You Must Be Some Kind of Therapist

Swell AI Transcript: 137. Nikki Johnson FINAL.mp3
Nikki Johnson:
Feel empowered to be able to ask those questions and to be able to use your instinct and your gut as a parent to make that decision for your child, because that is your responsibility. That child is your responsibility. They are in your hands. You are the only one who has to answer for what the child becomes when they grow up. Have they developed into a healthy adult human being by the time they are done with your care? You are the only one who has to answer that question. No one else has to, even though they may try to. The school may try to take it. The doctors may take it. The state may take it. You know, the social workers may try to take your child away, depending on where you are. But those people in the very end don't have to answer to that child because your child's going to look at you to see if you did the right thing. So you have the ability to make that decision. That's the best for you and your kid.

Stephanie Winn: You must be some kind of therapist. Today I have the pleasure of speaking with Dr. Nikki Johnson. She is the co-director of FAIR in Medicine. She's also a pediatrician, not currently practicing. Like many of my brilliant guests on this show, she's one of the sorts of providers that you wish you could have for your family, but because of her ethics, She has difficulty working in the field as it currently stands. So I'm looking forward to Dr. Nikki sharing her expertise today with families who are wondering why it's so hard to find trustworthy providers, especially for their kids, but also for people of all ages, as well as some of her wisdom on empowering yourself as a patient when it comes to healing and prevention. So Dr. Nikki, welcome. It's so great to have you.

Nikki Johnson: Thank you so much, Stephanie. Thank you so much for having me and thanks to all of your guests who have given their time to take a listen and watch and hopefully get something from Hearing Me Sweet.

Stephanie Winn: Well, I hate to be redundant, but like I said in the intro, I always feel like the therapists and health care providers that I have on this show are exactly the sorts of people that you would want to see as a patient. And yet, because of their ethics, are really struggling with the current state of the mental health field or the medical field. And some have left practicing altogether. We're chatting a little bit about your professional background. Could you give a brief summary for listeners of where you're coming from and then how you ended up where you are currently?

Nikki Johnson: Yeah. So brief summary. Just for everybody to know, I am living in Northeast Ohio and attended medical school in Cleveland, Ohio. Also went and did all of my training affiliated with the same medical school that I went to. Worked only at academic medical institutions. My specialty that I trained in was internal medicine and pediatrics, which is combined, but I ended up going into subspecializing into pediatric intensive care, which is taking care of the sickest of children from newborn states all the way up to adults with, you know, young adults with congenital heart disease and with some young adults with childhood cancers as well. And then I was very, very subspecialized after a couple of years of completing my training and going into ICU practice and then becoming also a mom. Myself, I ended up working in what we call pediatric procedural sedation. which is functioning like an anesthesiologist, but outside of the operating room. No kids were getting, you know, gas with me and they were not getting breathing tubes placed for these procedures. These are procedures where they needed to hold still or they were completely uncomfortable procedures that it was best for them to not be aware during those procedures. I absolutely loved what I did. I love the staff that I work with. I love my patients. And I got to know people all throughout the hospital systems. But the job that I did required being in a hospital, unfortunately, because of the procedures that we did and the emergency setup, even though it was extremely rare for us to require needing emergency help, it still was always the safest route to be near a place where they could get intensive care or emergency services. So, you know, when things started to get tough for me to practice, and we'll go about that in a minute, it was difficult for me to decide to leave because I knew that it was going to be a struggle trying to find a place to go. But in 2022, I decided to walk away and never go back to clinical medicine. And a big part of that reason was because I had been a consistent advocate for not only for patients, but also for physicians and nurses. And I find it very funny that you use the term provider. And most people who use the term provider don't actually understand why it's actually used and the origin of how it began to be used. But that is actually one of the reasons that frustrated me about the current practice of medicine and the way we do healthcare in the United States, period. It is very corporatized. It is very industry related. And the people who began to use the term provider to call physicians and anyone who was basically treating patients. Providers, it was done by insurance companies and pharmacy benefit managers, which are these big agencies that serve as the middlemen between insurance companies and physician's offices and pharmaceutical companies and that kind of thing. And they're the people who actually put the list of people in the directory. When you go and buy an insurance plan or what I call, you know, a health plan, those people are listed. in a directory for you to pick and they will be covered by the insurance carrier that you use. And they decided to use this term provider. Some institutions are even calling us caregivers now. And it is a way to lump everyone in together so that we are viewed as basically one in the same. Our skills and capabilities are pretty much lumped in together. And we are basically just the people who treat you and take care of you. But it is a way to separate us as the people who are kind of generating the revenue from your illness and our care of you and our labor. And so to me, I think of it as a very degrading term. It does have historic origins that are also very negative. And during Hitler's reign, the Nazis did call Jewish physicians providers as a derogatory term. And so that piece of history is there too. And that is why my Twitter handle and most of my social media is not a provider MD for that reason. It is, it just really highlights the problems in our healthcare industry that it's so related and so conflated with the corporate and industry side of things, and has gotten so far removed from the basic unit, which is the physician, nurse team, and the patient, who should be the center. And so that had been one of my struggles for many, many years, trying to figure out where we went wrong with that. And asking questions, advocating for changes that would make patient-centered care the focus were some of the reasons that made it difficult for me to continue practicing medicine.

Stephanie Winn: See, I thought your handle was just about the fact that you quit working directly with patients, but there's this this whole background. And I listened to an interview. I'm sorry, I forget the guy's name. He's from New York, though. You interviewed with this guy from New York and you talked about, do you know what I'm talking about? I don't remember. You don't remember? Okay. I mean, he had like a very distinct New York accent, but you were talking with him about how because of the way the managed healthcare system operates that there's an incentive to have providers that aren't MDs, right, so more like the nurse practitioners, and also some weird stuff about how doctors are not allowed to own hospitals because it's considered a conflict of interest even though The health care field is riddled with other conflicts of interest that aren't addressed. And I think something you mentioned in that interview was that there's been a shift over time in terms of the amount of doctors who work independently. And so part of what I'm understanding about your background is that While you still found working in the field sustainable, during that time you became highly specialized in a type of medicine that really cannot be practiced outside of a large, well-resourced facility. And so it's not like, I mean, I do know a handful of doctors who work independently, but the type of specialty that you did just would not make sense for a myriad of reasons, including, you know, the equipment that you need and the situations in which you're treating people. So it's really sad, though, not being able to practice anymore. Do you want to tell people what the final straws were for you?

Nikki Johnson: Yeah, so in the beginning when I started doing advocacy, I actually found my people online and I found people on Facebook. And, you know, just like everybody else, we get into groups, you know, and cohorts of people who think like us, right? And so I was finding physician groups of people who were having some of the same issues that our time with our patients was limited basically by insurance or by these people who were in our, you know, corporate office or, you know, the administrator working for the hospital basically saying that you actually have to have, you can only spend, you know, this many minutes with a new patient and this many minutes with the follow-up patient or urgent, you know, visit. And that time grew shorter and shorter throughout my training. You know, I graduated medical school in 2001. And even during, from the time I started medical school to the time, you know, I finished my, all of my training, that number changed. And I, so, you know, a large group of us were starting to see that we had lost control of how we took care of our patients. And I remember going into medical school thinking that I was going to be a family doctor. And I wanted to, some of my models and role models were people who actually took an hour with each patient, with each new patient, old patient, or even longer. And people were sitting in their waiting rooms, not complaining and hemming and hawing because they knew when their turn came that the doctor was going to give them just as equal amount of time spent with them to discuss everything that they needed. And that's what I want it to be. I want it to be that kind of doctor who really listened and took the time to get to know my patients, who sat down, who knew their families, And as I was going through training, I just started seeing that we didn't have that ability to do that anymore. And then there became fewer and fewer neighborhood practices, and more doctors were opting for working for these large health systems, which, you know, they made enticing. I mean, of course, you're gonna finish medical school with hundreds of thousand dollars in debt, And you're going to be worried about how are you going to pay off that debt? And how are you going to make life and ends meet while you're doing that? And on top of that, continue to learn how to take care of your patients and do the right thing by your patients. So, well, who wouldn't want to have some of that worry, you know, eliminated by having, you know, your benefits taken care of, your salary almost guaranteed, right? And then, you know, you, the patients just came to you, you know, you weren't really depending on somebody to refer you, you know, for refer patients to you. So that was, you know, kind of the easy way route. But, you know, as I was going through my training, I found my niche, you know, was not necessarily in family family practice, but that was one of the driving reasons why I chose to go into a subspecialty is because I thought that primary care was actually very, extremely difficult, doing it under those conditions where people were limiting the amount of patients you could see. And on top of that, you weren't getting a heavy reimbursement. So you could spend an hour, two hours with the patient, trying to keep them from going into the hospital. you know, trying to keep them from being sick, trying to set up resources for them so that they could do things, you know, from home and get healthy at home. And all of that time wasn't being compensated by insurance companies. So people who are listening don't really understand the payment structure. The incentive structure is based on things that we do to people. So the more tests that we order, the more procedures that we order, those things get reimbursed by the insurance companies. And I'm not saying that physicians are driven by that, but the industry itself certainly is. That is the incentive structure. That's the way it works. And so you can have the most caring physician, but if their time isn't getting compensated, you're going to eventually burn out on that. And so anyway, so I didn't go into that and I, you know, became a subspecialist and I did that because I absolutely love, you know, I ended up loving what I did. You know, I absolutely love talking to people and caring for people when they were at their most vulnerable, which is when their kids were critically ill. And so that was why I did that. I mean, I like the adrenaline rush part of that too. Like, you know, you have to, you have to be kind of a little bit of a crazy psycho to do some of those things. So I think, But yeah, I enjoyed that, but it became less enjoyable the more I learned. And the more that I discussed with people online, people were having difficulties. You know, they were just expressing these frustrations and there were fewer and fewer people who were actually listening and doing anything about it. So I found a group of people who, you know, I distinctly remember asking the question. It was somewhere around 2016, 2017. We're all in this group. We're all a group of physicians. We're complaining about this stuff, but who's going to do something about it? Who's got solutions? How can I sign up to work? And that's kind of where that started. And so I started working with different grassroots groups, physicians working together, physicians, practicing physicians of America. And then I ended up forming my own group, which is called Physicians for Patients. And at that time, that group came about because we were learning that the name provider was allowing so many other professional health professionals to come in and really start taking these roles. And that stemmed from the Affordable Care Act, believe it or not. So the Affordable Care Act made a large provision. Obviously, everybody knows that the goal of the Affordable Care Act was to get more people insured, right? And so everybody thought, yay, that's a great thing. More people will be insured. They can go and take care of their preventive health and, you know, keep from getting sick, and they don't need to go in the hospital in the first place, right? So, okay, of course, well, then to solve that problem, actually have to have more people who are available to keep people in preventive care. And so the people who were writing that legislation decided that those people were not doctors. Those people needed to be nurse practitioners because, Nurses could be trained a lot faster. And the nursing lobby basically said that, excuse me, nurses are just as good as physicians at doing primary care. And many of the physicians were like, wait a minute. No, primary care is like one of the most difficult Specialties, just like I was saying before, you have a limited amount of time. You have to diagnose people with things that, you know, it could be, they come in with some big symptoms and it could be a long list of things. And you could miss things with, if you're only given 15 minutes for a new patient or even just, you know, even 30 minutes for a new patient, you could miss things. And so it's very difficult. And if you're in a rural area and you don't have specialists, you don't have testing facilities, right, you have to really know how to do a great physical exam, come up with a long list of what we call a differential diagnosis, and decide what to do. And so it's difficult. And then we started, people started sharing stories about what was happening. They were getting referrals from these, people who were not physicians, who were licensed to, you know, basically practice medicine. And we started seeing states pop up throughout the country that were allowing this expansion of scope in nursing practice. And I have nothing against nurse practitioners. I have nothing against physician's assistants. I've worked with some phenomenal ones. And I know that there are some who actually can do primary care very well. But the majority of them who truly admit that, who truly understand that, and who are good at it and great at it, understand that they have limitations. And they understand that they need some sort of supervision by someone who's had not only more experienced, but a lot more, like a broader knowledge base. And that typically is a physician. Now, and I'm also not saying that physicians are perfect because physicians get a lot of things wrong too. And, and so, so this is a tricky slope, but the Affordable Care Act only focused on expanding the scope of practice of nurses. It did not include it in it, any provisions to allow physicians to get through, one, get through medical school faster, but two, to also even, you know, provide funding to train more physicians. That funding comes through Medicare, Medicare funding, and that was determined by Congress a long time ago, and they capped that off back in the 80s. And so they've had multiple bills to try and increase that funding so you could you know, get more people trained in rural areas and all these things, a lot of those bills never passed. They never leave committee. And so they did not include that in the Affordable Care Act. So you started seeing all these, like, nurse practitioner schools that were popping up, like, online schools. You can get your degree, you know, in three years. You go through nursing school and you finish the nursing school and you're done and, like, get everything done in four years. And I mean, like, it's just insane how fast they were turning out. And then we were seeing this in the face of a growing nursing shortage as well. So now we're seeing patients in the hospital who we don't have enough nurses to take care of sick patients in the hospital. Nurses are taking care of five patients, and in the ICU, two and three patients. And so these were dangerous levels where patients weren't really getting seen, but hospitals were compensating for it by adding more like people who were lesser skilled. So now you got somebody who can come in and take your vital signs, somebody who can administer your medications or, or, or, or right. Who just, and then they, they write it down, they go out of the room. And so the nurse is having to do less because they have to take care of more patients. Right. And so All of these things really did come from the Affordable Care Act. And so what we, what our group, Physicians for Patients, thought that we needed to do was educate people so that they understood that there was a difference between the people who were going to take care of them. And we shouldn't all just be called providers, that you should know who these people are on your medical team taking care of you. And so that was kind of our basis. And yeah, we did want to stop scope expansion, but we really, really wanted transparency. Number one, that was our huge deal. That was our big, big project. But then we started seeing you always have to go back and figure out what happened and why it happened and why this particular method was used in the Affordable Care Act. Well, the Affordable Care Act also at the time, as you mentioned this, cut the ability for patients to get catastrophic care. on catastrophic insurance plans, and it also cut the ability for doctors to, it made it illegal for physicians to own hospitals. So no new hospitals could form where physicians could own them. And so we'd already had transparency laws where physicians have to, you know, disclose every year, you know, any financial conflicts of interest. So if I'm doing research for a pharmaceutical company, clinical research, I need to expose that. If I go and have a dinner with a Pfizer rep and they pay for the dinner, I have to disclose that to CMS. That's fair, absolutely. We 100% agree that it's fair, right? You as my patients should know that, that I'm sitting down with people who may have an interest in influencing my care of you. You should know that. But the main people who were making the big money off of medicine, the pharmaceutical benefit managers and the group purchasing organizations, these people were exempt. and still are, exempt from those transparency laws and rules. And so once we started figuring out then, finding this out, we started figuring out that who was making the money and who was driving all of these major changes in healthcare. And so that's how I got involved with what's the large, the coalition that's called FridaCare. And we wrote our first white paper. It's a roadmap to lowering the cost of reducing waste and medical and health care. And then we wrote a second and published a second one. And the first one was 2018, 2019 published. And then the second one was 2022. And we called out the American Hospital Association as we called out all of these big industries. So all of the people that I'm working for now, are getting called out and they're not liking it. All of these major medical organizations are being tied and linked to all of these financial interests through work that we're doing. And other people were doing this work too, but we were kind of putting it all together in one place as our, you know, as our big, you know, idea on how to, you know, kind of get medical practice back between the patient and the doctor and to really lower health care costs.

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Nikki Johnson: And so all this time, I'm fighting against things that, something that we call maintenance of certification, which is a requirement that hospitals have for physicians and insurance companies do too, to make sure that we're continuing our education and, excuse me, and say that we're competent in our field. Absolutely, we should be able to be demonstrating each year that we're competent, especially when we have patients' lives in our hands. Absolutely, we should be doing that. But this maintenance of certification is a trademarked, or MOC is a trademarked product that comes from our larger medical organizations that are in cahoots with one another. And they were sort of forcing us to do it even though they were saying that it's voluntary. They were forcing us to do it because our hospitals and employers were requiring us to use that product and there was no alternative product. And so we started fighting at the state level that they were basically restricting our rights to practice. Our hospital association in the state of Ohio fought against that. So my employer knew this. I mean, I have my freedom of speech. They can't restrict, you know, things that I say and things that I fight for, but they are also going to know that I'm doing this, right? And so that sort of started things, and I knew I was on the radar of people. And I was always very upfront, and I told them. when I'm going to Washington, D.C., when I'm going to the statehouse, this is what I'm going to be advocating for. My name is on this paper, this kind of thing. And so they were aware of it. I didn't face any you know, kind of like an obvious blowback. But I did start to notice that I was under the microscope more. So, like, little things that would happen, even if there was sort of a minor, like, problem with the patient or a minor, you know, interaction with someone who disagreed with me, that was reported to my supervisor, that kind of thing. So, I was, like, having to explain things a bunch of times. So, to clear my name. So, that just sort of began things. Once COVID didn't necessarily start it, but in 2018 when the American Academy of Pediatrics published its position on gender affirming care. That was when I started to be vocal about that. And also the American Academy of Pediatrics was very politically involved. They were getting louder about their political leanings once Donald Trump became president after 2016. And mind you, I didn't vote for Trump in 2016. But when I started seeing medical organizations start to put their own like kind of political stamp on who they liked and who they preferred or who they didn't like, and especially when the American Psychiatric Association, you know, said, declared, you know, Donald Trump is mentally ill or, you know, I mean, I can't remember the exact term. I was just like starting to be hyper acute to what our medical organizations were doing. In 2018, when the AAP put out its position statement on gender affirming care, without having really any, what appeared to not have any thought into the unintended consequences of that type of care, and not really, to me, advocating for true informed consent. That's when I pretty much lost my mind. I thought that I was taking crazy pills. Like what is happening to medical organizations? What are we doing? We're going against every single ethical code that I learned and trained under. So I left the American Academy of Pediatrics then. It was also around that time I was still active in my state medical society. I was, you know, lobbying for some bills to kind of, you know, do more education, that kind of thing. A medical student group decided to put forth a bill, a resolution at the state medical association level, a resolution that will require the state department of education to introduce sex education in preschool. And when that resolution got voted in with, and my voice and maybe two other voices were the only people who were arguing against that in a live, like annual conference, that's when I knew, like we were outnumbered. The people who were like, like team sanity to me. was outnumbered and I was going to struggle working from within those types of ranks. And then COVID hit, you know, it was kind of around the same time COVID hit then too when I was having trouble trying to figure out why we were masking toddlers of all people and how we were mandating vaccines on children that we hadn't really studied. and we were outright dismissing any claims of acute myocarditis in young people. I lost all of my respect for people who trained me, people who taught me, and people who I thought were smart and thoughtful and ethically driven. And I became depressed about medicine. And I'm going to cry thinking about this right now, because it was a loss for me. And it just became really difficult to work in that environment around people that I felt like I was constantly pushing. for people to kind of think through these things and like, kind of, can we just go back to normal the way we do things that we read and we learn and we study and then we make decisions and we are thoughtful, especially about children. Like we're subjecting children to things that could have lifelong consequences on them. And we're not even having the debate about it. We're not allowed to debate about it. Our medical organizations are just flat out saying, no, this doesn't exist. And there's this consensus that really was never developed as a consensus because we never debated about it on how to do this. And it just became difficult to go to work every day. And my husband kept telling me, You need to leave or you need to find a different way to deal with this. Like either like not, not fight against it, just go to work, do what you need to do, and then come home, take care of your family, that that's important to you and all, you know, that kind of thing. And, and I couldn't, I couldn't do it. And, and so I took a leave of absence in August of 2022 and I never went back.

Stephanie Winn: Oh, Nikki, thank you for sharing your story and your heart with us. That was really touching and heartbreaking the way you brought it home emotionally there at the end to what's at stake and what's being lost. And I feel that too. I feel the sadness over the fields, losing the best people, you know, like I said at the beginning, like you are the sort of person most parents would would want seeing their kid. Yeah. And it's it's just so heartbreaking. This whole what happened with the AAP is It's probably its own episode and if anyone has particular expertise on what the hell happened with the AAP and wants to come on the show and talk about that, please reach out to me. There's so much you shared that I want to circle back to and one is this concept of perverse incentives. You were talking about a few things that brought that up, right? how insurance works, what it reimburses, the pressures on physicians to limit their services, you know, that idea that Thomas Sowell quote, no solutions, only trade-offs, that, you know, the ACA, the mission on the surface of something like the Affordable Care Act sounds very good in theory, but what happens when it's implemented, what gets lost or compromised in the process in terms of the quality of care, But I do want to come back to this concept of perverse incentives, because when you were talking about insurance, I was comparing it to my own experience as a therapist who once worked for a large company where we build insurance for mental health services, because that's what I can relate to. And just to give one small example, and this is for, you know, primarily I'm showing this for the non-professionals in the audience, people who themselves I mean, we are all patients, right? We've all seen a therapist and or a doctor at some point in our lives. And in my experience, a lot of patients don't understand how insurance works. And fair enough, I was somebody who built insurance and still was confused by it. It's designed to be labyrinthine. But I was taking insurance, you know, every insurance company paid different rates. That's one thing, right? And that right there is a perverse incentive because although you were supposed to say either I'm open to new patients or I'm closed to new patients, period. The truth is people can always appeal to you and say, hey, will you take this patient struggling with this particular issue? I think you'd be a good fit because you're great at helping people with divorce and this patient just got divorced, right? Or something like that, right? There's times when providers reach out, excuse me, providers, I'm just going to end up saying that, but mental health providers reach out to other mental health providers and saying, hey, Can you take this one person? I think they're really up your alley. And if there's some knowledge of whether they have an insurance payer that's on the low end or the high end, that's something that could theoretically affect a therapist's decision as to whether to see a patient or not. It also affects for therapists with more control over these things, like those in private practice, do they want to get on that panel or not? Right, so if someone has a particular health insurance that's through their employer, they didn't choose it. That information is hidden from them. They don't know that, oh, I happen to have an insurance provider that pays therapists some of the lowest rates. So although they're There appears to be a directory of mental health care providers. These people, they're all ghosts. Like half of them are deceased or no longer practicing, no longer taking this insurance. So that was one, right? And another that I've thought about is the fact that individual therapy, family therapy, group therapy, these things have different payout rates. And some health insurance providers were putting pressure on therapists to have to create extra hoops to jump through if they wanted to justify billing for a 60-minute rather than a 45-minute appointment. And then oftentimes family therapy would pay less. Wow. And that is something that really always bothered me a lot because I think it should be the opposite. Family therapy, there's more people in the room, more risk of high conflict. Although there was like some little code that you could bill as an add-on if it was like a high conflict session, but people rarely use that and paid like, I don't know, $5 or something. Ideally, you would want to spend more time with a family in family therapy. And I've looked a lot at the sort of descent of the field of marriage and family therapy because when it started, when the AAMFT was founded, American Association of Marriage and Family Therapy, was founded in the 60s when most people were married and had families. And the culture has shifted so much away from even valuing marriage and family. And then if you look at the fact that therapy has become much more focused on the individual. And so it's just adding insult to injury that a therapist might have in mind for their patient. You know, I really think it'd be helpful to bring in this family member they have a lot of conflict with. That might be the last thing in the world my patient wants, but if I can get them to see the value of actually bringing this person here to talk it out, this could really help them overcome some major milestone in their mental health recovery. And I'm not saying that all therapists are so unethical that they would say, but it pays less, so screw it. I'm just going to keep doing individual therapy. But I am saying that it feels like a problem to me that that incentive is there at all to prioritize one service over another when that might not be a reflection of what's in the patient's best interest. And that's just my little glimpse from having worked in the mental health field. Obviously, As an internal medicine doctor or a pediatrician, there's many more services to bill for and it just gets more and more perverse and again, more and more distracting from what are we here to do? What's our mission? It's to help the person in front of us.

Nikki Johnson: Yeah, yeah, exactly. And so, well, you know, and that's interesting too, because even in the field that I was working in, and just anesthesia, we did, our billing was similar to what anesthesia does. So if you go to the operating room, obviously, and you have to go to sleep for something, or, you know, have to get like a spinal or epidural anesthesia, whatever it is, the doctor still needs to come in and talk to you. Find out your medical history, right? Find out what medications you're using. Find out whether or not you want to go to sleep completely at all, right? Or just, you know, maybe just put that limb asleep so they can just do the surgery on that piece and then you can be awake during it. Whatever way, they're talking to you and basically help working with you to find out what's the best plan to get you through this safely, right? And, you know, and obviously get the care that you came there for. That part can take an hour or longer. That part we don't get paid for. The part that we get paid for is the time from the minute we start giving medication or in the anesthesia world, the gas to get you to sleep. from the time you're asleep, from the time to the time that I am with you while you're waking up. That is the time that gets billed and reimbursed. And then even then, it's sort of a flat rate, you know, of time. So when you're trying to, when you have people who have gone to school for many, many years, wrapped up hundreds of thousand dollars of debt, delayed family, missed weddings and, and, you know, birthdays and events at their kids' schools, and you're reducing the amount of time that you're getting them reimbursed for their expertise, you're pretty much telling them that this is how much, that they're not worth enough. You know, they're not worth all of that that they went through. And then when you start to allow other people who didn't go through all of that education and training to do the same work and say that they're the same and then lump them all in there the same, you know, code name, that makes people not really feel valued. And that's just human nature, period, that people would not feel valued in that way. And Are there people who, yes, who would make decisions based on how much they're going to be reimbursed for? Yeah, that's human nature, too. But just like I find in any other field of people, the people who really, really got into it to care and try to make people healthier and more comfortable in their lives, most of us are not going to make our day-to-day decisions about patients based on how we're incentivized to do it. But if you're in a practice by yourself or your practice depends on other people, those decisions do matter in how you run things. So on the positive end of things, though, there are people who are doing what we call direct primary care. And some of them are doing this in the specialty world and in the surgical world. where they actually are posting their prices. And so everything's transparent. So you know what it's going to cost to see them. If you you're you join their practice and it's a member and sorry, under a membership ship fee structure, like going to the gym and you pay like a monthly fee to see them. You have all kinds of access to them. Email, text message, phone call and visits as often as you want. And then they post the prices and you know how much things are going to cost if you need to do extra things like, you know, in the office or some of them even dispense medications. I am finding my friends who are doing that direct primary care are so much happier in their life and they don't take insurance at all. on their panel. So they're not depending on an insurance company to reimburse them. They're just getting your monthly gem membership. And that is their incentive to make you healthier. That's it, right? You're paying them for a service and they're pretty much at your service. And those people are happy because they can practice medicine again. They can spend as much time as they want with you. I personally have a direct primary care physician. She and her husband own the practice. They live very close by with their daughter and young children. And I get to go in and, I mean, the very last thing is, you know, I'm taking off, you know, I'm putting on a gown and getting examined. Everything up to that point is we're talking and we're sitting and we're getting to know kind of what's wrong or what needs, you know, or what's right and just building a relationship together. And that's what people want to return to. But there's a lot of government regulations and mandates. You have to keep an electronic record. You have to show so many things that you've done in order to you know, to prove that you're practiced in good medicine. And a lot of people are just really frustrated with that structure, but most of that is driven by insurance panels and things like that. So for the people who can opt out of insurance, that's great. Right. And that works for them and the people who can afford to, you know, have a high deductible health plan and keep a healthcare savings and they can pay their $90 a month. to see a direct primary care doctor, it works very well. And I highly recommend it for people, but not everybody can do that. And so I think that there's a way that we can restore and find that joy in medicine and reverse the incentive structure. but we also have to have patients who understand that medicine is not expensive at all. Healthcare is not really expensive. It's the way that we're doing healthcare that makes it expensive. Just for an example, people one of the popular things that came up during, you know, presidential election was lowering the cost of insulin, right? And, you know, under President Trump, they, you know, lowered it down to what, I don't know, it was $35 a month or something like that. President Biden stamped the approval on it, that went through, and now they want to kind of lower that cost even more and start to add other medications to that. Well, how about, so I know direct primary care doctors who can get insulin at a wholesale price and charge their patients $5 for a month's supply of insulin, right? How many people know that? Not many people know that at all. Or who are the people out there saying, okay, you're overweight, You're not exercising, you're not eating the proper foods, you know, that are maintaining your health. You're not doing things that are helping your mental health, which in turn is affecting your physical health. And this is why you have diabetes. Let's work on these things so that you don't need the insulin in the first place. So we're not incentivizing that type of thing. But it is possible because now that I have friends who are doing direct primary care and they can focus on that. I know some doctors out there who are just focusing on obesity medicine and teaching people how to not be obese and basically make lifestyle choices. Some of them use medications, of course, you know, with that. But they're also talking about maintaining a healthy lifestyle and helping you to get through that. And if you have a gym membership or a doctor membership, you are seeing this doctor like once a week or whatever, and you're checking in and they're seeing you, they can hold you accountable for the part that in the role that you need to play in this. And that's their primary goal is to get you healthy and to keep you healthy. And so I think those ideas are out there and people are willing to do that. But what we've done with health care has made it so that that is not as easy to do. There's many laws in each state. There's what we call certificate of need laws that prevent people from opening practices in certain areas just because they're saturated already with a certain type of practice. There's these non-compete clauses that people have to, you know, have to, contracts that people have to sign when they go and sign up to work for someone else that, you know, they can't can't lead the practice and do the same thing within so many miles of the next person, of their last employers. There's lots of rules and regulations that are preventing people from having these sort of independent practices to compete with these large hospital conglomerates. But we're finding ways around it. And I do think there's hope for that. And we do talk about that a lot in our free to care paper. But it's there. And for therapists, often you are taking someone's fee out of pocket and then waiting for the insurance to reimburse, because otherwise you're probably not going to get anything, right? If you're waiting and you're definitely not going to get everything you asked for or billed for. from those patients. And so the people who are really, really needing therapy and can't afford it are probably not getting their therapy. And that's not, you know, your fault as a therapist or the psychiatrist's fault or, you know, people have to eat, people have to survive, people have to like, you know, have to keep the building open and the lights on and the heat on and all of those things to actually run and practice and take care of people. So it's a There's a big practical side of this too, but this corporate infiltration into our industry is really, really what's the problem, and we have to get innovative about how we get that piece out of it, and so that we can get back to that, the center, which is the patient, physician, the therapist, the nursing team, all of the health professionals, and the patient and their family, and all the support structure. That's where we need to go. And that's what my goal is. And that's what I'm trying to work for.

Stephanie Winn: So let's turn our attention now to the parents in the audience who are struggling to get appropriate medical care for their adolescents. Maybe they're young adults. I happen to talk to a lot of parents of young adults who are over 18. But at that point, all a parent can do is make a suggestion to their kid and hope that their relationship is good enough that the kid won't fly in the opposite direction of making that suggestion. Of course, my course contains communication tools for parents of older, young adults, if you want to try to be more effective in the suggestions that you're making and avoid common pitfalls. But setting that aside, let's talk about the parents of those under 18. who are looking for a pediatrician or some kind of specialist, most commonly a psychiatrist. Those are really hard to find. Yeah. In some cases, theoretically speaking, and this I feel like I'm going to step on a landmine here, an endocrinologist. So let me just kind of preface why I'm even mentioning endocrinologists. I mean, our audiences, you know, got a lot of parents who are worried about the trans identification and their kids and the medical. things that their kids have been, in my opinion, brainwashed into thinking that they want. I think we have some of the most advanced psychological technology on the planet to make people think that they want something for themselves when really there are larger forces at play that are influencing them. That's my opinion on that. But for these young people who may need or want some degree of medical care or to talk to a specialist about something going on, you know, especially if there's, I mean, I generally lean, I'm pretty anti-psychiatry in a lot of ways, but I'm never going to tell someone don't see a psychiatrist if you think that that's what you or your loved one needs. So, you know, especially in cases where there's like severe OCD and the kid's only willing to take a pill, you know, like maybe an SSRI temporarily. Anyway, I'm getting a little ahead of myself. What am I trying to say here? There may be cases where an endocrinologist would, theoretically speaking, be an appropriate type of specialist, a pediatric endocrinologist. if we're dealing with, let's say, a young person with PCOS. And anecdotally, I mean, you know, PCOS rates are on the rise, endocrine-disrupting chemicals in the environment are on the rise. There are young people with endocrine problems, and there's a lot of overlap, it seems. The population's afflicted with those things. I'm referring to the work of Dr. Shana Swan here. Like, you familiar with her? you know, the phthalate syndrome and how those things tend to cluster with higher rates of autism. And these tend to be the things we're seeing in the community of kids who are easily hypnotized into thinking that they're trans, right? It's the ones who are autistic with PCOS or similar conditions. So there are times when Theoretically speaking, it would really be nice if there was an ethical pediatric endocrinologist who could figure out what's going on with the kid's endocrine system and if they are afflicted with some kind of condition. But then also, even for the healthy kids, things are going to come up from time to time. And I just talk to so many parents who feel like they're caught between a rock and a hard place because they They don't want to be medically neglectful. They want to make sure their kids get appropriate treatment, but they really don't know who to trust. You talked about the AAP's statement. We know that The Department of Health and Human Services has been really corrupt. The WPATH, so-called standards of care, which are completely arbitrary and not science-based, have somehow been elevated to the status of like official medical guidelines. So there's all these forces working against these families. What can you say to these parents who are struggling to find a provider?

Nikki Johnson: That is a fantastic question. And just so your audience knows, I do have two teenage daughters. So I'm not just a physician, I'm also a mom. And so, you know, my kids have gone through some, probably some of the similar struggles as yours, especially through COVID with, you know, social isolation. They, you know, they developed some difficulties with managing that isolation. And I know when I was looking for therapists or just, you know, just someone counseling and, you know, someone who could help my daughters because, you know, as when they're teenagers, they don't always listen to mom and dad, right? You tell them, you give them some advice and it's, you know, funny, just take a deep breath, just count to 10. That's so stupid, you know, like that kind of thing. And so even when you're just looking for another adult that you can trust to help them be your support team, you know, that's something that most parents will have to go through. And that, you know, it doesn't even have to be some serious medical condition, right? That you're looking for a specialist for, or even, you know, a medical team for. So I can identify with that for sure, or the parents and audience, but my general advice is, Never be afraid to ask questions, period. You can do an interview with every single one, every single person you pick to take care of your family. You are paying them, right? So, either through insurance or not, you have the right to know what you're getting before you go ahead and pay for it. And so, Some physicians are not going to like that. Some are going to be resistant to that. But the good ones are going to understand, especially in the environment that we're in now, where we only have a few minutes with people and you have to make some sort of decision, right? Often, they will ask for you to come in and not do something over the phone. This can't be an interview over the phone because you are actually taking some of their time. That's fair for them to request that. Don't feel like that's something that is basically them pushing you off. They just really want to maximize their reimbursement for their time, for all the reasons that I laid out a few minutes ago. Making a sketch, schedule an appointment and make it in an interview appointment. You don't need to bring your kid with you if you don't want to. but ask them how they practice. That's how I, when I got my doctor that I have now, who is a direct primary care doctor, I ended up making a bunch of phone calls or doing a bunch of, you know, kind of email or inquiries online because everybody's online now too, believe it or not. So you can go to their LinkedIn pages or go to their website, find their, you know, find their social media if you need to do that, unfortunately. And you could find out sort of how they think things through. Some physicians have blogs. Some physicians have podcasts that they do. You can find out information about how they think and what their practice style is and their practice philosophy is. You can find a lot of that information. I'll just go buy one on their website. But if you need to, you make that appointment. You sit down with them and tell them what your needs are and what you would like. to see and then ask or just ask them what their style is in their practice. And it doesn't even need to be more than 15 minutes if you have the luxury of that kind of time. If not, then you, you know, you'll have to schedule the appointment with your kid and go with your kid and don't leave your kid alone with them, no matter how old they are. You have every right to be there. you are responsible for them, no matter how old they are, as long as they are not an adult. I know that's going to be difficult in some states. Some of the Western states now are making the age of consent even lower so that children and adolescents can consent to things without their parents' input. That's difficult. But in most places, in most states, you have the ability to be there. And just ask basic questions. Don't be hostile. There's no need to be hostile. Be professional. You come with your list of questions and ask what their philosophy is, if they recommend medications, if they recommend procedures or tests. Ask, what's the benefit of doing this test? What's the benefit of this medicine? What are the potential side effects? And if they give you a bunch of mumbo-jumbo or sound like they don't know what they're talking about, use your parental instincts. You know when somebody's not being truthful and honest. You can tell that. or when they just don't know. Because believe it or not, there are a lot of physicians out there who really don't know all of the details. And if you know things, if you have resources, bring them in. Ask them to look it over. Don't come in, though, acting like you know what you're doing and, you know, and trying to showing them up with your information, because that's going to that's going to push people away. That that's just that's human nature. Remember that like we're human beings on the end of this, too, that we want you to respect our level of expertise and our training and our ability to understand things. And we should do the same, you know, for you. We shouldn't just assume that we know more than you. But if you have information that you want the doctor to look at, bring it in. have them look at it and have a conversation about it, you know, and see how much they understand, how much they can articulate their understanding of that with you. And if that leads you to feel that you that's somebody you can trust, and then that's the person that's for you and your child. And that's just that's just that's kind of my general philosophy. I pretty lucked out. I mean, I looked out pretty well with our child's with my daughter's pediatrician. She doesn't force things on us that we don't want. She asked if we want, you know, a certain vaccine or a certain medication. She will sit down even before I ask and give us the risk benefit information and then make it our choice, you know, and say what she recommends, but then also make it our choice. And if people aren't giving you the choice because it's your body and your and your child, then that's also a red flag. If they're telling you that you must do this or else, or that's a threatening type of style of practice, then that's also not something that I think is appropriate either. But Jen asked questions, Will found out questions, bring in information if you have it, and really get to know what their philosophy is and how they practice and really just make it a mutual respect situation. And I think you'll go a long way. and you're going to find people that you can't trust, unfortunately, yes. But there's plenty of us who are good people out there who don't necessarily buy into what our medical organizations are pushing. There's a lot of people who are just afraid of pushback. People like me, I've never been a person to just hang my head low and just kind of go with the flow. I've never been that way for as long as my husband has known me. He knew what he was getting into. And even though he didn't want me to see me in my career that way, he understood that that was who I was. And so there's not as many of us who are going to take that risk with our careers and be vocal about it, loudly, you know, vocal about it. but there are people out there who want to do the right thing for you and your families. So just, I don't want people to feel discouraged that there's no good people out there just because the American Academy of Pediatrics or the American Medical Association or the American Psychiatric Association is out there saying things. The majority of the doctors, especially from the gender perspective that I'm finding when I network with them, don't really know the industry very well, and don't really know the science, because they're focusing on something else. They're taking care of patients. And sometimes it's willful negligence, unfortunately, that they don't want to deal with it. They'll just refer you to somebody that they know will deal with it. And that's just, unfortunately, that's how it is. But you may go in knowing more than they do. And if people are immediately ready to pawn you off to a specialist on something like that, and they're not willing to take the time and learn. Yeah, that's a reflect to me too. And I'm not, and I wouldn't go flying towards the person that they recommend as a specialist, but generally people just, I don't think people are wanting to do harm to kids. Some people are, I'm not that naive of a person, but, but in general, the doctors who are, a lot of them are just basically spitting off things that, you know, they'll pull up the guideline and print it out and show it to you though, because that's the extent of what they know about it. And that's unfortunate that we are in that state. But I do want you to feel empowered that this information is there. There's lots of great resources that are available to you. You may not always need medical or a medical physician to get you your answer either. But at the same time, I don't want to give you that kind of advice to go on and just say, no, no, no, no, no, don't go to an endocrinologist ever. But just feel empowered to be able to ask those questions and to be able to use your instinct and your gut as a parent to make that decision for your child, because that is your responsibility. That child is your responsibility. They are in your hands. You are the only one who has to answer for what the child becomes when they grow up. Have they developed into a healthy adult human being by the time they are done with your care? You are the only one who has to answer that question. No one else has to, even though they may try to. The school may try to take it. The doctors may take it, the state may take it, you know, the social workers may try to take your child away depending on where you are. But those people in the very end that don't have to answer to that child in the end, because that person, your child's going to look at you to see if you did the right thing with them. And so you have the ability to make that decision. That's the best for you and your kids.

Stephanie Winn: Are you looking to launch a podcast, but find yourself overwhelmed by the technical details? Or perhaps you've already gotten started podcasting, but you struggle to keep up with the parts that aren't fun? Well, my very own podcast producer can help. Nick can provide whichever services you need in order to focus on what matters most, your content. Whichever parts of the production process you find daunting, he can help you strategize or take them off your shoulders altogether. Whether your podcast includes video or just audio, Whether you need someone to write your show notes and make clips for social media, or you just want your sound cleaned up a bit, Nick is your all-in-one podcast partner. His end-to-end service adapts to your unique needs, ensuring your podcast looks and sounds professional and polished. Let him sweat the technical details so you can relax behind the mic. Visit podsbynick.com to set up a free discovery call. Mention Some Therapist to receive 20% off your first month of service. Pods by Nick. Podcasting simplified. Well, those are encouraging words. I do want to share some of my own issues that I've run into in a blue state talking to a lot of people in other blue states. I mean, I talk to people at this point all over the world, but You know, there are some sort of worst case scenarios that get lodged in my mind, and I want to run these by you. So one is when you talk about bringing information to a doctor, you're very careful to say, you know, be respectful. Don't needlessly antagonize this person. You know, nobody's going to respond well to that. But one issue I don't have an easy answer for, but I do address in my course, is that I've seen people get themselves into precarious situations by putting their cards on the table before they know where someone stands. And I think, I mean, I'm always grateful to talk to people in places like Ohio who say things that are more encouraging, but then I'm thinking about the families I know in California. And I would say this, I say this to families and I'm very clear, like I don't have any easy answers to this. I'm just here to name the double bind that you are in. And it's the same with schools too, whether it's a school or the doctor, especially if your kid is already in the care. Like, if you are in a place where, like you say, there are these age of consent laws where your kid can go to their doctor who they like, who they're established with and talk without you, or where your kid is already enrolled in this school, and you are a parent coming and talking to the other authority figures in charge, and you make it very clear that you have, let's say, an anti-trans position, it almost doesn't matter how much evidence you bring or how official that looks because there are people who are going to immediately write you off as the bad guy. And then their rescuer complex kicks in. They see your kid as a victim and you as a persecutor. And now there's this authority triangulating your family, going behind your back. So there's that, there's a couple other things I wanna name. One other issue I've seen too is wishful thinking on the part of parents. It's the innocent until proven guilty attitude, which I think would under any other circumstances be the fair, normal and appropriate way to approach a professional. That you have no reason to assume someone's in the wrong unless there's evidence of that. However, I think in this current climate that when it comes to you know, anyone you're looking to for care of your child in one of these woke professions that's been captured, whether it's therapy, medicine, education, that you almost have to be hypervigilant and assume that until they've shown you that you can trust them, that they can't. And where that leads, just to name kind of the third thing on my list of problems here, is worsening triangulation where these medical authorities are now reinforcing your kid's antagonism towards you, reinforcing their sense that the medical procedures they want are going to do nothing but good for them. And like worst case scenario, when I heard, I'm not going to get into specifics because I don't want to violate anyone's privacy, but there was a family consulting with me where the kid was having a pretty serious medical issue. I'm not going to name what the issue was. But it was pretty serious, and the kid had been on cross-sex hormones for several months. And the family was going to mainstream medical providers who said, there's no way it could possibly be the cross-sex hormones causing this problem. And when you as an authority figure say that to a teenager who already thinks your parents are paranoid, crazy, and backwards, And I mean, the weight of that authority just cannot be overstated. And that's the sort of situation that I want to keep families out of. Like, the last thing in the world that you want is someone with this authority to come into your life and say, no, kid, you're right. Your parents are wrong. Cross-sex hormones do nothing but good for you. This medical problem you're having couldn't possibly have anything to do with it. It's like, well, now that's the nail in the coffin. Like, where are you going to go from here? So these are my worst case scenario things I want to do.

Nikki Johnson: Yeah. So, okay. Well, this is where I get to plug in affirming realities. Okay. So if anybody's listening or watching and doesn't know affirmingreality.com or affirmrealityconnect.com, it is, you know, headed up by Gabs Clark, but I'm also an advisor, clinical advisor. And our approach for minor children who are in situations like this is absolutely what Stephanie, what you've just said, is to never, ever, ever disclose what you're thinking. Give them the opportunity to put all of their cards on the table first and never do it in a situation when your child is with you. Unfortunately, you just can't. You cannot take the chance. You cannot take the risk. And if you have the means, You need to get out because you are in danger of losing your child, period. These people want to take your child from you. period. Those are everything you named or all the red flags that are of what is going to happen next is if you say the wrong thing, if you say something that isn't affirming or you're around a person who is going to think that you are harming the child by not affirming or by not taking a medicine or going a medical course, then they're going to do everything they can to get your child away from you so that they can put them on that path. So if you have the means, and that is financial means or family, where you can pick up and take your child away, you have to do that. You have to. That is the only way you're going to be able to salvage your child's physical and mental health over time.

Stephanie Winn: including with the care providers I see in it. I'm sorry to say providers. It's okay.

Nikki Johnson: It's in your language. It's ingrained.

Stephanie Winn: I'm glad you brought that up, Nikki. But you're thinking about it. I mean, it's been a while since I had on Gabs. I can't remember if she'd launched Affirming Reality when we had her on the show, but she's definitely grown a lot since then. We can certainly say that. And now, you know, she has you on her board of advisors, she's training coaches. And, you know, I'm every time I hear, I just, I always appreciate knowing that the advice that Gabs is giving to parents of younger children is pretty similar to the advice I give when I have an opportunity to speak with parents of younger children. The perspective you just articulated, I'm like, yeah, that's what I'm telling them too. And what I would say about everything I know about Affirming Reality is it's a great program for parents who have the leverage. If your kid is under 18, if they're with you and you have an opportunity, please use that opportunity while you can. I often have parents coming to me whose kids are in that age group who are reluctant to make some of the sweeping changes. But I think, you know, you and me and Gabs are all we understand the what's at stake if if you, you know, and how much time you have. My program, I think, you know, I've told Gabs to send me her rejects because, you know, if you're in a parent in one of these low leverage situations where you don't have that authority, your kid is over 18, maybe they're not even talking to you. Maybe they've started to medicalize. You know, that's where my program, ROGD Repair, is really just for those low leverage situations, what approaches to use in communication. But I'm really grateful for the work that you and Gabs are doing and the important education. And it means so much coming from you as a doctor, as a pediatrician, to tell parents this empowering message. So, you know, we only have a few minutes left, but on that note, What about, because I know you also care about patient empowerment to look out for your own health, not just leave it in the hands of doctors, right? So when parents are struggling to make a decision about whether to bring their kid to what type of provider, what type of interventions they can do at home or on their own, where they can do their own research, any messages that you want to send to those parents?

Nikki Johnson: Well, I think there's a number of resources. to go to. There's some great organizations that have a lot of information for parents to learn about, you know, really what happens with gender affirming care, what are the potential side effects for puberty blocking, for sexualizing hormones, for social transitioning. I think there's a number of resources out there. I don't, but I think the number one resource is you as the parent. You know your child the best, but it's going to be very difficult for you to first talk to your child and basically try to like, you know, shake the reality into them. because they've already received this information from sources who convinced them otherwise, right? And so if you come at them with a ton of information, trying to convince them that they're wrong, all that's going to do is just grow the wedge even bigger between you. And so I think the primary goal is to reestablish a good connection with you and your child, reestablish trust, and you're going to have to get very creative and use what you know as a parent about your child to be able to do that. And the basic goal is, yeah, to eliminate all of the input from those other external sources that are giving them all of this information and intervene and fill the void that you were removing with other things. So let me give, I know that's very big, but let me give it like sort of a specific example. So say your child's 14 and loves art. loves to draw or even likes to build things and very creative, likes to use their computer, Procreate, which is one of the big apps that are available on the iPad or Mac computer to be able to draw things and create things, create animations, create anime, all of that kind of thing. But you know your child's captured by gender ideology in the gender world. That device is going to be a key source for them to continue to connect with people who are giving them this information, connect with internet resources, I mean that including medical resources. with social media networks, including some of the networks on gaming type of apps, music apps, even like Spotify, for example, are keys to keeping your child connected with that type of world. And also ways to connect themselves with other kids their same age, even in their school, who are a part of the culture. It's going to be very tough, but you actually have to remove the device and take the device away. You just have to. You have to do it. That's like these are kind of these are extreme measures, but these are extreme circumstances, too. You don't want to lose your kid. And so what you need to do is take your kid to an art class. where they're actually doing that thing in a class. Do the class with them, if you can, or buy them a bunch of pencils and some notepads and sketchpads and get them to be creative. They're going to be resistant. They're going to hate you. They're going to say some mean and awful things. But eventually, if art is really the thing that they love and they want to do it, they're going to create giving given what you gave them. So but you have to be the creative person because you know your kid. Like I said, you are the number one resource for them. You know them the best. And so you know what interests them, and if you don't, you need to find a way to do that, to reconnect with them. Take a long car ride and get them to talk. It may take more than one to do that. Be creative, be innovative, but use yourself as your best resource. and reconnect with them and fill the void of the things that you need to remove in order to kind of remove this kind of toxic substance out of their life.

Stephanie Winn: And I know there's so much more there, Nikki, both as a parent and as someone who's studying to be an affirming reality coach. And I just want to highlight, as we're moving towards closing, I just want to reflect some of the logic and the wisdom behind that. It's my belief that parents need to serve as external scaffolding as their kids develop various skills and capacities. And I've noticed that sometimes parents with loose boundaries subtle on a subtle level there's an expectation that the kids be able to self-regulate in a way that they haven't demonstrated that they can yet and so in some ways taking away the thing that they're addicted to is the Kindest thing you can do because it's saying I know you're just a teenager. I don't expect you to be able to self-regulate This is how I help you internalize the ability to self-regulate as I know when enough is enough or I know when this is leading you down a dangerous path. And so you're taking away that choice from them. It's really an act of kindness. And then you're filling the environment with alternatives. And so where a lot of parents I work with get into trouble is they try to negotiate with the kids. So their boundaries are too loose. And they worry about the conflict. And it's like you said, they're going to be angry. Hopefully, you haven't let things escalate to the point where there's patterns where you're worried that someone's going to get injured if you have a conflict. If things are at that level, you definitely need professional intervention. If you don't feel like you can take away your kid's device without something getting broken or someone getting injured, that's a serious problem, and it's beyond the scope of us to advise in an educational resource. But barring that, you know, barring anyone's safety being threatened in that way, I think it's just so wise to be prepared to receive the blow of your kid's angry mood and their disappointment with you. And in my course, I don't so much focus on the interventions, although I do, of course, say, yes, you need to reduce screen time and access to, you know, these types of things. But I'm more focused on like, The how of the communication part. So I have tools like strategic apologizing, which is where you're saying you're expressing that you're sorry and that you know what you're learning and what you want to do better as a parent, but you are regaining control of the narrative at the same time. So you're sort of absorbing the blow of their anger. Anyway, I feel like we could have a whole other conversation sometime about these types of things. And I do just want to bookmark the things that we didn't get to because there's more where this came from. There's also, you had a very interesting story to share before we started recording about your own advocacy with other parents in your community to protect kids from gender ideology in a private school that your kids went to. So I thought that was a fascinating story. So I just want to bookmark those in case we're ever able to have a follow-up conversation. And this is where I encourage people to follow you. So please tell people where they can find you. Oh, awesome.

Nikki Johnson: Okay. I can find out just about everything you want to know about me on my website. It is NikkiMJohnsonMD.com. And I am on social media just about everywhere as at NotAProviderMD. And also you can follow my work through fearforall.org where I'm the co-director of the medical arm there. So that's it. Thank you so much for having me, Stephanie. I really appreciated the time and I hope I could both not only, you know, educate your audience and also be a source of inspiration for people.

Stephanie Winn: I think you did an excellent job of that. Thank you so much, Dr. Nikki, for joining me. It's been a pleasure. I hope you enjoyed this episode of You Must Be Some Kind of Therapist podcast. To check out my book recommendations, articles, wellness products, guest episodes on other podcasts, consulting services, and lots more, visit SomeTherapist.com or follow me on Twitter or Instagram at SomeTherapist. If you'd like to go deeper, join my community at somekindoftherapist.locals.com. Members can dialogue with other listeners, post questions for upcoming podcast guests to respond to, or ask questions for me to respond to in exclusive members-only Q&A live streams. To learn more about the gender crisis, watch our film, No Way Back, the reality of gender affirming care at nowaybackfilm.com. Special thanks to Joey Pecoraro for our theme song, Half Awake. If you appreciate this podcast and want more people to find it, kindly take a moment to rate, review, like, comment, and share on your platforms of choice. Of course, just because I am some therapist doesn't mean I'm your therapist. This podcast is not a substitute for medical advice. If you need help, ask your doctor or browse your local therapists online. And whatever you do next, please take care of yourself. Eat well, sleep well, move your body, get outside, and tell someone you love them. You're worth it.