely true. Yeah, and we've known that forever. It's not new news. Nobody has ever thought that the breast cancer is going to spread to the other breast. I don't know where anybody would say that or why they would say that, nobody thinks that. But if someone needs to have or chooses to have a single mastectomy, they may choose or may want to have the opposite breast removed, and there are some reasons to do that, but they're very personal reasons, and I think they should be discussed with people. There is a big movement systematically and internationally, it's always been a thing in Europe, they think we're nuts for amputating all these healthy breasts, and I think it's a patient choice. If a patient says, no, I want to keep my breast. I want to have something that's myself that's soft and warm and sensual and hasn't been altered by surgery or treatment, I want myself.

(30:11):
Sure, that's great. The thing that we always warn people about it, if someone chooses to have a single mastectomy where you're going to have one breast that's been surgically altered and kind of frozen in time, you're going to have one breast that's going to age and change. So even if we do the perfect match and do a beautiful job of matching the breasts in the moment, you're going to have one breast that's going to age and change and it's going to be 10 years older and 20 years older and 10 and 20 years, and you've got one breast that's going to be sort of frozen in time. So if that doesn't bother women and it doesn't have to, it's completely reasonable for a woman to age that way. But if that might bother someone, well then if they were to choose to simplify following things up and wanting symmetrical breasts, well then that's a personal choice, and I can't say that that's the wrong choice for women. But there are a lot of centers and a lot of big movements to say, you know what? Let's not do so much surgery. It's time saving, money saving, and it's maybe not necessarily thinking about women's needs, but at the same time, it's not necessary. It's absolutely not necessary to remove all these healthy breasts. But again, I know a lot of people who still want that, and I wouldn't tell them that they're wrong, and I wouldn't tell them that they can't until we change how women feel about their bodies. But foreseeable future, I know a lot of women, they want symmetry, they want a cosmetic outcome and they want ease of follow-up. They want to know, they want to have ease of anxiety that they don't have this thing called scanxiety where they have to have more scans and to be checked up all the time, and they're just terrified to have the ball drop or the shoe drop on the other side, so to speak.

Eva Sheie (31:47):
What are the current controversies in breast cancer treatment today?

Dr. Richardson (31:54):
Again, there's a lot of the deescalation that's happening. I mean, I've seen a couple patients that were older where there's two big movements. The first is called the Choosing Wisely campaign, and it involves a lot of things other than just breast care, but it basically is talking about, especially for older people, do we really need all these scans? Do we really need to do all these extra tests and do we really need to do all these extra treatments for people that are of a certain age, not because we don't care about them, but just because it might complicate things and they might not really benefit from them. For instance, one of the things that we throw out there is that patients over the age of 70, if they have a very small, very weak cancer that meets certain qualifications that maybe we don't need to check their lymph nodes, maybe we don't need to expose them to radiation, because the point of those things really is more of a academic exercise to just see, just for looksie, for curiosity, is it in the lymph nodes?

(32:46):
Yes or no? We don't really think it is, but oh, look, it's not, oh, great. Well, do we really have to look if we really don't think it's there and it's probably not there? Is it going to be life or death difference to no, that information? The answer is it's not. It's usually not any different. The other thing is radiation. If a 70 or older patient is going to have breast conservation therapy, a lot of times we would recommend radiation. If it's a very, very weak cancer, there's a very low probability it might come back in the breast. And if it does well, then we can deal with it a second time and probably that person will continue to live a long and happy life, and the addition of the radiation probably won't make them live any longer. And there's side effects of radiation and cost of radiation.

(33:25):
So if we can avoid that and the person's still going to live just as long, well, maybe we avoid it. So having that conversation with people about, well, what can we do without, and what if we do do without? What's the worst case scenario if we do it and if we don't and let patients choose. I think informed patient decision making is really important. A lot of women, especially in the world of breast care, are just so terrified that they're going to die and that time is of the essence that they really don't, they're not given a lot of choice and they're not encouraged to maybe do a little investigation that, you don't have any time for that. We got to get you into the operating room tomorrow to save your life. In reality, that's usually not how it works at all. We think that it takes probably about two to five years from a cancer being born as a cell to getting to the point where it's detected either by exam or by imaging, and

Eva Sheie (34:16):
Really? Two to five years?

Dr. Richardson (34:18):
So two to five years is the thought. Now, that's a scary concept, but it's also very reassuring. That means we have time. There's, there's not anything that's happening in seconds, hours, or days. We usually have time to do some investigations and usually we're going to have a great outcome even if a couple of weeks goes by. And it also makes me sad that there's these mixed messages that so many women get that time is of the essence. Early detection saves lives, get in there, ladies, you're going to die if that, you've got a weapon of mass destruction taped to your chest, there's a bomb in your chest. And then on the other hand, it's like, well, we can't see you for three months and you feel a lump and we'll get to you when we can and oh, you do have a cancer, but we don't have an opening in the OR for another three months, so you're going to just have to sit there.

(35:00):
So it's a very mixed message that time is of the essence, you've got your life in your hands, but also sometimes we may drag our heels because we have to in our major medical centers and our major medical systems, and you're just going to have to suck it up and deal with it. The reality is that both of the things are true. I mean, it is completely safe usually to wait a certain amount of time, and there is not usually a change in outcome with a certain amount of time. But then the question is, well, how long is it? A breast cancer is not like a human embryo where in X amount of days it's going to be so large and then Y number of months it will spread outside. And by Z, you've lost your ability to cure it. It's not like that you can't predict. But the way things work usually work and things keep getting better and better and better. Breast cancer deaths, I believe are down in the 35% range over the last 20 years. So it's huge. I mean, that's a huge amount. And people, I really like to come at it with hope that even if we find what ends up being a cancer, probably what we're going to do is going to work, and you're probably going to live for many, many years with and through being told this information. So it's a real hopeful time and things keep getting better and better.

Eva Sheie (36:19):
What do you wish that the patients knew? Because I feel like there's this huge layer of information that we all sort of absorb over time that isn't necessarily helpful.

Dr. Richardson (36:30):
I'll have patients with these horror stories that come in and they have a huge breast cancer, and they're like, I went to four different doctors and they all told me it was nothing. And I'm like, well, did they touch you? No, nobody touched me. The person who did the ultrasound just smeared the gel around, and then she came back in talking with someone else who was in a dark room down the hall, and they said there was nothing there. And I was like, well, did the doctor come in and touch you? And did they look at it? Did they offer you a biopsy? Did they offer you any other way to ease your mind or give you more information even if they thought that your imaging was otherwise okay? And they're like, no, nobody touched me. Nobody talked to me. It was just like, you're fine.

(37:03):
There's nothing there. And that really, I mean, I understand the system is inundated, it's overwhelmed. Things are usually obvious. There are very, very relatively few tiny numbers of patients who are in that situation where nobody could figure it out and they were missed and things were lost in the shuffle. That usually does not happen. For the most part, we are catching the cancers and we are catching them with screening, and we're pointing out things that patients didn't even know were there. We can see two millimeter and three millimeter growths on an ultrasound. We can see calcium deposit patterns that tell us that there's stage zero cancer before there's any lump or anything that you can feel with your hands. That's huge. There's been huge developments and advancements for sure, and I don't want people to mistrust the system, but what I would like people to know is that if you have that voice in your head, or if you feel like you're not being listened to, then continue to press on and continue to say, well, what else can we do to give me more information about this situation?

(37:59):
Is there an alternative? I know you're telling me there's nothing here. Is there something else that we can do to take a tissue sample to do a different form of imaging like an MRI? Can we do rather than just tell me you're fine. There's nothing there. Can we do some short-term follow-up just to make sure that this behaves clinically like we expect to? Or if you really say there's nothing there, tell me why you think there's nothing there, when I can feel something. Tell me what I'm feeling then if there's nothing there. So that sort of, I think that interchange and yes, people need to advocate for themselves, but at the same time, I don't want people to feel like that the system is a failure and that they're going to be let down, they should expect to be let down. That's not the case at all. But I do want people to be confident that there's nothing wrong with questioning and making some demands from the system to say, well, okay, you're telling me there's nothing there, my own body says otherwise. What can we do to remedy this disagreement between what my breast is saying and what this radiologist is saying? Yeah, so I think that that's really important for people to feel confident to be able to do.

Eva Sheie (39:03):
We're supposed to be talking about you, right?

Dr. Richardson (39:06):
Oh, no, no, I can't do that. That's super uncomfortable. No, but I love, love what I do, and I love getting to work with patients every day. I love getting to tell healthy people that they're healthy. I love performing ultrasounds. I love doing procedures. I love operating. I love solving problems. I love calling and giving people good news. One of my favorite things ever is when we find a patient with a cancer that we think is going to respond really well to chemotherapy, and we give them chemotherapy first before surgery, and then very, very frequently we'll do the surgery afterwards and we will find that there's no cancer left. They have what's called a pathologic complete response. And I just, happy dance, happy tears. I just love, love to tell people that we've been successful, like we hoped and expected to be. That feels really good. I like being right. I really like that.

Eva Sheie (39:58):
I think you have the right job. You developed

Dr. Richardson (40:01):
I love my job.

Eva Sheie (40:02):
I read on your website that you developed a procedure called the Goldilocks procedure. Can you tell us what that is?

Dr. Richardson (40:08):
That was a lot of fun. It was really fun. Dr. Grace Ma, who we did this together, it was like that kismet, you got chocolate in my peanut butter. You got peanut butter in my chocolate moment.

Eva Sheie (40:18):
That's the second time, time today that has come up.

Dr. Richardson (40:20):
Really?

Eva Sheie (40:22):
Yes.

Dr. Richardson (40:22):
That specific. Oh yeah.

Eva Sheie (40:24):
Chocolate and peanut butter.

Dr. Richardson (40:26):
Which is a delicious combination, by the way, which is one of my favorites.

Eva Sheie (40:29):
Do you have Nextech? Do you use Nextech?

Dr. Richardson (40:31):
Yeah, I love Nextech.

Eva Sheie (40:32):
Well, Nextech and CareCredit got married and they made it the actual commercial with the chocolate and the peanut butter, and they're very proud of it.

Dr. Richardson (40:41):
I wasn't aware of that, but I'm for it on all levels.

Eva Sheie (40:44):
They think it's hilarious.

Dr. Richardson (40:44):
Branding wise and the actuality of the physical combination of those two. Well, what was really funny was I happened to be with my dear friend and former colleague, Grace Ma, who's still in Atlanta, and she's still fabulous. And we literally had this moment, we had a patient that was the perfect storm patient. She's this lovely lady who had had cancer in the past and had a lumpectomy and had cancer come back. So here she was, she had quite large breasts, and she said, I don't want any reconstruction. I said, okay, I respect your decision, but what I'd really like you to do is I'd really like you, we have to do a mastectomy at that point. If someone has especially years and years ago, this was in 2010, I believe, if somebody had a lumpectomy and radiation and they had a recurrent cancer, it was like we kind of had to do a mastectomy, so we didn't really have choice. Anyway, so I said, we have to do a mastectomy.

(41:37):
She said she didn't want reconstruction. I said, that's fine, but if we just remove your breast and do nothing, if you are very unhappy with that, we've really burned a bridge. So I really hope that you'll talk to my plastic surgery colleague, Dr. Grace Ma. And if after talking to her you still feel that way, well then of course I respect your decision. So she went and talked to Grace Ma, and she came back and she said, I absolutely agree that I should have talked to Grace Ma. I don't want a breast. I don't want reconstruction, but I want her to close it. I want her to do the suturing to sew the incision shut. And I'm like, wait, what? Wait, no, no. That's not the point of this. I'm very good at suturing. I'm completely capable. Believe me, I'm a surgeon. We do the surgery, we do the sewing.

(42:17):
I'm a sewer. I got this. You don't need another person to come in. That's not really good use of her time yet anyway, okay, fine, whatever. And I love Grace, and Grace loves me. And so Grace, on the day of the surgery had drawn a breast reduction pattern to kind of help close the tissue. That's what she had decided to do, and we hadn't really discussed it previously to that. So there was this sort of strange, usually when we do an incision pattern for this sort of thing, it's like a giant eyeball shape and giant eye shape, like an almond shape thing where you close the lid of the eye, you remove as much skin as possible, and you just make everything flat, flat, flat. And then you have a long scar across the middle, kind of either at an angle or straight across, and it looks like an amputation, it looks terrible. And somebody doesn't have a breast, great. You've accomplished your goal. They no longer have a breast and it's closed. That was the height of the height of the option at that time. Or you did full reconstruction where you saved as much skin as you could and you put stuff inside that they'd have a boob, and there wasn't any middle option. So with this patient, I wasn't exactly sure how Dr. Ma wanted me, where she wanted me to cut and where she didn't want me to cut it, I didn't know what she wanted me to take away, and I didn't know what she wanted me to leave. And of course, with surgery, if you cut away the skin, you cannot put it back. You can't. It's not possible. I mean, you can't just sew it back up. It's quite a very complicated thing. So rather than possibly really mess something up, I just left all of the skin in place and I did my mastectomy as if we were going to put a big implant in, just do a normal mastectomy as if we were going to just put the implant in.

(43:45):
And when, Dr. Ma was a little bit, she was doing another surgery, and I had some time. I was pretty quick doing my surgery, and so I had all this tissue that was left behind and I kind of folded it in the pattern she had drawn on the patient, and it was like a breast reduction pattern. I kind of folded it in together like origami. And I went, wait a second this looks like a breast reduction. There's enough tissue here, it's not cancer tissue, it's not breast tissue. I took that out already. It's just the skin. It's just the fat that we would ordinarily just put an implant under or an expander under. How about we save this and kind of put it back together, partitioned it into this shape that looks like a breast? And Dr. Ma came into the operating room and it kind of started that process, and I was like, can we do this?

(44:32):
Is this right? Am I right in saying this is how this goes together? And she was like, yeah. And a little, she was like, didn't you do a mastectomy? I don't think she was really clued into exactly what was happening. I thought she was like, oh, did you just do a really big lumpectomy? What do we have here? It just didn't really occur to her because it wasn't flat. I didn't cut away all the skin to just make it flat. All the skin was still there. So we put it back together in this breast reduction pattern having removed all the breast tissue. And at the time, we removed the nipple too. What we did, nipple sparing mastectomies weren't as much of a thing then. So we just did what we usually did, and the patient loved it. Now, the patient had very asymmetric breasts, and so she had one breast that looked like a extreme breast reduction, but it looks still like the shape and the fullness of a breast.

(45:18):
And then she had her other natural breast that was quite large, and so she was very uneven, and we offered her like, well, would you like a reduction on the other side? She's like, nope, nope. I'm good. I love this. She's like, this is great. And she said, when I put a bra and I have something that kind of holds everything down, I have cleavage, I can put in a, she put in a prosthesis into her bra, but she had cleavage. Everything looked really pretty. And then we said, well, this is kind of a thing. This can be its own thing. Let's keep going with this. Again, everything was sound. We didn't do anything off the cuff where nobody had ever done it before. It was still a mastectomy where we could have just put an implant underneath, and it was still a safe pattern of folding and sewing, closed, just skin and fat.

(46:02):
So we weren't doing anything different. We were doing two things that had been previously been done, but just never together formally. And I had a couple doctors after we did it after the fact that said, I've done that a couple times. And I was like, okay, well great. I'm glad I'm not alone in this thought process. But we really said, Hey, this might be something to talk to patients about, something to write up as a paper or something to just discuss, to have a talking point about. And I'm really glad that people see the value in it, and for the right person in the right situation, who doesn't want to look mutilated, they don't want to have their breast amputated. Maybe they don't want implants, they don't want extensive surgery. They don't have to move tissue from around their body to go through the trouble of recreating a breast, or if they're very big and they're comfortable with being a lot smaller, it's a really great option for the right person. So even though it's peanut butter and chocolate and I didn't invent peanut butter, and I didn't invent chocolate. But it feels pretty good. And I think Grace Ma is also very kind of proud of the fact that we've impacted somebody's life somewhere where they might've had a different outcome and they might've had fewer choices. And I think that there are people that are really happy that they had that as an option. So it feels really good to be part of that.

Eva Sheie (47:13):
So then did you kind of chocolate peanut butter, your Goldilocks mastectomy with Dr. Cassileth's SWIM flap?

Dr. Richardson (47:20):
Yeah. So Dr. Cassileth's, so when we do it, it's for anyone who's listening, basically I'm going to describe if you have a breast and you remove everything from the inside of the breast and you have the top half of this, if you kind of cut the breast in half and you've got the bottom half of the skin that you can wad up and use that as filler, and then you've got the top half that you can lay on top of the bottom half, well then you have the semblance of a little bossom that you can make. And how big that little bosom is is dependent on what skin and fat the patient has left behind. So it's sort of a real estate issue. We don't get to decide how big it is, it's just whatever the patient has for us to work with. Anatomically when we've removed all of the breast gland tissue, that's the milk making tissue that could cause cancer.

(48:01):
When we get that out, what do we have left behind? Is it a very thin rim of fat and skin or is it a very thick rim of fat and skin? It's different for different people. So when we first designed it, when you kind of take the bottom and the top together, what's in the middle is the nipple. So if you're taking the bottom and putting it in the middle and you're taking the top and putting it over the bottom, well then where does the nipple go when all that, ah, it's in the middle here. Where's the nipple supposed to go? So the easiest thing to do is just not have a nipple and not have to worry about it. Dr. Cassileth said, well, you do know there is ways to kind of divide it and keep the blood supply intact with the nipple, keep the nipple alive and kind of swing things around and layer things up so that you can keep the nipple in place.

(48:45):
And so I said, well, we should obviously call it a nipple sparing Goldilocks. And Dr. Cassileth said, obviously you can't call it that because we plastic surgeons have a nomenclature that's based on the blood supply to the thing that you're leaving. So it has to be a flap. So where is the blood supply of the nipple coming? So what can we call it that has a nice ring to it? So we came up with SWIM, which is SWIM. So it's superficial, so just the superficial tissue. Wise pattern, which is the shape of the way, you usually put things back together in a breast reduction pattern. Wise pattern, internal mammary. So internal mammary is sort of like the blood supply coming from the central portion in between the ribs here, that usually comes this way from the inside up. And that's usually the blood vessels we keep intact to keep the nipple intact.

(49:39):
So basically it's just a fancy way of saying nipple-sparing Goldilocks, but it's something that she feels like is more legitimate for plastic surgeons and for the medical community to be a flap based moniker. So SWIM flap or Goldilocks SWIM or nipple-sparing Goldilocks, it's all the same thing. It's just reappropriating and sort of custom folding whatever we have left after a mastectomy so that it looks like a beautiful breast and it really just makes sense the old fashioned way of taking that eye shape and closing the lid of the eye. What ends up happening is everything is very tight in the middle and flat in the middle, and then you've got bunchiness on either ends, which is the exact opposite of what a breast is, which is a lot of fullness and looseness in the middle, and then it tapers down and it's more tight on the sides. That's exactly it is. So it's taking the tissue that you've left over and just kind of reappropriating in that configuration.

Eva Sheie (50:34):
And do patients find you for that specifically now?

Dr. Richardson (50:38):
Some do. Some do. There are a lot of amazing practitioners all over the country that have taken this on and that have great results. So I love doing that surgery and I love working with patients. And I do think that we are pretty bold in the way we save the nipple. A lot of practitioners are not as confident at doing that, but I encourage them to try. It's a little bit more common for a doctor to take the nipple off entirely and make it very thin, put everything back together and then essentially make the nipple like a skin graft and just put the nipple on top and hope that it clings on and it gets blood supply from the underlying skin. So that's called a free nipple graft. I think that's a little bit more common if someone's going to keep their nipple with a Goldilocks procedure.

(51:23):
But I mean, whatever a doctor and a patient is comfortable with, I highly encourage patients, if patients hear from doctors that it's not possible or it can't be done and yet it is being done. If the patients don't kind of demand it and say, well no, I want you to try this. I know that these other doctors do these things, I want you to do this too, then no one's going to grow. But there has to be that safe place where if a doctor hasn't really tried something or doesn't have a lot of experience in it, that patient has to say, I understand there's risks involved. I still want you to do this anyway. And then that doctor has to feel comfortable that they're not going to get sued or blamed or have an angry patient because they have an expectation that they haven't met.

(52:02):
So it's hard to be innovative, it's hard to be innovative. It's hard to be bold as a surgeon. Fortunately, I've got these amazing partners that are so skilled that we do try things with the patient's understanding we have this great thing that we can do and it's baby steps. It's working with what's already exists and what's safe. But we constantly want to try to make things better and push the envelope and to do things that we haven't done before that we feel like are safe or an improvement. Dr. Cassileth was one of the first champions of doing the direct to implant reconstruction, which is super fabulous. When I moved here from Atlanta, we didn't really do direct to implant in Atlanta. And I remember telling her, are you sure we can do this? And she was like, hold my Cosmo as they say, this is exactly what we can do. We're going to fly with this. And that's what we've done for the past 10 years. It's been great. Just really amazing outcomes. And I wish more patients had more expectations of their surgeons to say, I want this too, rather than be told, oh, you can't save your nipple, you have to have an expander. Everything is, that's not possible. It's like, well, how come these other doctors are doing if its not possible? So I think it's a good conversation for patients to have.

Eva Sheie (53:18):
I feel like we could talk about this for probably five more hours. Yeah. So, okay. Your website is BedfordBreastCenter.com. There's lots of information and resources there. Your Instagram is, tell me what your Instagram is.

Dr. Richardson (53:37):
What's our Instagram? Bedford Breast Center. Thank you. Thank you.

Eva Sheie (53:43):
Got it. Okay, I'll put that in the show notes. And so then my last question would be just give us a flavor away from work. What do you do for fun?

Dr. Richardson (53:52):
Oh, I love to sing and I love to paint. I love to paint. I paint big paintings and there are some in the office.

Eva Sheie (54:00):
Where do you sing?

Dr. Richardson (54:01):
Where do I sing? I mean now mostly karaoke. It's usually just mostly karaoke with my friends. If there's somebody playing and I will pay to sing a song with a band, I have no shame. None. No shame. And in the or I've got easily 10,000 hours in the OR. I got the Beatles beat in the OR.

Eva Sheie (54:27):
Do you get to pick the music?

Dr. Richardson (54:29):
No, I let, anyone can veto. Anyone can veto, but for the most part, nobody really chimes in. It's usually Foo Fighters or Ella Fitzgerald. It's usually one of those two things.

Eva Sheie (54:42):
I've got a friend in San Diego who they read the Daily Mail to each other in the, OR every day, all the B list celebrity gossip.

Dr. Richardson (54:51):
That's kind of awesome. That's kind of fabulous.

Eva Sheie (54:55):
They're not sure why the anesthesiologist has not quit yet.

Dr. Richardson (55:01):
Well, we have the best anesthesiologists. They are all fabulous. And Adam Brown, one of our excellent, amazing anesthesiologists, sometimes he's like, I need to play DJ. I need to do this today. I need this. I need to hear this music for me, we're like, Adam, absolutely. You just drive. So he's great. So whatever's going to make the room happy. I don't want anybody hearing anything that they don't want to hear. But I'm not good with silence. I need something.

Eva Sheie (55:33):
Usually it's good for the energy.

Dr. Richardson (55:35):
There's a lot of joy in the OR. There's a lot of good energy in the OR. We have fun. No bad.

Eva Sheie (55:41):
As there should be.

Dr. Richardson (55:41):
No negativity. No negativity. So we have a lot of fun, a lot of singing.

Eva Sheie (55:47):
Thank you for sharing yourself with us today. It was really a privilege.

Dr. Richardson (55:51):
Thank you. It's awesome.

Eva Sheie (55:52):
If you are considering making an appointment or are on your way to meet this doctor, be sure to let them know you heard them on the Meet The Doctor podcast. Check the show notes for links, including the doctor's website and Instagram to learn more. Are you a doctor or do you know a doctor who'd like to be on the Meet the Doctor podcast? Book your free recording session at MeettheDoctorpodcast.com. Meet the Doctor is Made with Love in Austin, Texas and is a production of The Axis, theaxis.io.