Dr Louise Newson [00:00:02] Hello. I'm Dr Louise Newson, and welcome to my podcast. I'm a GP menopause specialist and founder of the free balance app. My mission: to break the taboos around women's health and hormones, shining a light on the issues we've been too afraid to talk about, from contraception, sex and testosterone to menopause related addictions and beyond. We're covering it all. I'll also be joined by experts and inspiring guests, sharing insights and real stories, as well as answering your questions and tackling the topics that matter to you the most.    

Dr Louise Newson [00:42:00] So, I’ve been speaking to Dr Karan on my podcast today. He’s an author, he’s a doctor, medical educator and he’s also a podcaster for Dr Karan Explores. I’ve met him before, but actually this conversation was even better, we talk about the responsibilities of being an educator, we talk about the joys and the thrills actually of educating people so they can make decisions that are right for them about their conditions. We talk about lots of things; how medicine is sometimes a bit institutionalised and how we need to be the best advocates we can for our patients, it’s a great conversation, so enjoy it  

‍Dr Louise Newson [00:01.25] So, Dr, Karan, you are in my podcast studio, whereas last time I was like, in your seat, somewhere else, wasn't I?
‍
‍Dr Karan Rajan [00:01:32] I know. Thank you so much for having me. It's a really nice, comforting place to be. This is.

‍Dr Louise Newson [00:01:36] Yeah, well, you know I love doing podcasts. I don't know about you, but it's a real privilege to meet other people and have a bit of time, because we're all busy. You never really get to know people properly. You see them on social media, you see them whatever, but you don't really know the real person. So it's great, isn't it, doing podcasts?  

Dr Karan Rajan [00:01:57] It’s like a little confession box, isn't it?  

Dr Louise Newson [00.01: 58] It is, actually, it's good. So you are a doctor, you're a health educator, and I was trying to think, when I saw you couple years ago, how many, like millions of followers you had on TikTok, it was, think it was like one, maybe?  

Dr Karan Rajan [00:2:014] Something, yeah. I mean, I used to care a lot more and look at the numbers, but...

Dr Louise Newson [00:02:19] But who cares really? But, you know, it's quite a responsibility having a role of being an educator, like and I think things have really changed. I'm older than you, but education has changed for our patients, but also for healthcare professionals as well. And I've worked as an educator for like 20 odd years, done a lot of evidence-based medicine. So, I've written four books on evidence-based medicine. They were hot topics for MRCGP, so people doing the membership Royal College of GPS, I because I'm a girly swot, I made loads and loads of notes. And then when I got distinction from the exam, I was like, well, I want to share them with everyone else. And everyone's really busy to read the guidelines and read the papers. And because I've got a pathology degree as well. I like basic science. I like to know what's going on. So I thought, right, I will write a book, because the internet wasn't really out there quite the same. It was harder to get evidence. So, then I wrote the book, but then you have to write the second edition and the third and the fourth edition, because evidence changes, guidelines change. But actually, I got a lot of credibility for the book. It got the number 10 for the BMJ bookshop. I was really proud of it. But then I had my second child, and I was like, I haven't got time to write. But then when I started menopause work, I started to educate via Instagram, by media, just in different platforms. But somehow it hasn't been so credible. Like people now sometimes refer to me as a social media influencer and seem to forget that I'm an academic, scientist, doctor. But actually, the people that I'm trying to educate, ie, women, men, doctors, really like it. But it's weird, isn't it? How the just because it's not a book, people think it might be different?  

Dr Karan Rajan [00:04:10] Yeah, I think if you look back through history, things which are modern, revolutionary, which break trends are always there's a lot of inertia behind those sort of movements, when people were writing letters, and then when email first came on, people probably thought, oh, that seems really cheap and maybe unsafe, but now it's the standard of communication for, you know, business and other things as well, even entertainment. So, I agree with you that the sentiment of social media is cheap, it's fun, it's not real, signs it's not serious. I think we need to rethink that, because there are so many educators online. It's the medium of choice for most people, not just, you know, Gen Z, Gen alpha, but actually people in their 40s, 50s and 60s, they're using social media as a search tool. You know, it's the new Google. You're not going to look up on Google anymore. How to. To build a cupboard, or how to cure acid reflux, you're going to search on TikTok, on YouTube, on Instagram. So as educators, and not just you and me, because we have been adopting it for years, as educators, again, like you know, as a collective, we need to look at those platforms, because in 5, 10, years' time, there may be something else which is even more bizarre, and we need to be open to that.

Dr Louise Newson [00:05:25] Yeah, and I think it’s, I feel, and I still do every day. It's such a privilege being a doctor, like it's a massive privilege. And, you know, I learn, and I've learned so much from my patients. I've worked in all sorts of areas, very deprived areas in Manchester, which have been my favourite jobs, actually reaching and talking to people that I never thought as a, you know, school child that I would ever, you know, at homes, that I've been to people I've spoken to. You've done the same. And, you know, in hospital, people turn up in A and E, and you're like, my goodness, but then, actually, this power to be able to reach more people is even more of a privilege, really, and it's a responsibility as well, though, isn't it?

Dr Karan Rajan [00:06:04] Yeah. I mean, in a clinic, I might be able to see 20 patients across three hours, and that's me going really fast and probably not giving enough time to each patient. If I make a video online - so the example I often sort of think about is when I think about this is back in 2020, I made a video about haemorrhoids. Haemorrhoids is one of those embarrassing problems that a lot of people suffer from. There's a lot of taboos surrounding it, because people don't want to own up that they've got haemorrhoids. A lot of people listening or watching to this probably have haemorrhoids. They're probably sitting them right now, that video is not a sexy topic, but it got over 2 million views. And I'm not egotistical enough to assume that 2 million people are going to benefit from that haemorrhoid advice I gave. But even if a small fraction of a fraction, say, 2000 people took something away, that is a huge amount of people that I could, you know, see across 100 clinics, and still not get to that number.

Dr Louise Newson [00:07:00] Yeah, it's really interesting. I, I used to work on Embarrassing Bodies. And my husband's a genitourinary reconstructive surgeon, so he was the penis doctor on Embarrassing Bodies. And he's very he's got very dry sense of humour, and it went down very well on television. And I worked as a medical advisor, and there was, like a live phone in, so we'd answer questions and that sort of thing. And that was, I think, really pivotal for the way the public learnt things that, like you say, were a bit taboo, bit embarrassing, like piles, we've all had them at some stage, especially women after childbirth. Do I go to a doctor, or do I buy something over the counter? But then what do I ask? What do I do? Do I pretend it's a friend, you know? Whereas actually, you know, it was amazing some of the calls that you got, and I was find it really interesting on those phones, because people would phone up. You’re like well haven't you spoken to anyone? Oh, gosh no, I wouldn't talk to my doctor because he's my mum's doctor, or he's whatever, and it's and he's like, gosh, wow. This is why it's so powerful that you are not judging anyone. They are choosing to learn from you as well, which I think is the other thing that people forget actually, when people are criticising whatever it's like, well, they're choosing to learn from you. If they don't like the way you look or what you say, they can unfollow you can't they?

Dr Karan Rajan [00:08:15] Well, I think also the brilliant thing is that it democratises education. So someone who maybe English isn't their first language, and would maybe be afraid to have this conversation, can get that translated into Swahili, French, Spanish, Farci, whatever they want, because of the auto caption function on most social media platforms. So it's almost like a guilty pleasure. You know that, you know I wouldn't want to admit to my friends that I love to listen to Taylor Swift, but it's that guilty pleasure, like, Oh yeah, I'm watching this haemorrhoid video in silence, and no one's judging me.  

Dr Louise Newson [00:08:48] Yeah, I think so. I think it's so, so important, and I like the way that you say about democratising knowledge and education, because as a doctor in the past, I was privy to reading all sorts of journals, all sorts of articles that it was only me as a doctor was able to. And then years ago, I started working for patient.info and started writing patient information literature. Now that sounds a bit weird now, because everyone's got access, but Tim Kenny, who set it up, was amazing. Him and his wife were GPs, and they talk talked about the first patient they saw who realised they needed more information was someone that had raised blood pressure. It's very common hypertension, isn't it? There's a choice. You can have an ACE inhibitor, you can have a calcium antagonist, different medication, but it's a lot in 10 minutes. So they decided to write a patient information. What is hypertension? What are the treatment choices? Give it to patients like this is why you're having a blood test. And they said, gosh, it was amazing. The consultations were so much better afterwards. So then my job was to write patient information, but we were always referenced to the guidelines, to the evidence, and I wrote about all sorts of conditions. I did it for 20 years, it was great. But then we realised, after about 10 years, that the doctors were reading it as it was coming out of the printer, going, Oh, I didn't realise that was, you know, first line treatment or whatever, because it's hard to keep up to date as a doctor. So then we wrote patient plus it was called, so it was more detailed for the doctors, so they had more information. But what was great about doing that, was realising that the patients actually sometimes wanted the patient plus version, and patients want as much information often as we know. And I think that's great, but some doctors feel it's quite threatening if patients are really empowered and knowledgeable, don't they?

Dr Karan Rajan [00:10:36] Yeah, and I think that's really the sort of really archaic and bad way of thinking, because that takes it this to this paternalistic view of that doctor patient relationship. And I think doctors shouldn't be gatekeepers of knowledge. They should be an advocate for the patient. And when I've seen patients in clinic, I want them to come to the table on a level footing, so they know a lot more than the average person, or then someone would expect a patient to know, so they get more out of the consultation. So the sad truth is that when we see patients in clinics or see them on ward rounds, you're not going to have more than 5, 10, minutes, 15 minutes at most, with these patients. So instead of going over the basics, wouldn't it be far more useful to ask those specific questions, like, okay, if this happens, what do I do? And they're actually asking really detailed personal questions to them, and we're not going over the basics again, because all of that can be covered at home with these leaflets, but now in video form.  

Dr Louise Newson [00:11:35] Yeah, of course, it's really interesting. So when I started my clinic like I only wanted to work one day a week doing menopause care. This was like, nine years ago, 10 years ago, nearly I rented a room in a hospital because I couldn't get a job in the NHS doing menopause work. So they said, Oh, it's just gynaecologists, and there's no interest, no money, whatever. And I wanted to get my friends off antidepressants. So I said, okay, I'll just do this. So, I started to see women who were more than just my friends, who would travel a long time, and they'd say, Oh, Dr Newson, I think I'm menopausal. I haven't had a period for eight years. Okay, having all these symptoms, but I tell you what, I don't want HRT. So I'd spend the whole consultation educating them about what hormones are, how they work, all the disease preventive effects, how we give the natural body identical hormones, different to synthetic all this stuff. And then I went home, and I just thought, this is, this is really like, I feel like I'm not individualising care. I'm just a robotic person telling them the same things because they didn't have access to any information. So that's when I started to write my website, but then I'd come home and I'd be dictating my letters, and then I'd realise most people had similar symptoms, especially mental health symptoms. Most people had joint pain, most people had given up their job, having really difficult times. And then I thought, well, actually, it was my daughter. We were just having supper one day, and she was like, mummy, you keep telling me all these stories. They're awful. About these women suffering, you need to post on Instagram. And I thought, oh, I don't even know, I'm literally scared, but she was setting up her Instagram account, and I thought, I need to just see what she's doing, you know? And so, then I got her to, like, help me find pictures and to start to post. But then I started to get DMs from women all over the world to say you've struck a chord. That is me. I had no idea. I thought I had fibromyalgia. I thought I had chronic fatigue. Maybe it's my hormones and it that, like that sort of sensation, like, I love helping people that I don't know. And I'm sure you get it sometimes where you're like, wow, this is going to make a big difference to people's lives, actually.

Dr Karan Rajan [00:13:40] Yeah. I mean, people want their pain points addressed. They want the relatability. And then what you've done with the menopause education is there's a lot of women who, again, don't want to seem like a burden to doctors, and they've been perennially told, traditionally told that those symptoms are just parts of life, and they maybe have to suffer through them for this period of time. And so they've been maybe reticent to go to a doctor, thinking, oh, they're just gonna maybe give me some antidepressants, they're gonna give me some painkillers, or, you know, maybe do nothing. So they actually suffer in silence. But then when someone is educating them and say, actually, there are some lifestyle factors I could change. There's some, you know, things I could actually get prescribed to improve my symptoms. That's when it becomes relatable. And then they want to seek out more information. And ultimately, someone will only be educated if you provide them with the education. There's a desire for it. But then if there's a lack of education out there, then no one's ever going to raise their level of knowledge.

Dr Louise Newson [00:14:36] Yeah, but sometimes, I don't know whether it happens to you, but I sometimes feel really guilty for what I do, because I do a lot of education for healthcare professionals as well, which is great, but you can only change people that want to change when you're talking about, you know, evidence and prescribing, especially when. And we're talking about testosterone as well as HRT, lots of people are stuck and won't change the way they prescribe, but a lot of my work, like yours is empowering people, women, especially with hormonal problems. But then what really makes me very sad is that I feel like I educate people and they say, gosh, maybe I don't need antidepressants. Maybe I could take hormones. They go to their doctor, who says, no, you're too old, you're too young. Of course, it's not menopause. Where did you get this information from? Don't stop your antidepressants, don't think that your whatever, that your joint pain, your poor sleep, is due to that. And then they become really frustrated because they can't afford private care. They're being told out of date information, and then, like, they're almost worse. It's like dangling a carrot over them, and that's what I worry a lot about. Like, have I got it wrong? Should I have not done this? But then it's not fair that I've got knowledge that others haven't got.

Dr Karan Rajan [00:15:52] Yeah, I guess what you're saying is you're giving them this forbidden fruit of knowledge, but then they can't access it through their normal roots. And I think as doctors, sometimes, you know the sort of medicine as an institution, it's quite rigid. We're sometimes reliant, and sometimes, for good reason, reliant on certain algorithms and flows of treatment and the pathways, and that's good, because that gives us the evidence base to be safe, but sometimes that also limits us in terms of how open we can be to new, evolving evidence. Just because something is emerging evidence doesn't mean it won't work for some people, and I think, you know, that's something I've softened my stance on a lot over the years. So for example, you know, something like magnesium as a supplement. You know, if you looked at use of magnesium for sleep, there's not reams and reams of literature out there saying that everyone should supplement with magnesium for sleep. However, anecdotally, I've benefited from it when I suffered with insomnia years ago, and there are loads of people who also benefit from taking magnesium, and if you told those people, there's no evidence, that's not going to change their mind or stop them taking it. So it's actually finding what works for different people. And I think sometimes as doctors, we need to be receptive to looking at specific protocols and treatments for specific people, because if we just dogmatically stick to algorithms. We are losing people for whom the algorithm doesn't work.

Dr Louise Newson [00:17:19] I think that's it's so right, because medicine is a science and an art. You know, the science, of course, but the art is individualising care. But the other thing is, is that even our guidelines, people often read the top level. So lots of people say, Louise, you don't follow guidelines. Well, which bits? And there aren't any bits. And, you know, there's lots of people that think the guidelines say something, and you when you question it, they're like, oh, no, but they told me there was something about this, like treatment pathway in this guideline. Well, no, there isn't. And I know the guidelines black and white. So then it's the way that the guidelines are interpreted as well. And in medicine, I think sometimes, and I'm sure it's because people are busy as well, there's a lack of professional curiosity. Like, if you said to me, the best treatment for haemorrhoids is, I don't know, smelling some flowers in this, in this, you know, in the field, I think, well, that's a bit weird. But let's, let's look at the evidence. How does that work? Does it really make a difference? Rather than saying, no, that's absolute rubbish. And you know, when a new treatment comes out, one of two things happening, that everyone starts to prescribe it with very little evidence, or everyone says, no, that's rubbish. And it all depends the way that what's in the guidelines, what you know, who's marketing, it, whatever. But I think sometimes in medicine, we get very siloed, we get very focused, and we don't have this professional curiosity. And I think it's because people are tired as well, aren't they? There's very little bandwidth, isn't there to expand your mind when you're working full time?

Dr Karan Rajan [00:18:48] Yeah. And I think that is something like we were talking before about, you know, you're publishing books, and then you had to keep publishing further editions, because as soon as you publish something, it's out of date because of evolving evidence. And it's the same with what we learn in medical school is out of date once we leave medical school, a lot of it, I mean, anatomy is the same. I mean, our bodies don't evolve in that short time scale. But there are certain guidelines for managing specific conditions which change. But yeah, as you said, if you're working 12 hours a day as a doctor, as a healthcare professional, what extra time do you dedicate to looking at new research? And I think that's where it's key. We actually have to say, hang on, this sounds weird, but is there any evidence behind it? Is it safe? What's the sort of risk/benefit ratio? Even if the evidence isn't strong, could it work in a safe capacity and offer a relatively low side effect profile to someone, but have huge upsides. And I think it's just being really open to, I don't want to say experimental things, but things which, you know won't be suitable for the mainstream population, but for those specific people for whom the mainstream treatment hasn't worked. Could it be an option for them?

Dr Louise Newson [00:19.53] So I remember when I came on your podcast before you were talking about times when people have had a surgical menopause, so ovaries removed. It might because they've had bowel surgery. They might have had endometriosis, for example, and you've been involved as a bowel surgeon, and the ovaries have been removed. And like many doctors, not always thinking about actually, I'm removing their hormones as well. And I remember you saying that was quite a moment, like light bulb moment, thinking about the hormones that these poor younger women weren't getting.

Dr Karan Rajan [00:20:22] I mean, I think sometimes we get such tunnel vision, like as a surgeon, you think, okay, we've got to remove the cancer, gotta remove that organ, gotta remove this disease. And that's almost compartmentalising the human body into specific parts. But as we know, everything's interconnected. The ovaries are not just a reproductive organ. It's an endocrine organ. It's a metabolic you know, it produces like various hormones which influence metabolism, influence mood, memory, all these other things. So the knock-on effect of the bowel surgery could be systemic. And for me, I didn't realise actually chemotherapy, bowel surgery, removing, you know, these organs can have ramifications beyond just that target organ. And there's, you know, huge cohorts of women who suffer from surgical menopause because of, you know, those things aren't, maybe, pre planned, or part of that treatment conversation where the surgeon talks about the complications for the bowel surgery. But have you mentioned the gynaecological, metabolic, endocrine complications that could arise as well, and that could doggy for the rest of your life.

Dr Louise Newson [00:21:32] Yep, so we did an audit, which we just presented a conference, looking, I won't say the names, but three teaching hospitals in London. These were young women that had a surgical menopause for benign conditions, so not for cancer. They had their ovaries removed. The guidelines are very clear these women should have their hormones replaced because of the long-term health consequences of not having hormones. Guess how many were offered or prescribed HRT?

Dr Karan Rajan [00:21:57] 10%?

Dr Louise Newson [00:21:59] Less than 5%.

Dr Karan Rajan [00:22:00] Wow

Dr Louise Newson [00:22:01] And then how many do you think were prescribed testosterone?  

Dr Karan Rajan [00:22:05] Probably similar amount or less than 1% maybe?  

Dr Louise Newson [00:22:07] Zero, there was none at all. Then can you imagine removing someone's thyroid and then never giving them thyroxine?  

Dr Karan Rajan [00:22:16] Yeah. That's really worrying. But also, I'm not shocked, because in my own experiences of dealing with these patients working as part of a team. It's not a conversation that would be at the top of the radar. So I also think you know how I was involved in that sort of treatment flow over the years as well. So it's not surprising.  

Dr Louise Newson [00:22:38] But you know, I said to my husband a couple of years ago now, like Paul, if you remove someone's testicles, both of them, as a man, like if you remove their testicles, so they had no testosterone, because obviously testes produce testosterone. Would that man get testosterone replacement? You know what he said? He said, of course, these poor men, they'd have awful symptoms. They would have brain fog. They would have reduced memory. They had poor concentration. They would have erectile problems, yeah, but that's what, that's what women are having. They're having a castration. Like 50% of our testosterone is in our ovaries.

Dr Karan Rajan [00:23:19] Yeah. And I think also, I guess, you know, interestingly, maybe for men, it becomes more well, for men, the degradation and the loss of testosterone production is insidious over many years, and you almost don't notice it. So a man in his 20s who eventually becomes 50, 60 he's not going to notice an immediate cliff of a drop off. But in women, there is that obvious cliff of a few months, or, you know, that sort of time period in their life. But even despite those obvious manifestation of those symptoms, it still strikes me as odd that even though there's more awareness now, there's still not enough being done for enough women.

Dr Louise Newson [00:24:00] I don't understand, especially young women. So young women really worry me because their risk of future inflammatory diseases like heart disease, osteoporosis, diabetes, dementia, mental health, clinical depression really increases. Even study shows that women are more likely to have Parkinson's disease more likely to have neurodegenerative diseases when they don't have their hormones, the longer so especially these young women. But there are also studies from the 80s showing that women who have testosterone in addition to oestrogen after having their ovaries removed, have better wellbeing, better cognition, but most women, if they get hormones, is only oestrogen. And there's this, like myth about testosterone, and I don't really understand. I know it's labelled from the teste's testosterone, but it’s a female hormone as well.

Dr Karan Rajan [00:24:46] Yeah, I think the problem is labelling those androgens or those sex hormones as the male hormone, the female hormone. I mean, men have oestrogen as well. They have a small amount of oestrogen. If you increase your adiposity or your obese, you'll have more oestrogen. So I think you know, genderising those hormones is also not beneficial as part of educating people on that and almost you know you this really is evident in the fitness space, where historically, women have shied away from weight lifting because they assume that lifting weights will boost testosterone and boost their muscle mass, and they look muscular and not, you know, so aesthetic, but it's not, doesn't work as simple as that. And I think it's, you know, almost saying testosterone is the male hormone is not only wrong, but also harmful and misleading in the long-term conversation.

Dr Louise Newson [00:25:40] Yeah and I think also a lot of people, men, more than women, inject testosterone, which is synthetic, so it's not pure testosterone. So when people worry about the risks of heart disease, for example, yes, with a synthetic, chemically altered artificial testosterone, but not with the natural and I, it took me many years to realise the difference between natural and synthetic. The same with contraception. You know, ethinylestradiol, a chemically altered artificial oestrogen, is not going to be the same as oestradiol. They're completely different. But it takes a while to realise that, and until you realise that, it's very hard to sort of look at the difference and work out the difference metabolically and with risks as well.  

Dr Karan Rajan [00:26:26] Yeah, I think generally, when you know, I've learnt a lot more about menopause and perimenopause or the transition over the years, because there's been more voices like yourself talking about it. And so I think you know that actually is a positive thing, but it, you know, does that then trickle to the people who need it most? And sometimes you wonder, do you, does it just reach people who are in those certain echo chambers? Because then there's still a huge population of people who it's not reaching. And because the people who reached right now, they may already be educated, they may be listening to podcasts like yours and already be doing the things that you're telling people to do. But what about those people who don't listen to those podcasts and other things because they're going to get their education from the average person who is bit more savvy. So you know, it's sort of getting that information trickling to everyone.

Dr Louise Newson [00:27:19] Yeah, and that's why it's great when doctors like you, others will talk about hormones. You know, you mentioned about endometriosis a while ago, and everyone's like, wow, he's talking about it, which is brilliant.

Dr Karan Rajan [00:27:29] Sometimes, though, I've seen a comment once in a video where I think I was talking about some women's health thing and how it affects the gut, or something like that, and someone commented great information - would prefer if it came from a woman, yeah, and I was just a little bit shocked. I mean, like, why does my gender matter if the information is still evidence based? And sometimes, and I feel that comments like that could actually prevent, you know, more male educators from talking about women's health issues, if they do get, you know, feedback like that.

Dr Louise Newson [00:28:09] You see, I think, like a lot of my work, is not thinking about women's health, it's about thinking of health of women. So then, if I'm really worried about cardiovascular disease, like I personally take hormones to reduce my risk of osteoporosis. I'm really scared of osteoporosis. Like you, as a man, male doctor should know everything about osteoporosis, whether it's in a man or a woman, but if we talk about health of women, I think it's fine that you're a man. Somehow women's health is about our gynae bits, and it's a bit embarrassing and, oh, I don't want to talk about it. So I think this genderised medicine really worries me, because then it's like thinking my ovaries are only about reproduction. Of course they're not.

Dr Karan Rajan [00:28:52] You know what? That's really good. And I think actually reframing women's health as health of women is spot on. Because even if you if we continue to talk about endometriosis. Endometriosis is labelled as a gynaecological disease. It's not. Because number one, it's probably part autoimmune, probably part inflammatory, probably part dysbiosis of gut microbiome, genetic, environmental and the ramifications of endometriosis are systemic. It affects hormones, metabolism, mood, so actually, it's a systemic issue, not a gynaecological issue, because then, by labelling it a gynaecological issue, you're almost, you know, psychologically preparing women to accept that the symptoms would be vaginal, pelvic pain. Things like that, period related. But actually, as we know, you can get full body symptoms with endometriosis. So actually, your point of health of women is apt for basically any, anything.

Dr Louise Newson [00:29:50] Yeah, anything. I totally agree, and I think having that mind shift then hopefully will help doctors to be educated in different ways as well. Because, you know, I'm not a gynaecologist.  I did gynaecology as part of my training, and I, it wasn't multi system enough, if you see what I mean, and being holistic as a doctor and an educator is really important.

Dr Karan Rajan [00:30:10] I mean, meaning that I'm not a gynaecologist, I've had interactions with young women who have eventually referred to gynaecologists. I've scrubbed in in joint operations with gynaecologists, and I've seen endometriosis. And honestly, when I first saw endometriosis, I didn't know what I was looking at. I called the gynaecologist in, they said that could be endometriosis, and I realised, if I'm going to be a holistic surgeon, I need to go to more gynaecology operations and look at what things could be overlapping with mine. And that's again, part of that education that we're talking about. I learned general surgery. But general surgery is a very narrow field. It requires input from vascular surgeons, urologists, gynaecology, sometimes cardiothoracic surgeons. So actually, going into those other surgery and learning more about those things are as important as become a specialist in your specific area.

Dr Louise Newson [00:31:02] I totally agree. I think the more we can work with others collaborate but think about the person as a whole. It's so important. There's so much really to unpick. But I just wanted three take home tips. Is it possible, three things that you are most proud of that you've done as an educator?

Dr Karan Rajan [00:31:22] I think number one has to be advocating for people and patients and knowing that they don't have to just accept information that's given to them that they have. You know, the option to counter that and seek second opinions and go to the table with more knowledge. Secondly, would be trying to laymanize, medical education as much as possible. And I feel I've really kind of, you know, that's the hill I'm willing to die on. I mean, I think that's what's needed. There's a lot of jargon that we still use. I probably still use as well, and it's making that accessible to as many people as possible. And thirdly, it's de-tabooing the taboo, whether it's, you know, health of women, or weird things, talking about constipation, about bottoms, about discharge, about all sorts of other things, and I think breaking the ice. So that word taboo should not be associated with any disease or condition, because your mother, your father, your sister, your wife, may suffer from these things. So, you know, why should it be... there are people who die of embarrassment. You know, I had a patient of mine years ago who had metastatic colorectal cancer. It spread throughout the body. It could have been picked up earlier. They had six weeks of painless rectal bleeding, and they were just embarrassed about going to the doctor, and it could have been caught up then. So that person, in that case, was literally dying of embarrassment. You're at home, you've got bleeding, and you're too embarrassed. And I think that's also quite something I'm proud of.

Dr Louise Newson [00:32:53] Really important. Keep going and keep educating. So thanks for coming today.

Dr Karan Rajan [00:32:58] Thanks for having me.