Obstetrics & Gynecology: Josh

Show Notes

In Episode 2 of No Referral Required, the hosts welcome their first guest, Nashville OB-GYN Dr. Josh, for an honest and wide-ranging conversation about what it’s really like to care for women throughout pregnancy, childbirth, and beyond. From his journey into obstetrics and gynecology to the realities of being a male physician in a specialty increasingly dominated by women, Dr. Josh shares thoughtful insights into building trust with patients, navigating birth plans, and balancing the medical and emotional complexities of women’s healthcare. The discussion also explores what patients can expect from their OB-GYN, the collaborative role of midwives and nurse practitioners, and how modern maternity care differs from what many people imagine.

The episode goes beyond the clinical side of medicine to reveal the deeply human experiences behind the profession. Dr. Josh candidly discusses the emotional weight of difficult outcomes, the challenges of malpractice concerns, the importance of mental health support for physicians, and the realities of practicing obstetrics in both urban and rural settings. Through stories from his career and personal life, listeners gain a rare glimpse into the joys, fears, and responsibilities that come with delivering babies and caring for families. Equal parts educational and heartfelt, this conversation highlights the compassion, resilience, and humanity at the center of women’s healthcare.

Transcript

Lara [00:00:12] As a reminder, this podcast covers sensitive and sometimes difficult medical topics. Listener discretion is advised.

Courtney [00:00:21] Hey, everybody, and welcome to episode two of No Referral Required. Welcome back.

Mandy [00:00:26] Hey. Hey. Hi.

Courtney [00:00:27] We are all here. Lara. Mandy. And Courtney. And we actually have a guest with us today. Our first guest. Our first guest. Hooray. Oh, we need an applause round. I know. Woo. That’s what it is. That’s what I should have done in my other job. Yes, that’d be so fun. Okay. Anyway, we digress. Yes, but our first official guest is with us.

Mandy [00:00:53] Welcome Josh.

Josh [00:00:55] Thanks for having me.

Mandy [00:00:56] We’re so excited.

Josh [00:00:57] Very excited.

Mandy [00:00:58] So, you know, we decided that these first few episodes should be something that the majority of the population, when they visit the health care system, might have some interaction with. And so it made sense. that we have a general OBGYN practitioner, since greater than 85% of American women will see one in their lifetime. I’m not sure what happened to those other 50%. I know, gosh. I know.

Lara [00:01:21] 18 seems high for never having seen one.

Mandy [00:01:23] Yeah, honestly. Guys, go see your doctor. Yes. Yes, please. But that is a high number. So we decided we would start with that. And so Josh joins us. He is a Nashville OBGYN in private practice, but didn’t start out that way.

Josh [00:01:37] That’s right.

Mandy [00:01:37] Started in academics. with myself and Lara. And so that’s how we know him. Josh, why don’t you start by telling us about yourself and how you got into the practice of OBGYN?

Josh [00:01:49] Well, thanks for having me. This is super fun and exciting, and I’m honored to be here. But I grew up in South Carolina in the upstate and lived there pretty much my whole life. And ended up going to Wake Forest for undergrad, spent five years sort of doing, I’m single and I can do whatever I want stuff before I settled back down and decided to go to med school. And OB-GYN was my last rotation as a third year. We hear that a lot. Yeah.

Mandy [00:02:22] They put it off for some reason. I know, right?

Josh [00:02:27] I don’t recall if I actually put it off or it just happened to be that way, right? But it was clear that I didn’t really have too much of an excitement about doing OB is what everybody called it, right? No one knew about GYN stuff. They just called it OB because you just deliver babies.

Courtney [00:02:47] Just birth babies. That’s all it is.

Josh [00:02:51] But so I met an attending during my rotation there that sort of perked my interest. And he and I connected, and he sort of put me under his wing and said, let me show you what it’s really like. And he did. He showed me not just the day-to-day activity of what he did and what the job entailed, but what’s it like at home. He was married with kids, and this is what it’s like, and this is how it could be if you do this kind of job or that kind of job. And on top of that, the actual job was a lot more exciting and stimulating than I thought it would have been for some reason. I was going to be a pediatrician from day one.

Lara [00:03:31] Really? Oh. I can see that, too. Yeah, I can.

Josh [00:03:37] There’s probably a deeper story there. My dad was an OB-GYN.

Mandy [00:03:42] Oh, okay.

Josh [00:03:43] A lot thickened. I saw what it was like for him when I first noticed that’s what he did. he would get all these phone calls at night.

Courtney [00:03:57] Dr. Huxtable. Yeah, exactly. Old school too. Right.

Josh [00:04:00] And he didn’t have to be at the hospital like you do now. There came a time, I don’t recall how old I was, where he, I remember him talking and saying, well, I can’t stay home anymore. They’re requiring me to be at the hospital.

Mandy [00:04:14] Oh, yeah. So in-house. In-house.

Josh [00:04:17] And so we would go, whenever he was on call, we would go eat dinner there. And we’d take dinner there, go get pizza, or we’d make dinner or something and go there and sit with him. And then we would all leave and he would stay. And then many a times I would come home from school and he’d be on the couch just, just out after a long night of call. And, you know, so I was like, I don’t, I don’t think I really want to do that. He’s always at the hospital. But my friend, Dr. Coe was his name, in Broward General down in Fort Lauderdale, sort of tweaked that interest back in a way that I thought, you know what, I need to look into this a little bit more.

Mandy [00:05:06] Yeah, that’s really interesting that you had two different practitioners that had two different experiences speak into your life that gave you a different impression. Very much.

Josh [00:05:15] Yeah. So I sort of switched gears a little bit and did a couple of rotations as a fourth year. And sort of that sort of interest persisted enough for me to say, that’s what I’m doing. And so ended up training at Vanderbilt and stayed on there after I trained.

Mandy [00:05:38] And now you’re in private practice. That was a big change for you. A big change. I don’t think you saw that coming.

Josh [00:05:44] It’s very interesting. One of my colleagues who was involved in the development of the practice where I am now called me one day and said, I just wanted to let you know about a thing I’m doing. And I listened to it and was like, It sounds awesome. Good for you. Right. And she said, well, do you know any doctors that would be interested? And I said, no. You know, she said, right.

Courtney [00:06:19] Good luck.

Josh [00:06:20] She said, well, if you hear of anybody, let me know. I said, no problem. And I don’t remember how long it was between that conversation and when I got a phone call again. And it was more of the like, What about you? And I was like, well, I haven’t really thought about it, to be honest. I haven’t considered that. And she said, would you consider? I said, well, yeah. Why not? And so, you know, one thing led to another. And it was a timing thing. There were some other things going on at the job I had at the time. And it just it made sense. Looking back, my wife would probably disagree with that. in some form or fashion, although she’s very aggressive with the, let’s take some risks and do something that’s like hard in life. That’s kind of her MO. She’s like, take a challenge, why not? And so, yeah, it was the right time. It was a timing thing, but it was the right time. Yep.

Mandy [00:07:28] All right, I’m gonna ask one more of my questions and then I’m gonna let somebody else talk. So let’s talk about the elephant in the room, and that’s your Y chromosome. So as Lara and I practice, we often hear from women, I think because they’re fine telling it to us, because we are women, that they would never think of going to a male ob-gyn, because he, quote, can’t understand what I’m going through, end quote. I can understand where they’re coming from. women predominant in, or women dominance, predominance, predominance.

Lara [00:08:17] Predominance, yeah.

Mandy [00:08:18] I think so. It’s like 80% now. Yeah, in OB-GYN. And the career, and how that’s affected you, or has it affected you? Do your patients talk about it? What’s your experience?

Josh [00:08:33] Man, that’s a long conversation.

Lara [00:08:37] Longer than we have today.

Josh [00:08:38] Maybe longer than we have. I will say, in my training class, I was the only male. So there were six of us, and the other five were women. Of the 24 of us, there’s six per class at my training institution. I think there were three men, maybe four. In OB-GYN training nowadays, it’s persisted. There’s maybe one every class, maybe two.

Lara [00:09:14] Huh? Yeah, it is. My residency class was zero. Really? Mine was one out of six. Because once you lose even one, it’s hard to recruit back. That’s right.

Josh [00:09:27] I wouldn’t say that that affected me in any way. I think I approach women’s health care in sort of this fashion, when someone says something like, you could never understand, right? Something like that, which not many people have said that to me. Maybe they think it, but they’ve not actually voiced it. But I try to approach that human on that level, which is, you’re right. I don’t.

Courtney [00:10:02] Yeah. I mean, how much can you? Can you? I do not understand. Anybody, anybody is a doctor, right? Unless you’ve literally. But that’s right. Yes. Everything is so different for each person. Sure.

Josh [00:10:14] Yeah. I think. I think if you show any human, not just in women’s health care, but any human, any form of compassion towards something there, a relationship sort of develops in a way that it would not otherwise. And so I’d say that is the way I practice. I come at patients that I take care of trying to grasp an understanding of their life in their shoes and trying as best I can, which I can’t understand everything, to give them the understanding that I care a lot about you and what’s going on in your life, your marriage, if you’re married. your kids, one of the things I ask for from patients who ask for, what can I do for you? And I just, it’s very simple. Send me a picture of your kids. I wanna know how your kids are doing. The ones that you delivered. The ones that I delivered. Yeah, yeah. And I probably have 30, maybe more. every once in a while, just get a, just get a photo. Just say, Hey, he or she’s one or two or three. And that’s what you asked for. So I’m doing it. Yeah.

Courtney [00:11:32] , so that’s such a good idea there. I need to write that down. I got to be graduated from eighth grade. So that’s like, you know, a milestone or whatever.

Josh [00:11:43] The, the, you know, so that’s, I’d say that issue doesn’t, I wouldn’t say it’s something I think about a whole lot.

UNKNOWN [00:11:52] you

Josh [00:11:53] Because it doesn’t bother me.

Courtney [00:11:54] Because you’re able to make a connection no matter what, human to human.

Josh [00:11:57] I haven’t had, I mean, I don’t think. I don’t think I’ve had much of a problem establishing trust in the women I take care of, just because I’m a male.

Mandy [00:12:10] Your human factor has exceeded your gender.

Josh [00:12:13] Well, I hope so. A knowledgeable doctor. I know people with a Y chromosome who happen to be OBGYNs. who are like that. And it’s a struggle. Yeah, it is. It’s a struggle. I’ve seen one.

Courtney [00:12:30] My current one is not that, but I’ve seen one that I was like, nope, nope.

Josh [00:12:35] I mean, that’s a pervasive thing in the world.

Courtney [00:12:37] Yeah.

Josh [00:12:38] Women are basically taught you. This is what you do. This is what I do. You stay in your lane. I stay in my lane. And when it comes to women’s health care, it’s don’t question the doctor. Don’t even ask a question. Don’t even think that you could think about talking about things that you want to talk about. Just keep your mouth shut. Whatever he or she says, that’s what goes. And there’s obviously space for discussion, but there’s a pervasive behavior of I’m the doctor. You do what I tell you. You don’t have any voice in this. And I think that creates space for distrust and potentially outcomes that are not great.

Courtney [00:13:34] What do you think about, I know so many women who their OBGYN is their primary care also. They don’t maybe go see a PCP anywhere else. Is that what you see? Is that a good practice as a patient or do you, you know,

Josh [00:13:53] I am a lot of women’s only solo practice. Yeah, right. Yeah. And I would say I feel pretty comfortable in most spaces doing that. OK. You know, nowadays in training, there is a lot more training for OBGYN residents in the spaces of Typical primary care right right now if you have really bad diabetes or really bad high blood pressure or you refer them Yeah, that requires a lot more follow-up and engagement with not just you but your staff right just to make sure patients are not falling through the cracks with certain conditions, okay, but you know, if you want to call me for a sore throat or get a strep test or anything that’s sort of like I would call my PCP for, I can do those things.

Courtney [00:14:42] Okay.

Josh [00:14:43] Feel very comfortable.

Courtney [00:14:44] And that doesn’t cross any kind of boundaries that you have?

Josh [00:14:47] Not for me.

Courtney [00:14:48] Okay.

Josh [00:14:48] I think there are some people out there that it would call your PCP. Yeah. I don’t have time for that.

Courtney [00:14:52] Right.

Josh [00:14:53] I do pap smears and I deliver babies. That’s what I do. Right.

Courtney [00:14:56] Yeah. Yes. Yeah. Yeah. So. , so your day to day, a day to day, a typical week for you because you do surgery as well or no?

Josh [00:15:08] I do.

Courtney [00:15:08] Okay. So what is, what is a week in the, in the life of an OBGYN look like?

Josh [00:15:13] For me, it is a full 24-hour labor and delivery shift. So I go to work at, say, 7 a.m., and I go home the next day at 7 a.m. Monday through Friday? No.

Courtney [00:15:26] Okay.

Josh [00:15:27] One day a week.

Courtney [00:15:27] Okay, one day a week.

Josh [00:15:28] Okay. The next day I have off because I’m probably wiped out. I’ll see patients one to two days per week during that same week. And then I’ll probably have either a half day, sometimes a full day, but more usually it’s a half day of surgery. C-sections or gynecologic surgery, hysterectomy, things like that. That’s my typical week. And then I also have to cover weekends. And we typically do somewhere between 36 and 48 hours straight over a weekend, say a Friday, Saturday kind of thing. once a month, once every six weeks, something like that. So it’s not terrible. When we first started this practice, my partner and I were on every other night, 24 hours. It was rough. But now we have more physician partners so we can spread it out a little bit easier. So it’s a lot better. It’s a lot better.

Courtney [00:16:34] Okay. When it comes to childbirth, and this was just me being, cause I’m the non medically trained one, but I think I was surprised what having a first baby and you probably get this, I would assume reaction from lots of first time pregnant women is you’re not, Oh, if you were my provider, you would maybe not be the one to deliver. like my child. Y’all are all like, well, duh, but that’s a, that’s a big wake up call for, because you go to, I go to see you every week, you know, every, you know, you know, every month or two months and then every week at the end and all that kind of stuff. And then you’re like, but we’ve had this whole thing and like, we have a birth plan, you know, all that silly thing that doctors are like, , that’s funny. , How do you explain that to somebody? Do you find it that people have that understanding, they think like that, and you’re bringing them back, bringing them to the world of reality? Or do people walk in already knowing that, and I’m just…

Josh [00:17:33] Some people do. Okay. But the person who might not, again, I try and grasp an understanding that they have about what their expectation is, so that they think, that I don’t think, that I think you’re a lunatic. Like, how could you dare think that I would, right? And that would create this sort of like, oh my gosh, I wasn’t going with, like, calm down, you know, like, how could you think I would be there 24-7? You know, so I absolutely understand why a relationship that has developed over nine to 10 months of two or three humans, if you’re partners with you, right, would expect that partnership to finish out.

Courtney [00:18:21] The big moment, I need you to be there.

Lara [00:18:23] I think a lot of physicians in an ideal world would love to be there. That is the highlight of somebody you’d follow. You cared for this woman and their baby for so long. How many hours in what you just described in your week, that’s a 60, 80 hour work week usually?

Josh [00:18:41] If that description is exactly what I do, yeah. But it’s not every week like that. So it averages about 50 for me, which is not terrible. I can work like that. In my previous job, I had sort of worked myself into sort of like a six-day work week, which is a problem.

Lara [00:18:58] Yeah. It’s challenging. Yes.

Josh [00:19:00] And half, not half, a good portion of that was actually work from home, catching up on stuff that I didn’t have time for. But no, I absolutely understand why women would be confused by that. I do. I absolutely understand. And I say, I get to be me, too. I have an awesome wife, and I have four kids. I get to do that, too. And I’ve had one patient. in my career since 2007, who has said, I can’t do that then. I’m gonna have to go somewhere else. And she did. And I was like, by all means. I sent her to someone that I trusted who did that. She said, I’m doing that. And there’s plenty of people in many metropolitan areas, including Nashville, that that’s their MO.

Courtney [00:19:56] That’s how they operate. Someone’s on call, right?

Josh [00:19:59] Of their practice. Someone’s on call. But if you come in and you were my patient and I’m not on call, you have to come in. My partner is going to call me and say, she’s here.

Courtney [00:20:11] Yeah.

Josh [00:20:12] What do you want to do?

Courtney [00:20:12] Yeah.

Josh [00:20:14] You come in, you get paid. You don’t come in, she or he gets paid. So that’s a, a lot of people come in. They’re at home eating dinner. They drop everything and come in.

Courtney [00:20:25] Well, I mean, I know I said Dr. Huxtable, but that’s what I, that was my understanding was the Cosby show was like, he was just always, he saw people in his office at their home and then he would go into the hospital and carry his little briefcase thing, you know, and be on call. Oh yeah, I got to go see Ms. So-and-so. She’s having a baby.

Lara [00:20:43] you know whatever so well i think the model in the 50s 60s and 70s was that was very much that but the number of patients you followed was enormously it wasn’t 85 percent of women right maybe it was twice a month yeah okay so you could do it yeah but in the modern model you have these huge patient panels, and you’re seeing them. And there’s probably somebody delivering every night in your practice. For sure. For sure. So it’s just not the same. But I think a lot of people, I think even the physicians, would like that, if you could follow fewer and deliver two or three of your own patients a month. Absolutely. But I just don’t see how that structure can work. Yeah, it’s not feasible.

Mandy [00:21:25] And it’s not financially sustainable.

Josh [00:21:28] That’s right.

Mandy [00:21:29] So Courtney mentioned something that I wonder if it’s a bad word, and that’s a birth plan. Oh, is that a bad word in your practice?

Josh [00:21:36] Not a bad word.

Mandy [00:21:37] No, no.

Josh [00:21:38] You welcome it. Absolutely.

Courtney [00:21:41] To what extent? What does that look like? What’s a healthy one to have that’s realistic? Because some people are like, I want the lights down low. I want this music playing. I want this exact song to play as the baby’s being born. I don’t want any medical intervention that’s not necessary. What’s the line that you can I don’t want to say guarantee because that’s never medicine, right? There is no guarantees, but that you can try your best and it would, and it makes sense. It’s not, it’s not a big ask. Is there a line?

Josh [00:22:12] I mean, it’s gray.

Courtney [00:22:14] Okay.

Josh [00:22:14] Yeah. I mean, of course there’s one. I don’t know what it is and neither do the parents.

Courtney [00:22:20] Right.

Josh [00:22:20] They don’t either.

Courtney [00:22:21] Yes.

Josh [00:22:22] Neither of us do. OK. And until we all come to that agreement. Yeah. You know, it can be challenging. Right. I mean, you know, a birth plan can be as simple as like, I just want to have a healthy birth. Sure. Yeah. That’s my birth plan. And, you know, it can go all the way to, I want the dad or the partner to deliver the baby. I want them to do immediate skin to skin right there. I want the cord to stay clamped, stay unclamped until the placenta comes out. That’s a thing. You know, it can be very, very minutia when it comes to details of a birth plan. And I think the issue on really either side, whether it’s the provider side or the patient side, is some kind of a control mechanism.

Courtney [00:23:19] Sure. Oh, yeah. It’s the scariest thing you’ve probably done at that point in your life.

Josh [00:23:25] Right. And again, I don’t know that a patient’s trying to control anything other than wanting to have like a birth that she wants to have.

Courtney [00:23:33] Yeah.

Josh [00:23:34] Right. What’s wrong with that? There’s nothing wrong with that. My control is, no, I need the birth to be, you know, I need to not have a bad outcome.

Courtney [00:23:44] Yeah, right.

Josh [00:23:44] I don’t need to lose either one of you here. So if your birth plan navigates a space where there’s a potential for something bad to happen, I’m not going to let it happen. Sure. I’m going to put my hand down on that one.

Courtney [00:23:56] Right. Yep. Is that different per provider? Like you have a different line than maybe somebody that you work with, like in your practice?

Josh [00:24:03] Yeah, I’m, I’m, I’m currently right. I’m way more comfortable with navigating birth plans with anybody that wants to have one.

Courtney [00:24:12] Okay.

Josh [00:24:14] Because I know at the end of the day, I have no idea what’s going to happen.

Courtney [00:24:18] Right.

Josh [00:24:18] Right. I have no idea.

Courtney [00:24:19] Yes. It’s not a contract. No. It’s a plan.

Josh [00:24:23] And all I can do is choose to be engaged and present in potentially something that is difficult during a birth.

Courtney [00:24:32] Yeah.

Josh [00:24:34] And not necessarily shame someone for having a crappy birth plan. Sure. Right. I mean, so what’s wrong with having any birth plan that anybody wants? Right. Even if there are things on there that potentially are unsafe.

Courtney [00:24:48] Yeah.

Josh [00:24:49] Right. And those things occur. You tell them?

Courtney [00:24:52] You say like, this part I’m not sure about, like ahead of time.

Josh [00:24:55] That’s right. Yeah. You have to be honest. You can’t just, you know, pull the wool over. Right.

Courtney [00:24:59] You have to be honest about- Your blood pressure is really high. We’re going to give you some magnesium. That’s going to happen. Right.

Josh [00:25:04] And so then what do you do when said person says, I hear you. I’m not doing that. Do you then not take care of them? Do you make them feel bad?

Courtney [00:25:19] What do you do?

Josh [00:25:20] I say, I tell them, here’s why I think this is the healthiest thing for you to do. Sure. I understand why you wouldn’t want to do it. I try again, even there, I try to say, what would it be like for me to step foot into that person’s.

Courtney [00:25:33] Yeah. In this moment. Right.

Josh [00:25:35] You feel this way and I want to know why. I want to engage you. And she still might say, I’m not doing it. Yeah. Well, I can’t force it on her. So I don’t. Right. But that doesn’t mean I quit taking care of her. Yeah. You know, like I still in there if she has a seizure, which I’ve seen. Yeah. Right. I’m sure I have to do something. Yes. Right.

Courtney [00:25:59] And, you know, I don’t do this. This could happen. That’s right. I will medically have to do to keep you alive.

Josh [00:26:04] Correct. Yeah. So it’s it does make the space a bit more nerve wracking. Yeah. Because you’re always in this like, oh, it’s going to happen kind of stage. You know, but that happens even in folks that that are like, I just want a healthy birth. Right. I was going to ask.

Courtney [00:26:22] They come in and they’re like, do you feel that in every birth?

Josh [00:26:25] Like there’s it’s the job that I do, at least in the obstetrics world. It can happen in gynecologic surgery, but it’s more common in obstetrics where you kind of always feel like there’s like something around the corner. Cause there is. The reality of the situation is there is always something around the corner, we just don’t know who it’s going to happen to. And we have all these risk factors, and if you have these four risk factors you have a higher risk of having this that and the other. You can have the healthiest mom show up, who has no problems, and she gets sick.

Lara [00:27:16] I think that is one of the scariest things.

Josh [00:27:18] So you kind of always have to be prepped for anything. And it makes it psycho-emotionally grueling.

Courtney [00:27:28] Draining, yes. It’s grueling. What’s the most scary you’ve ever been in a situation?

Josh [00:27:33] , in a, in a labor and delivery. Yeah. Yeah. Labor and delivery.

Courtney [00:27:35] Well, any, because you do so much more than that. Maybe I don’t want to narrow it down that much.

Josh [00:27:39] Like, no, it’s a, it’s a, it’s a, it’s a labor and delivery, real deal. , hemorrhage blood loss, where you’ve done everything you know how to do and it’s not, nothing’s working.

Courtney [00:27:53] Yeah.

Josh [00:27:55] And you. At my previous institution, I could call 10 armies and they would all show up. Now I work in a smaller institution, more of a community hospital. And it’s me and an ER doc. night. That’s it. There may be a medicine person on call taking ER admissions, but there are typically like three doctors at night. And so if you call your partner to say come help, it’s like 30 minutes. So you got 30 minutes to figure something out. Blood loss that you can’t fix.

Courtney [00:28:39] Okay. That’s the scariest thing.

Josh [00:28:41] Is incredibly scary. Right.

Courtney [00:28:43] It’s already a very bloody procedure.

Josh [00:28:46] It can be.

Courtney [00:28:47] Yeah. Because we have more blood. Yep. Right. That’s what I was told. Yes. Yep. You’re right. Okay. That’s why Nathan’s like, there was your blood everywhere. And my doctor was like, it’s because she had more to begin with. It’s not like we were just spraying it everywhere. For sure. Right.

Josh [00:29:03] For sure. Right. Yeah, that’s probably, those are probably the scariest moments where you feel out of control. Because you’ve done everything that you were trained to do, and she’s still bleeding.

Lara [00:29:17] Which is a long list of steps, too.

Josh [00:29:19] It is. It is. It’s super… Luckily, those kinds of things, when you get that far, they’re actually pretty rare. The things that you do in line that you’re supposed to do, something works. , you know, but, but you, I mean, I could tell you a couple stories of, of like, none of that worked. None of that worked.

UNKNOWN [00:29:41] Yeah.

Josh [00:29:42] And, , it’s, it’s frightening.

Courtney [00:29:44] I just think.

Josh [00:29:45] And just saying that out loud, by the way, whoever’s listening, like an OBGYN said they were scared. Oh. Are you allowed to be human? Right. I am.

Courtney [00:29:59] Well, I think so many. This is what we wanted to show people. Right. So many Americans, at least. I mean, maybe other countries, whatever. But you think that medicine is a final thing. It’s a set and cut and dry. This is what happens. You literally go into a hospital. You come out with a baby. Baby and mom all come out. Because that’s what we want to think about. We don’t want to think about, the miracle that it is that two human beings come out of the hospital. You know what I mean? So I think there’s a, it’s good to hear that. It’s good to hear that you’re fully aware of this. None of those things are a surprise. You’re anticipating, you know, that’s, that’s what I want to hear. Like, okay, if I’m walking into a scary situation, I at least want the doctor to be like all, you know, all, you know, all the way around. Yeah. Yeah, I’ve seen things. I know what we’re going to do. Yes, I’m ready. I have 10 backup plans and all that kind of stuff. Yeah. Anyway.

Mandy [00:30:57] So 60 to 85 percent, I found this statistic online, of OBGYNs are sued at some point in their career. I mean, you’ve mentioned a lot of things that could lead up to that. I’m not going to ask you. But if you know anything about that process, that would cause a lot of people to leave their career. So working through that, I think, is a huge success for people when they’re able to separate that and still treat women knowing that there is always something around the corner. Can you talk about that? The stress. Yeah. The stress of that.

Josh [00:31:37] Yeah. You know, It’s it’s probably it is other than. Well, it could be on the same plate as as getting a 3 a.m. phone call about your 20 year old kid that something happened to your own child.

Courtney [00:32:00] Yeah.

Josh [00:32:00] Right. Which. Two numerous to count parents have gotten that call. I’ve gotten the call.

Courtney [00:32:07] Yeah.

Josh [00:32:09] Right. It’s like the thing you fear the most, the 3 a.m. phone call. Right. It’s in this profession. And again, it could be obstetrics or gynecologic. I don’t I mean, I’ve had some difficult gynecologic surgery outcomes that I still feel to this day like I did something wrong. And No one can tell me any different.

Courtney [00:32:38] .

Josh [00:32:38] Right. And some of that is health. Some of it’s actually sickness. OK, on my part. Yeah, sure. I see a therapist. Sure. So.

Courtney [00:32:46] Oh, very good. Yeah, we can touch on that. But you’re a human. You’re a human. I think everybody has that experience. What’s your profession? I did that wrong. you know, or I, and people say, no, no, no, no, no. It was all blah, blah, blah. But you still feel it very much.

Josh [00:32:59] So, you know, I, and, and, and I could be, , maybe one out of a hundred. I don’t think so. I think some people just hide emotion. I don’t very emotional human. And so, , people know when I’m not feeling great, they can just tell you don’t have a poker face. Right. Okay. And so, , When it comes to that, I mean, it is probably the thing that I think there’s probably an idea out there that patients or the general public thinks that, specifically in our field, Do they even care? Do they know what they put us through?

Courtney [00:33:44] Especially going back to the male-female thing. That’s another layer.

Josh [00:33:50] Men don’t know. I will make this very short and sweet. I care. I carry things at night. I don’t sleep at night. I weep. Tears shed over babies, moms, dead moms. I’ve done two obstetric cases of mothers that died. And I will never, it will never not be off of me. Sure. Ever.

Mandy [00:34:21] Yeah.

Josh [00:34:23] And that’s not anybody’s fault. It’s not, it’s not, it just happened to me. And I don’t think I did anything wrong, but it still happened. And I mean, I carry that stuff every day of my life. And yeah, the whole like suit thing is, is, is a challenge in this country because anything can, any outcome can be sued. Right.

Courtney [00:34:48] Yeah.

Josh [00:34:50] And it’s a scary thing because it becomes more of a personal vendetta sometimes. I mean, sometimes you actually did something bad. Sometimes. But most of the time, it’s just, you know, if a kid has a bad outcome, it costs money to take care of the kid, a lot of money. And so would you, I don’t blame people for doing it, because some people don’t have that kind of money to take care of the kids. So some of that’s the reality of the situation, to take care of a kid that has needs, it costs money, right? And that’s how they get it. I get it. It still feels really bad that that your name is is pinned on like insult to injury.

Courtney [00:35:40] You’re already sad about the outcome and terribly sad. Something else happens. Yeah.

Josh [00:35:44] I mean, I have a colleague that we probably talk every single day just and it’s not it’s not necessarily about I need you to like hear me and then fix the way I’m thinking incorrectly about an emotion because emotion is emotion. And we just, we talk just to say, I’m saying this out loud to you so you can kind of hold this with me. And so I’m not hiding the way I feel. Because if I hide the way I think, I start thinking really badly about me. But if I say it out loud to someone who understands, yeah it’s it’s it’s it’s easier to live with sure but it is it’s a thing Mandy that I’ve it’s a once it’s a daily thing for most Obi-Joans to carry some form of like this is hard and it’s painful and there’s a lot of joy. But the hard things and the painful things are hard and painful. Yeah. And they don’t just rub off. You carry them for the rest of your career. I do.

Courtney [00:36:57] Does it affect choices that you make in the future with patients?

Josh [00:37:01] Great question. It’s, it’s, , I mean, one of, one of my sort of most difficult, , births was, was it what’s called an assisted birth where you, you use either a vacuum or a force up to help a baby get out. , And so that was a very challenging birth. I still use those instruments, despite that. Now, the first five or 10 I did after that, I was… Heart rate 200, like, oh no, do a C-section on everybody, right? Just C-section everyone. I think the answer to your question is yes and no. I think the heart rate 200, there’s part of my body that’s trying to teach me something, like pay attention. This is serious. Pay attention. So it’s supposed to do that. But it is hard to train your brain and body to say, do the right thing. Yes, this outcome over here didn’t go like you thought, but that doesn’t mean you did it wrong. It just means that it didn’t go well. Is that yours to blame? I mean, birth is beautiful and traumatic in the very same field. They share the same fence post. It’s beautiful and traumatic. very traumatic. I mean, just think about the idea of a human being fitting through.

Courtney [00:38:44] Yes. Physics or the space planning of this. Yeah.

Josh [00:38:50] So the idea that it is safe and you know, it’s like, you know, what you see on TV is just not reality.

Courtney [00:38:58] Yeah. My OB had a doctor or had a patient who he was not even like his partner was caring for her when she was having a baby, but she took off the belt, the heart heart rate monitor to go to the bathroom while she was in labor. And between that time and coming back, the baby died and nobody knew because it takes a minute to get the things back in the place and all that. So he would not let me get up. I could not. I mean, I could get up, but I had to stay attached to everything. I was not allowed to do it. Cause I was like, Oh, my birth plan was that I wanted to walk and bounce on the ball and blah, blah, blah, blah, all those things, which I am not downplaying either. I wanted to do it. And he was like, I don’t let people do that because of that. He said it was very early in his, Oh yeah. And I was like, okay, when you tell it like that, it makes more sense to me. I don’t want to hurt you. So yeah.

Mandy [00:39:50] Let’s move to the logistics of the practice a little bit. So there’s a lot of ways to practice medicine, and more and more patients will be like, well, I don’t even see the doctor anymore. Now I see the PA or the MP or the midwife in practice. Historically known as mid-level providers, but I don’t think that’s a very perceived term anymore.

Courtney [00:40:08] That does sound offensive to me when you say that.

Mandy [00:40:10] I’m like, oh. We try not to use that term. But just in case someone’s heard that term, that’s what I’m referring to. How does that work in your practice? And what do you feel like has been the boon of that? How has that helped things? And do you feel like it’s detracted at all?

Josh [00:40:27] Yeah, I mean, I think our practice is a collaborative model. That means we have physicians, midwives, and nurse practitioners who work together to take care of humans who happen to be women. And I happen to think my sort of way of thinking about healthcare is that that is probably a safer and better model than a true one-on-one. Because I think people are able to connect with different humans throughout that care model. And potentially you have people who say, well, I saw this or I caught this. Not that I missed it, but you just saw it. One day it showed up and one day it didn’t. That’s right. Yeah. And I think the sort of the older model of doctors have to do everything. Well, we can’t. I can’t do it all. It’s too much. I just can’t. So, I happen to like that collaborative kind of model. It’s what I practiced at my previous institution. That’s what we did. And there’s actually data, at least on labor and delivery units, where if midwives are sort of the lead professional on a labor and delivery unit, the outcomes are better. just generally speaking. And that probably has a range of reasons. I’m not sure there’s one reason for that. And it’s not like just to give the doctors a break, because we still have to get calls from the ER. And we still are involved in labor and delivery, obviously. But I think the idea of having humans connect with more humans to see where do you establish a better relationship, it works better when it’s not just one person, I think. And I can see why there are folks that say, no, no, no, that’s my person. I’m only going to him or her. I will not see anyone else. And I actually have those people in this practice who are like, I will not see anyone else. I will always see him. And, you know, I think the hard part about that is, you know, hopefully it never happens, but it sometimes does, where someone like that realizes, like, I’m just as human as that other person over there who you said you didn’t like. I just am. I just am. And so I may have a bad day. Now, my wife says, you aren’t allowed to have bad days. At least when you’re delivering babies, right? That’s their moment. You can’t have a bad day. And, you know, there’s some some space in the middle there where both are true. Right. I can I can be human and have a bad day and show up for a human.

Courtney [00:43:30] I think that gives you more space in your personal life, emotionally, you know, mental space. You talked about your dad coming home and just you were like, oh, I don’t know that I want that. But then you chose it. Do you think Considering his home life and your home life, I know there’s lots of factors that go into that, but as it relates to your profession, do you think having a team of people has made it more tenable for you to practice medicine? For sure. Okay, so definitely a more positive outcome for everybody involved, patients and doctors.

Josh [00:44:00] I think, I think, I think it, I think it, yes, I think it is, it’s a way better model than that that sort of single care system. And single care system stories are out there that are really good.

Courtney [00:44:17] Yeah.

Josh [00:44:17] I just my my sort of way of flow of life needs a more collaborative care model than than the one on one.

Mandy [00:44:25] All right. Before we get into our speed rounds rounds, I’m going to ask one more question before we do speed rounds. So one of the things about OBGYN is this mass exodus from rural practices where we can’t, the country can’t sustain them. So if we picked you up and plopped you in a rural setting, what’s the first thing that you would do?

Josh [00:44:57] If I’m alone, am I alone?

Mandy [00:44:59] Yeah, you’re alone.

Josh [00:45:00] Hire a midwife.

Mandy [00:45:01] Okay. Great.

Josh [00:45:04] Yeah. And a nurse practitioner. That’s what I would do.

Mandy [00:45:08] Do you feel like it’s the lack of support? I’m sure it’s multifactorial, but as someone who’s in private practice, what do you think is the main issue there?

Josh [00:45:19] In rural health care? Yeah.

Mandy [00:45:20] For OB-GYN.

Josh [00:45:22] Yeah. I mean, the numbers on paper in the women’s health world don’t work.

Mandy [00:45:34] Yeah.

Josh [00:45:36] I take care of- It’s not sustainable.

Mandy [00:45:38] It’s just not.

Josh [00:45:40] I take care of women for nine to 10 months. Okay. And I’m, I can see them for six or seven or eight visits or 10, 11, 12 visits during the pregnancy. And I, I get paid the same. It does. So each, each visit is not a billable visits. That’s actually changing into like six months where each visit becomes a billable visit.

Mandy [00:46:06] No matter how acute or sick they are.

Josh [00:46:09] That’s right.

Mandy [00:46:09] Or healthy and eating. Correct.

Josh [00:46:11] And that’s for a general OB-GYN. If I actually send them for a consultation to a higher level care, they can bill them a consultation fee. Right. But I don’t. Right.

Mandy [00:46:21] Nor could you.

Josh [00:46:22] Nor could I. That’s right. And so when you take that and then you move into more rural areas where there is a higher population of underinsured patients, then that number makes even less sense because the reimbursement from that insurance company is less. And so the way to do it or to survive is you have to see three or four times the number of patients. compared to a middle downtown Nashville practice seeing only commercial insurance. And it’s just, it’s not sustainable. You can’t live as a human like that and do it safely. And then you just break even by the way.

Lara [00:47:14] And you’re tired.

Josh [00:47:15] And you’re exhausted. And you have no life. And your spouse is ticked. And your kids don’t know you. And not to mention, you don’t get to be your own human. You don’t get to do the things you want to do. And that’s sort of the MO. The more rural communities, I would say in Tennessee, but probably in most states, that’s the concern. You cannot financially sustain a practice model that requires people to just see more and more and more. And instead of seeing patients over a 30-minute window, you back it up to 20, then to 15. Because that’s the only way you can make it work financially is to see more people do more things. Right. And everyone suffers, I think. Yeah, for sure. Yeah.

Lara [00:48:05] Yeah. Sort of a reflection of what we value. Yes. Not always women’s health in rural areas. Right.

Courtney [00:48:11] Yeah.

Josh [00:48:13] Yeah, I mean, I don’t know exactly what I paid my gastroenterologist to do my colonoscopy, but it took him about 15 minutes.

Courtney [00:48:21] Yes, right. And I didn’t even, I said hello, and then I was asleep. Seriously? Yeah.

Mandy [00:48:26] Yeah, I know, right. It’s frustrating. And you saw someone for months.

Josh [00:48:30] Or I do a tubal ligation on somebody that is not a great surgical candidate, so I take some risk, and I get paid a couple hundred dollars. Right. And that just, you can’t, you have to do hundreds of the surgeries to make it work. And I think on top of that, we didn’t really, we sort of navigate or negotiated the space of lawsuits and whatnot. But as far as like, you know, malpractice and what it costs, I think we’re number two, maybe one with neurosurgery. I’m not sure who wins out there.

Lara [00:49:06] We’re always up there. There’s a little teeter at the top.

Josh [00:49:08] Yeah. So we carry that as well. And yet the reimbursement for what we do. You know, there’s a lot into finances when it comes to women’s health, especially labor and delivery. Lots of hospitals want to keep the NICU sort of, you know, let’s have better outcomes. Let’s take care of moms better so that they have better outcomes, which means they go to the NICU less. But you got to fill the NICU because that’s how we make money.

Mandy [00:49:41] That’s how we make money.

Josh [00:49:43] So you can imagine from a human perspective, if I’m in the middle of that space trying to do the right thing, You’re penalized. Yeah, I have lots of things that are pulling.

Lara [00:49:55] A lot of levers going.

Josh [00:49:56] Saying, ah, this is my priority. Yeah, but this is my priority. And this is mine. And this is mine. And eventually, if you’re just a good human, you do the right thing.

Mandy [00:50:06] You just do what you do. Just do the right thing.

Josh [00:50:08] And if they go to the NICU, great. If they don’t, great. Great. But again, you have to live in that space day in and day out and it can be exhausting.

Lara [00:50:18] You have to get those spreadsheets. And you’re like, I don’t care. Okay, speed rounds. Speed rounds. This is the fun part. Quick answers. Quick. Not too much thought. So are you superstitious?

Josh [00:50:34] No.

Lara [00:50:35] Okay. I feel like so many of us in medicine are. I’m terribly superstitious. Not at all. Okay. What other specialty do you have to ask for help the most from?

Josh [00:50:45] General surgery.

Lara [00:50:46] Okay. Okay. Is that more on L&D or more with GYN? GYN. GYN.

Josh [00:50:50] Okay. And that’s mainly because that’s who I am.

Lara [00:50:53] That’s who’s there.

Josh [00:50:54] I don’t have a GYN oncologist. I don’t have a mentally invasive gynecologist surgeon. I don’t have that. That’s who I have.

Lara [00:51:02] What’s a word or phrase you end up saying multiple times a day?

Josh [00:51:06] All things.

Courtney [00:51:09] The word’s all things?

Josh [00:51:10] All things.

Courtney [00:51:12] Give us an example.

Josh [00:51:13] Wait, you said this was like rapid feed.

Lara [00:51:17] We want to know more.

Josh [00:51:20] You do want me to?

Lara [00:51:21] Yes. Give us an example. How would you respond to all things?

Josh [00:51:26] I’d say over the last 10 years, I have navigated spaces where I am confused about why said thing happened. And I think I’ve sort of lived in this space of like, I need to reduce the number of bad things happening and increase the number of good things happening. Because that’s the way it’s supposed to be.

Mandy [00:51:47] Ideally.

Josh [00:51:49] And if the number of bad things happening are, they tend to be, this is the way my mind thinks, reflective of something about me. As opposed to, no, it’s just a bad thing that happened.

Lara [00:52:04] Yeah.

Josh [00:52:05] And where my counselor and some friends of mine have sort of helped me navigate is actually they share the same fence post, and they have to.

Mandy [00:52:17] The good things and the bad things.

Josh [00:52:19] So they all belong.

Mandy [00:52:21] All things belong.

Josh [00:52:23] I don’t like that.

Courtney [00:52:25] That’s a Mr. Rogers moment. You can have two emotions at the same time.

Josh [00:52:30] I understand it’s too mysterious for me to navigate. Why a baby that died or got hurt or a mom that died has to belong. I cannot explain that. I won’t. I can’t even think. But I don’t know how else to do it other than to have belief that it can be mysterious that they all belong. Everything belong. All things. That’s what that means.

Lara [00:52:59] That was deep. Theological. I know. I’m glad we got the expansion on that. Who in your inner work circle could you not live without?

Josh [00:53:08] A name?

Lara [00:53:09] Or a position. A title. A role.

Josh [00:53:11] Wait, say that again. Sorry.

Lara [00:53:13] Who in your inner work circle? Who can you not get through your day without?

Josh [00:53:17] My partners. OK. My doc, my physician partners.

Lara [00:53:20] Your colleagues do what you do. What other medical specialties gross you out? I think we all have one.

Josh [00:53:30] Gross.

Lara [00:53:31] So mine’s anesthesia because I can’t do secretions. Ortho.

Josh [00:53:35] Blood?

Mandy [00:53:36] No, the bone. Sorry. Like if someone comes in with a dislocated toe, I’m on the floor.

Josh [00:53:42] Probably GI. I don’t like poop.

Lara [00:53:48] Fair.

Josh [00:53:49] Fair. Probably poop. They’re in poop all day long.

Lara [00:53:53] From start to finish. Yeah, I know, right? Would you encourage your children to pursue a career in medicine?

Josh [00:54:00] Of course.

Lara [00:54:01] Okay. All right. And do you have a joke about your area of medicine? That’s clean. No. No? No, I don’t.

Mandy [00:54:11] There’s so many OBGYNs.

Josh [00:54:13] I’m sure there are.

Courtney [00:54:13] I just don’t have any. I would love to know. None in your back pocket.

Josh [00:54:17] None in my back pocket.

Courtney [00:54:18] I had a question that I thought, did you deliver your own children?

Josh [00:54:22] I delivered my first kid.

Courtney [00:54:25] Okay. And then decided no. Or did your wife decide no? Yeah.

Josh [00:54:29] My first kid was 34 weeks and she broke her water.

Mandy [00:54:35] Oh, like you didn’t mean to deliver her.

Josh [00:54:37] No. We got to the hospital and I’m like, this is, this is not real. And the nurses are like, it’s very real. She broke her water and she’s five centimeters. And I don’t know. I think we got there at like 6 a.m. and by noon he was born. Wow. So the attending rolls up in there and I think the nurse had told him that I was a first or second year med student.

Lara [00:55:01] I think I was a second year. Oh wow.

Josh [00:55:05] He’s like, he handed me the gloves and I was like, I didn’t have a clue what I was doing. I was a second year med student.

Mandy [00:55:11] I hadn’t touched anybody.

Josh [00:55:13] Put the gloves on. So put the gloves on.

Mandy [00:55:15] I’m just going to say, Josh, there’s no way you were ever going to be anything other than an OBGYN. I mean your dad, OB-GYN, your mentor, OB-GYN.

Josh [00:55:22] So I delivered Marshall. Eli, my second, was breech. And she didn’t want to do a version. So we did a C-section.

Courtney [00:55:32] I like that sound for division. It works. And then my third, Gabe, I was a second year resident.

Josh [00:55:42] , in training and I just knew too much.

Mandy [00:55:46] Oh yeah.

Josh [00:55:47] So I was like, I’m, I’m just the dad. Oh, I told them to turn the monitors off.

Mandy [00:55:52] Okay.

Josh [00:55:52] I don’t want to look at the tracings.

Mandy [00:55:54] So they would type them at the nurses. Yeah.

Josh [00:55:57] So they had them outside, but in the room turn, turn the monitors off.

Courtney [00:56:01] Nothing. Oh, that would have been nice.

Josh [00:56:02] And then when the birth happened, it was one of my favorite attendings who did it. , I just said, I’m, I’m holding, I am dad.

Lara [00:56:12] I’m on this side, I am dad. Isn’t that funny, the more you knew at each stage, the less you wanna be a mom.

Josh [00:56:19] So I delivered Marshall.

Lara [00:56:20] Okay, all right, that’s fun. All right, final question. If you could do any job in the world outside of medicine and still support yourself.

Mandy [00:56:28] You had to.

Lara [00:56:29] Yeah, you couldn’t do OB-GYN anymore, what would it be?

Josh [00:56:35] I think, My wife Brandy and I’s sort of dream job, whether or not it would like financially support us, would be to create a space where It’s either like, I mean, it’s kind of still, you know, fizzling a little bit, whether it be like a coffee shop kind of place or a B&B, something like that, where people came back to say, like, I want to go see them.

Lara [00:57:10] Yeah.

Josh [00:57:11] And we remembered them. And we say, oh, yeah, how’s your house? This, that and the other. And we sat and had breakfast with them, had coffee, had a drink at night or something. , something like that, whether it be here or, you know, on a beach somewhere. Yeah. I don’t I don’t know, but something that created tons of space for humanity to be together. Something like something like that. Yeah. We still talk about it often and we’re nowhere near it.

Lara [00:57:41] Maybe that’ll be your retirement gig. There you go. You could host people at…

Josh [00:57:44] I have a long way to go. My little girl is only 11, so I have some work to do, unfortunately.

Courtney [00:57:48] But that’s the kind of OBGYN I want to have. Somebody who wants to be hospitable. Like, I want a doctor that, like, likes people.

Josh [00:57:55] Yeah.

Courtney [00:57:56] And it sounds like very much, I’m just meeting you, that you like people.

Josh [00:57:59] Well, I think the thing I love about my job is helping to create spaces where women can feel like, I can trust this guy and his team of people that work with him. Like, I don’t know what it is, but I’m gonna keep coming back to you. You create a space that’s comfortable, and I can say anything. And I can say, I might disagree with you. It’s okay, I can disagree with you, you can disagree with me, and we can still be friends, kind of thing. So yeah, I think that’s true.

Courtney [00:58:36] Okay. Well, thank you for being here.

Josh [00:58:39] Thanks for having me. It’s been so great.

Courtney [00:58:40] Great. So yeah, y’all make sure you’re following us on Instagram and we will be back soon.

Mandy [00:58:47] Bye. This podcast is intended for informational and educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. The views and opinions expressed by the host and guests are their own and do not constitute medical guidance for any individual case. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or health concerns. Never disregard professional medical advice or delay seeking it because of something you have heard on this podcast. By listening to this podcast, you acknowledge that the hosts, guests, and producers are not responsible for any decisions or actions you take based on the information discussed.