Orthobiologics: How Menopause and Hormones Change Orthopedic Care | Conversations in Regen Episode 24

Orthobiologics is reshaping how clinicians understand menopause and joint pain, revealing how hormonal shifts may be a missing driver of musculoskeletal degeneration.
Visit my Website : https://pxllnk.co/AD/BOBsite – Explore Orthobiologic Clinical Resources

This content is intended for medical professionals, including physicians and clinicians interested in orthobiologics and regenerative medicine. Patients are welcome to watch for educational purposes, but the discussion is not a substitute for medical advice.

In this episode, Dr. Ariana DeMers, known as the Queen of Business Orthobiologics, is joined by Dr. Nancy Yen Shipley to explore the evolving intersection of orthobiologics, hormones and joint pain, and orthopedic care in women. The conversation challenges traditional orthopedic thinking by examining how hormonal transitions such as perimenopause and menopause may influence tissue health, recovery, and treatment outcomes.

They discuss how joint pain in women is often managed without considering endocrine and hormonal factors, and why this gap may limit outcomes in regenerative care. The episode also explores how integrating hormonal awareness may enhance biologic strategies such as platelet rich plasma therapy and other orthobiologic interventions.

Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.

Learn More here: https://thebusinessoforthobiologics.com/programs-explanation 

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Transcript

SPEAKER_00 0:00

A significant proportion are going to be MRI negative. I think it's something like 40%, right? Are gonna have knee pain that looks like arthritis, talks like arthritis, you know, quacks, quacks like arthritis, and then they're gonna have a stone cold normal MRI. So what are these women actually missing?

SPEAKER_01 0:21

And why has medicine been getting it wrong for decades? Welcome everybody to Conversations in Regenerative Medicine. We are an exclusive web series of pioneers in regenerative medicine. We definitely tackle topics that are controversial and uncover cutting-edge insights that are shaping the future of interventional orthobiologics. So we are exploring the frontiers of PRP, BMC, MFAP, and all the controversies around these topics. So I would like to welcome Dr. Nancy Yen Shipley from the great state of Portland, right?

SPEAKER_00 1:21

Oregon, yeah.

SPEAKER_01 1:22

Wow, yes, but you know, Portland and Oregon maybe are not the same. So we love it so much. So Nancy Shipley is a board-certified fellowship-trained arthroscopy and sports medicine surgeon and regenerative medicine aficionado. She is a sought-after educator and advocate for hormonal health in orthopedics. And she has successfully built a whole person orthopedic practice of integrating, PRP, BMC, adipose therapies, as well as a hormonal health. And she is really passionate about helping physicians understand how the endocrine environment shapes regenerative outcomes. So thank you so much. She's also a founder of the podcast at the 6% at Nancy MD. So for all of you who want to tune into her podcast, this is you know in kind of highlighting women who are in male-dominated fields like our orthopedic colleagues. And so Nancy, welcome to the Conversations in Regenerative Medicine. Thank you so much for joining us.

SPEAKER_00 2:41

Thanks for having me.

SPEAKER_01 2:43

So for those of you who don't know who I am, I'm Dr. Ariana Demers. I'm also a board-certified fellowship trained sports medicine orthopedic surgeon and a regenerative medicine expert. I do a lot of training and educating both in orthobiologics and ultrasound, as well as teaching in the business of orthobiologics. I have successfully moved my rural Northern California practice away from insurance and focus on cash-based orthobiologic procedures, as well as a whole person health. And I am passionate about helping other doctors to incorporate orthobiologics and whole person wellness into their practices seamlessly. So for all of you out there, thanks so much for joining the conversation. We get to hear about internationally renowned experts in the regenerative medicine field. We get to explore controversial topics in orthobiologics and regenerative medicine. And our goal is to help all of you gain actual insights that you that you can actually implement in your practice immediately. And then our favorite part is to have these live QA sessions to get all of your burning questions answered from our experts. So the orthobiologics, I believe, will be first-lane treatment in for musculoskeletal care in the next five years. And the train is leaving the station. And if you are not actively offering these treatments for your MSK patients, you gotta get on the train. The problem is that successful integration orthobiologics is sometimes hard. We know orthobiologics is the best treatment for our patients, but how do you successfully launch these programs? Maybe you've tried some things, but maybe you're a little unsure about the science or the technique, the cash-based business, how to talk about money, marketing sales. And maybe you thought, gosh, you know, I'd love to do it, but I'm just not good at business. But it's not our fault because we did not learn this in school. And for those of you who are in private practice, maybe some of you are struggling with how do we be successful in this cash-based business and capitalize on the $4 billion orthobiologics market out there. And maybe some of you are thinking, gosh, I deserve more. Why is this so hard? So if you are struggling and would like to have more success in your practice, please in the chat just write kind of what you wish you had more guidance on. And we'll hope to talk about that in the next 60 minutes. So how do we win? While we are gonna talk about the science today, we also need to consider how we talk with our patients. So we all win, right? Our patients deserve this too. So we need a system, and we're not gonna go over this whole system today, but we are gonna get you a little further down this journey to be wildly successful in your orthobiologic practice. So we are going to get started, and I'm so excited to have Dr. Shipley here. So without any further ado, Dr. Shipley, we have questions. So let's get down to business. And this is really so fun. Now, you are a board-certified orthopedic surgeon. Okay, co-founded the Portland Menopause Collective. Now, that's not a normal combination that most doctors would expect, or patients for that matter. So, what made you realize that the hormones and orthopedics were not two separate conversations, but maybe different sides of the same conversation?

SPEAKER_00 6:45

Yeah, thanks for introducing me. And, you know, I've I've had an evolution of my practice. You and I both had some parallel experiences, you know, and we kind of go through the orthopedic training, and it's generally very cookie-cutter. And we are trained to be surgeons. And at least in my training program, I think, probably in yours too, there really wasn't a lot of emphasis on thinking about orthobiologics or even thinking about the person as a whole, right? Like, I mean, it is we we super specialize in our field. Like, not only are we just doing sports, might just be a shoulder person, you know. And I always joke with people saying, you know, I'm only a left shoulder person, I don't do right shoulders. But joking aside, you know, I think we're so super specialized that it's really easy to lose sight of the whole person. And we, you know, we we have the tendency to think about our our patients as conditions or or body parts in orthopedics. So for me personally, you know, I think the evolution into thinking more about the the more systemic transitions that we go through, and in particular in midlife, and in particular for women and perimenopause and all the hormonal changes that we experience was in part because of personal experience. You know, as I I was kind of going along, doing my surgeon thing, and then, you know, and I've always felt younger than my age, and then all of a sudden, this train that wasn't gonna stop just kept going, and I got one frozen shoulder, and then my other side froze, and and I was having, you know, but all the other perimenopausal symptoms too. And I I think, you know, I was already starting to pay a little bit more attention to, you know, what where does bone and joint health fit into longevity and health span? And I already had an interest in that. But then when it struck me, I was like, okay, I really need to rethink about how I'm serving my patients as a physician because what I've been trained on and what I what I know is not enough. And so that kind of led me further down the journey of learning more about not just regenerative medicine, but also thinking about how I can better serve not just all of my patients, but really kind of honing in on a group of patients who I think get forgotten in orthopedics in particular. I was already as an orthopedic surgeon getting a lot of second opinions, third opinions, fourth opinions and from women who weren't feeling heard, who felt like they were left behind. And so, you know, I really thought about that and thought about how am I doing, am I doing my patients a disservice, not being more aware of of where they are in their phase of life, what is happening hormonally. And so that ended up with me connecting with a group of other women physicians in very different fields, like a sleep medicine doc, obesity medicine doc, a hormone specialist, and forming the Portland Menopause Collective, where we hold educational events for both the general public and for others in healthcare here locally in Portland, but potentially beyond.

SPEAKER_01 10:37

Awesome, awesome. Yeah. So I think that so resonates with me. And I think the one thing that you said, and I I hope everyone heard this, is how are we serving our patients? And what struck me is my perspective on young and healthy and active when I was 35 versus 50 is different. And so I can just see this perspective of the, you know, when you're a young, healthy, athletic, orthopedic surgeon, you kind of write off the you know, the this older generation who now is very near and dear to my heart. And I'm like, I am not ready to be written off, and I definitely want to be performing at the highest level. And so I think it does deserve a uh a second look through a separate lens to be able to say, okay, this is not just some old lady washed up, post-menopausal, you know, decrepit, roll under a log kind of gal. And I think we all maybe need to consider that what that is maybe old thinking. Yeah, and I think there's a new paradigm that's coming into where you know hormonal replacement is gonna be more common, and our lifespan and our health span are going to continue to expand, especially with the focuses on longevity. So I have another question for you. When a patient walks into your clinic with joint pain, cartilage loss, tendon injury, and they are that perimenopausal, postmenopausal, how does that change your clinical thinking when instead of like that hormonally intact environment?

SPEAKER_00 12:36

Right. So, you know, if I take the first piece of that, and this honestly surprises my patients a lot, I will ask them, so where are you from a hormonal standpoint? And it literally, probably nine out of 10 women are shocked that I'm even asking. And I kind of have to tease it out of them because I'm like, no, this actually makes a difference. You know, are you having other signs or symptoms of perimenopause? And so I do a lot of education in my clinic, and I'll explain to them that you know, menopause can be a period of time that, or perimenopause can be a period of time of 10 years where your estrogen's kind of doing this while it's kind of starting to tank, but then it goes up and down, up and down. And that's why some of these, some of these symptoms, whether they're muscoskeletal or hot flashes or you know, mood changes, can be episodic and kind of hang around for a little while and then disappear and hang around. And, you know, and so I'm I am frequently educating that, hey, you know, this has a connection to what you're experiencing now from a musculoskeletal standpoint as well.

SPEAKER_01 13:49

Yeah, absolutely. Well, clearly we have more questions to ask you from as the specialist, as you know, the aficionado of orthopedics and hormone expertise. So there's this conversation in regenerative medicine about whether we're treating the tissue or we're treat we're treating the terrain. So, how does this in the endocrine environment fit into that conversation? And what what does it look like to get that terrain right or before the procedure? Is that is that something that you're considering?

SPEAKER_00 14:27

Yeah, absolutely. You know, and and I'll bring something else up that I frequently, this is how I talk to my patients about it. I, because I am a surgeon, I I will talk to them about, you know, what is happening structurally. So a good example here is if somebody is seeing me for their shoulder and they have, you know, an acromion that's doing this, right? Like you and I know, type three chromion, they clearly have an impingement. Maybe they have some AC arthritis, there are huge bone spurs that are guillotining their rotator cuff. Then there is a structural issue here that I'm going to talk to them about addressing, in addition to what orthobiologics may do for that poor rotator cuff that's being beat up chronically. So I will talk to them about treating the tissue, right? Thinking about biologically what needs to happen to help that tissue improve. But I also talk about structural, and this is where it marries well with the types of surgery that I do, which is, you know, I really focus on joint preservation and not letting somebody go on to hopefully go on to needing a joint replacement. But I will talk about like, okay, we need to decompress this from a structural standpoint, but you know, surgery is not the only answer because yeah, we can get rid of this bone spur, but then what about that poor tendon that has been beat up to hell for the last however many years? So that's where we need to treat the tissue. But then the the third layer of it, which is what you bring up, which is terrain, right? You know, what what about the background setting that this person is bringing to the table? And if they are somebody who is perimenopausal, estrogen is tanking, and we know that all of these musculoskeletal structures have estrogen receptors. So our tendons, our joints, you know, if if they on a systemic level are still kind of seeing their hormones kind of doing this, then we're missing a piece of the puzzle, right? And so, you know, there's there's the kind of the structural piece of it, there is the biologic piece of it of the local tissue, but also what are we doing kind of on the the more systemic whole person level so that once we do the surgery and you know, if we're doing these injections of PRP or or whatever, are the results gonna stick? Or are they just gonna have a new problem pop up?

SPEAKER_01 17:13

Yeah, you bring up such good points. You know, I I love the way that you think of it. I think of it in a similar way, you know, to get to the root cause of what the problem is, I think you have to say, okay, you know, do you have a structural problem? If yes, then maybe surgical intervention is part of this. Do you have a biologic problem? If yes, then, or the biologics is part of this conversation. Do you have a functional problem? If yes, then probably therapy is gonna be a part of this. And then do you have a background terrain problem? You know, are you optimized from a hormonal standpoint, from a cellular health standpoint? Do you have the building blocks to actually affect positive change in your body? Right? Are you gonna be able to do we we can set up the stage, but can you take advantage of this? And then the other piece of this puzzle, and I'm sure you're aware of this study that shows that hormone decline men and women are a big driver of arthritis. The difference is that women's hormone decline starts in the 40s and men's hormone decline or andropause starts in the 60s, and so this is a two-decade difference, which starts to explain why women have arthritis at such a higher percentage versus men, and so uh is there a way that we are able to kind of head the it this off at the past for everybody? Is this part of the solution?

SPEAKER_00 18:54

Right, you know, and and I'm glad you brought that up because you know, we as as we start seeing these hormonal fluctuations in women in perimenopause, you know, we start to see the appearance of joint pain, aches and pains, feeling stiff, and and a significant proportion are going to be MRI negative. I think it's something like 40%, right? Are gonna have knee pain that looks like arthritis, talks like arthritis, you know, cracks, cracks like arthritis, and then they're gonna have a stone cold normal MRI. And and these are the women that get blown off, that go to one or two or three other orthopedic surgeons before they land in my office. And and it drives me crazy to hear some of my poor patients say, you know what? I went to someone and they just said, you know what, this is aging. Get used to it. You're just getting old. I wouldn't, oh my gosh, I like I can't even imagine saying that to someone. It's I'm mortified for them. And there's just so much more to the story, like you alluded to.

SPEAKER_01 20:09

Absolutely. So you built your new office, form and function orthopedics, around this concept of treating the whole person, not just the joint. So, how much, and I'm sure everybody's wondering, how much of this whole person approach is hormonal assessment? How do you structure that conversation with the patient who maybe came in as like, I just want a cortisone shot. I don't I don't know about this hormone stuff.

SPEAKER_00 20:38

Yeah, it's funny, we get patients that come in who they just want a cortisone injection, right? And I take that as an opportunity to educate it, you know, just like you. I am very cortisone hesitant. We know that it has a detrimental effect on our tissues, on our articular cartilage. There are a few rare exceptions where I'm like, okay, let's go straight there. But, you know, I there are going to be patients that are gonna be undeterred, but uh it's my duty to educate on the risks. And if they say, you know what, I I take that risk, I still do them, you know, I'll still, I'll still give a steroid injection, but you know, not before I am giving them my whole spiel on why it's bad for you. And here are some better options, and you know, and I really try to cite the data without their eyes glazing over, you know, just I think that's part of the the art of medicine is being able to talk to a patient in terms that they understand, but also showing them what the evidence shows and also what your experience is as a physician. And you know, I really try to. To get them to wrap their heads around not just thinking of cortisone as you know a quick fix, because we know that there are consequences down the road. And I bring in the conversation of orthobiologics, I bring in the conversation of you know how other adjuncts might be helpful, like laser therapy, classware laser therapy is an adjunct that I'll use. And you know, and and really try to make sure they know what they're getting into when they're asking for cortisone.

SPEAKER_01 22:34

Yeah, absolutely. Yeah, I like the cortisone hesitant. I am like cortisone averse. And really, I think most of our patients, and you know, tell me if I'm wrong, but I think when patients understand that there are risks, and I think historically we have been remiss to talk about the actual risk of cortisone, the fact that it elevates blood sugar significantly, the fact that it has been linked with a cause of osteoporosis, that it does show weakening of the tissues and accelerating arthritis. Like if they were actually knew what they were signing up for, and my patients are like, oh gosh, I don't want that. And you're like, right, exactly. But I do think we've been quite remiss in having a balanced conversation about the actual risks, unfortunately.

SPEAKER_00 23:27

So yeah, go ahead. Sorry, I was just gonna mention, you know, like for me personally, this was an evolution. I did not come out of training with with kind of this philosophy. And just like everyone else who I graduated residency with, and especially, you know, the those of us that went into sports medicine or treating cuffs and you know, tennis elbow and knee arthritis, like I I like my colleagues just gave these out like candy. And so it's you know, I look back and I'm mortified, and I'm just like, oh my gosh, you know, I feel like I've been enlightened. And but, you know, the vast majority, I think, of of orthopedic surgeons are still like pew, pew, pew, pew with the cortisone, you know. So, so yeah, that that was a development that happened later in my career.

SPEAKER_01 24:21

Yeah, absolutely. Me, me too, honestly. This is an evolution. I've been doing it, you know. We both, I think, have been doing this for the last 20 years. And so if we're not evolving, I think that that's another concern, right? There's just so much new science out there. So I think evolving and reinventing yourself and reinventing how you show up in the world and how you show up for your patients, I think is really important. And you know, just to uh go with the dogma that we've out that we learn from our training programs and just perpetuate that forward, I think deserves some scrutiny for sure. So clearly we have more questions for you. So I think we are only six percent, one of six percent of the orthopedic surgeons, as am I, right? That are women. So that's a pretty low number. I think you know, maybe hopefully it'll it'll start raising, but it's been stuck at that percentage for a very long time. Now, do you think that that hormonal blind spot in orthopedics exists in part because it's been historically practiced by physicians who never think about their hormonal transition until much, much later? And what does that mean for all of our patients?

SPEAKER_00 25:40

You know, I think it it it is a yes and no answer, right? I I definitely think that that because the field is not quite balanced in terms of diversity, that women's issues tend to be put a little bit on the back burner. And yeah, and there for sure there is a blind spot. Fortunately, you know, more recently there have been papers on the musculoskeletal syndrome of menopause, and it's it's beginning to be a little bit more on the radar of orthopedic surgeons of all genders, but you know, it's interesting because you look at ob-gynes, right? And there are a lot of women Obi-Gaines. It's I don't know the exact percentage, but it's definitely not not flip, you know, it's the opposite, close to the opposite of uh what our field in orthopedics is in terms of gender distribution. But you look at you know how much damage the women's health initiative study had created in terms of hesitancy and fear to look at hormone replacement options as a treatment, and an entire generation of women who miss out on this. I mean, that a lot of that hesitancy, even within the the Gyne specialty, comes from that era, right? And so even in specialties where you have a balance of gender, I think that there has been a hormonal blind spot just kind of across the board because of WHI. And we're now seeing a lot more that the general public is being exposed to, us as in healthcare that are being exposed to about a lot of the things that have been disproven within that study and the actual safety of you know thoughtful and individualized hormone replacement, such that it's become so popular now that everyone's in a panic because the the estradiol patches are like running low and there's a shortage.

SPEAKER_01 28:00

Uh yeah, I totally hear you. And I think you're exactly right, you know, my husband's in OBGYN, and so we have kind of gone down this learning path together, and it's new and it's not taught in school. And so, you know, seeking out this knowledge when reality kind of hits head on with what you learn in school, and you're like, gosh, that's this is not in the textbooks. Um I think this is this is a hot topic, you know. Everybody's talking about it, you know, there's hormone replacement clinics popping up all over, and with the internet, like man, you can get anything under the sun apparently off the internet. It just depends on safety. But I think that's a a really good point that it's not just a blind spot in our speciality, I think it's a blind spot in medicine. True. And uh, you know, the tide is turning, but it's gonna take uh a whole lot of education, and it it does break my heart that an entire generation of women have been condemned to worse health from that single study. And hopefully, we hopefully we can kind of write that ship and improve about you know our lifespan, our health span, in part with thoughtful hormone replacement, both men and women. Um so if you can go back and tell yourself one thing at the beginning of your orthopedic career about hormones and musculoskeletal health that you now know, what would it be? And and you know, you know, the second part we talked about, but what is that one thing that we you were like, oh my gosh, this makes so much sense?

SPEAKER_00 29:45

Yeah, you know, I and and I feel like I'm still learning so much every day, right? I'm I'm on this journey of better educating myself as well. But you know, I think if I looked back to when I first started treating patients coming out into practice, you know, I think I really wish I had a much more of an awareness that that tissue age or tissue conditions and chronologic age are not always this the same. They're not on the same path. And that the environment, the environment of their, you know, their hormone status, their endocrine environment is is such an important variable. I really just wish that I had taken this path to thinking about the whole human way earlier than it took me on my own, right? And it really wasn't until I started to experience things myself that I was like, oh my gosh, I have been missing something this whole time, and really just, you know, in some ways doing a disservice to my patients. And I can't believe I practiced for so long that way. So, you know, I think I think some specializing is good, right? Like there's the data of, you know, what is it, like 10,000 hours of doing something to become an expert. Specialization is good. We know that, like, especially in surgery, you have better outcomes if you do a lot of something, right? It makes sense. And so I'm not knocking the idea of specialization, but I think we gotta really just hang on to a little bit of a holistic approach and and maintaining that awareness. Like, I'm I'm not the one prescribing hormone replacement therapy, right? But but it's it's the awareness of how that that plays into their overall health and and their musculoskeletal health that I think needs to be in place.

SPEAKER_01 31:45

Well, you just took the next question right out of my mouth. I was gonna ask, number one, are you testing for your patients' hormones? And number two, are you prescribing hormones for your patients?

SPEAKER_00 31:57

I am not right now, but I have, you know, some really just our our community here in Portland is great, very close-knit, very collaborative. And I have several people that I have on speed dial and that I also refer to frequently and partner with to make sure that this is being addressed. So, you know, I still have a fairly traditional orthopedic practice in certain ways, but but you know, like we've talked about things that really differentiate my approach and more of a holistic approach to bone and joint care. But I do refer out to some partners in the community where I identify somebody as like you're not getting the appropriate attention to your current hormonal status. And if they have already been seeing their PCP, they've already been seeing their guy and they're hitting a wall, and I know that they need more, then that's where I'll refer them to someone who really specializes in hormonal health.

SPEAKER_01 33:04

Awesome, awesome. So much, so much good is coming of this. So, you know, some of you I think are saying, okay, well, what's the next step? How, you know, should I do hormones? Should I not do hormones? And you know, for the orthobiologic practitioner, we've we've really started to talk about this orthobiologic knowledge base and this regenerative medicine consideration. And now I think we need to also have this knowledge under our belt, but figure out how to use this knowledge for the right patients. How to either attract the right patients or care deeply for those patients who really do need a more thoughtful approach, a whole person approach. So this is our orthobiologic practice lunch system with orthobiologic knowledge, how to attract the right patients, how to create a sustainable cash-based business, how to talk to your patients in a way that it just makes sense for them to go forward with orthobiologics, with hormone considerations, improving the terrain, and then clearly uh putting it all together for success. So I I did want to go ahead and put a little shout out. This is Dr. Nancy Yenshipley, and I I wanted to direct you. These are her how you can get a hold of her. This is the form and function orthopedics. F2ortho.com is her practice, her new beautiful practice. It's amazing. Or her brand is Nancy M D. I I said that. Man, that's lucky. That wasn't taken. All right, that's great. And my favorite new thing that she is doing and talking about, we've been talking a lot about lifespan, we've been talking a lot about health span, but she's got something new for you guys. So this is a joint span. So, Nancy, can you talk a little bit about this? This is a little quiz on your website, uh, the F2 organization site.

SPEAKER_00 35:09

Yeah, so you know, I I really feel that when we think about our joint health, that it is a major foundation of longevity and health span. And so that's where I came up with the the name joint span, because if your joints, if your musculoskeletal system is optimized, then that is going to ultimately positively benefit just about every other system we have, right? Like your joints are working well, you can achieve good cardiovascular health, you can achieve good brain health. So there's there is that link to our muscoskeletal system to just about everything else. And so I created this concept of joint span and separated it into a number of levels, almost like you know, steps on a stair, where you can take this quiz. I purposefully made it really simple. It's not like you know, taking the SATs or the MCAT all over again. It's a very short quiz and it gives the quiz taker an idea of what level they fall at, taking into consideration what they're capable of, what their recovery is like. And then based upon that, I have recommendations for what might help you get to the next level. And some of it, some of it is, you know, what when you know us in healthcare are going to say, well, duh, you know, this is this is these are the basics. Like you can't get away from the basics to optimize your muscoskeletal health. But I also mix in sort of where orthobiologics might fit in to help you get from, you know, level two to level three to level four, right? And be maximally optimized, which then will translate from not just joint span and longevity of your joints, but overall longevity and health span.

SPEAKER_01 37:16

Awesome. Well, congratulations. That's quite an achievement. So for everybody that's interested, head over to her website, ftortho.com, take the quiz, check it out, and really start to consider how it is that we can think about joint span and health span and lifespan in a different consideration in this whole person health application. So congratulations. I did want to, for those of you who are interested in really kind of that next step and saying, okay, well, how do I do this? How do I put all the pieces together? I don't know what to do, I don't know how to start my orthobiologics practice. I wanted to invite you to an event that we're putting on. It's put on by TrueMD, which I am one of the founders of. And this is a three-day immersive event to engineer a predictable cash pay practice. This is in Scottsdale, Arizona, June 5th through the 7th. And this is an intensive. You're going to be working side by side with the experts to construct your 90-day plan for a full launch of a successful comprehensive micro practice for orthobiologics that is built alongside your existing practice. Additionally, this includes two-night stay at the Phoenician on Us, as well as the online MSK Ultrasound Shoulder Primer. Also on US, put together by AMSKU, the great Colin Rigby and Ryan Martin. For those of you who are not familiar, AMSKU is one of the premier ultrasound guided platforms to learn ultrasound at a very high level. We'll also be implementing the AI practice tools implementation. So, how do you harness AI to be able to launch these streamlined micro practices? And then clearly these 90-day cash-to-pay revenue infrastructure framework that we're going to create days zero through 90 in a private personalized implementation environment. So I am going to offer that to you. Please, please, please consider. I'd love to see you all there. This is a personalized, limited to 40 physicians. So once we hit the 40 physician cap, we cannot accept any money else. So please get there or be square. Uh this is the little QR code. We did miss that April 1st deadline, but scan the QR code. Please come see us, and then we're gonna go to our question and answer. So thank you so much. I will go ahead and get to these uh questions. So we have a couple of questions in the chat. If you guys have any questions about you know orthobiologics and hormones, uh considerations, how do you kind of merge these in your practice? We can talk absolutely about that. This is one of my passions as well to be able to merge this seamlessly. So JP says, great talk. What about men? Would you recommend prophylactic TRT to offset arthritis? And could you prescribe testosterone gel instead of injections? And I think that's a really good consideration. What do you think, Dr. Shipley?

SPEAKER_00 40:42

Well, you know, I don't, I don't prescribe testosterone myself, and so I'm not doing the one prescribing hormones and so, and I'm not an endocrinologist. And so, you know, we we do know that testosterone is is anabolic, right? And we do know that this is going to, you know, have anabolic effects on muscoskeletal tissue, potentially improving your lean muscle mass and improving your bone density. But, you know, is is there the data to say, hey, this is gonna prevent you from getting osteoarthritis if we just just dose you up with testosterone in general? I I don't know, and and you know, Ariana, do you please comment on this yourself as well? You know, I don't know that there's enough data out there that I would be in a position to just say, hey, let's just let's just do this and we're gonna we're gonna prevent the arthritis. I'm curious what your take is because I'm not the one, I'm not prescribing that right now at all.

SPEAKER_01 41:41

So yeah, so in our clinic we do. Um, we have a much more comprehensive, you know, I am an orthopedic surgeon by training, but I've done quite a bit of a deep dive on hormone and BHRT and TRT replacement, as well as significant longevity training. And in the longevity circles, there is a concept of andropause similar to menopause. And we know that testosterone is anabolic and allows us to maintain our skeletal muscle mass. And we know that is one of the prime pieces of the puzzle to maintain and and prolong that health span. The more you can maintain your lean muscle mass, the the better chance you have of not only being able to be active, we know when you are active, our joint health actually is improved. The more weight-bearing exercise we can do, the the better the joint health is, the more responsive the cartilage is, the more responsive the subchondral bone is, and the more that you are exercising and releasing those myokines and those extra kines, we have significantly decreased systemic inflammation. And so, can we prove that adding TRT is a prophylactic treatment to avoid arthritis? I don't think that we can connect those dots. Do I think that consideration of hormonal status and longevity is a reasonable consideration to try to do your best to preserve the biology that you own and you know replace back to the level, not go, you know, overshoot at age 40 when you're not deficient. It's just replacing that deficiency rather than you know, kind of looking at these weightlifters and those kinds of things. That's that's way off to the side. So that's the and and then from from a testosterone gel versus injections, uh the topicals are less predictable for treatment, but definitely some somewhere to start. Click you injections twice weekly are the most predictable way to maintain a testosterone level. So we have another question for you. So she says, Good evening. Thank you so much for this presentation. I'm a physician in women's health looking to start some regeneration. Of medicine within my cash pay within my practice as a cash pay service line. We currently are insurance based. Can you talk a little bit about how you offer these things to your patients without sounding like a saleswoman?

SPEAKER_00 44:13

Yes. So, you know, and I know you have a lot to say about this too, because I I've spoken to you about it and have certainly learned a lot about it from you as well. But in in my practice, you know, I'm I am talking about orthobiologics to just about, I mean, it really should be all of my patients in how this may play a role, but you just about everybody, because you want to you don't want to hold something back that you know is gonna make them better and feel bad about you know it being not covered by insurance, right? And so, so I I would say that, and and I'll try to organize my thoughts because it's such a multi-layered question, right? I would say that because I have positioned myself, and if you look at one my website, it's clear I'm an orthopedic surgeon, I do surgery, but I also make clear that that I offer regenerative medicine, I think about the whole human. And if you position yourself and your outward-facing materials, whether it's web or you know, social media or wherever, your marketing, as this being a cornerstone of what you offer, then then that creates the funnel where the people who seek you out are gonna expect you to bring this up, right? And so I think that piece of it is really important. Now, of course, I'll have people just looking for any orthopedists and maybe they're they're not looking at it deeply, but our patients are such savvy consumers now that most of the time they have researched you before they've even called your office. And so what I found, and it, you know, it's not like this is some kind of magic, but you know, what I found is if you talk about it, then they're gonna want it. And so, and then and you're not selling it, you're presenting things that will interventions that will help them get better and help them feel better. And so, you know, the the outward-facing stuff, I make sure that that my practice is is known for offering regenerative medicine. And it's also clear on there that like I always mention the insurance doesn't cover this. And so in my office, when I am presenting different treatment options, you know, I I just say, well, you could, you know, these are the things we do, right? We can we can look at structural issues, functional issues with PT. This may benefit you. Some people will get steroid injections. This is why I don't like them. We could also do PRP. This is why I like it. These are the upsides, these are the downsides. We know there are not a lot of downsides, and I kind of present all the options, but then I will sort of kind of cone down on what I think their treatment plan should be and what I would do if this was me, because XYZ. And and I think when you when you present it in that way, and and I still include like what the traditional you know ortho might do, but I educate them as I'm going along, you know, talking about it, it naturally will most of the time the the patient's gonna say, oh well, what you're saying makes sense. I I trust you, doctor, and yeah, let's do that. And then I'll bring up that, you know, insurance doesn't cover this right now, but I'm not going to limit what I present to you and what I offer to you because Aetna says that they're not gonna pay for it, right? Like they're not your doctor. And so that's how I address that piece of things. So Ariana, I'm sure you you have a lot to add to that.

SPEAKER_01 48:13

Yeah, so that's perfect. And it is just education. And I am gonna go a step further and just leave people with this thought because a lot of us physicians have this uncomfortability about coverage and what insurance will cover, and a majority of physicians only offer what the insurance company covers, and I would go so far as to say that is not ethical. And here's why if you are restricting what you offer based on what the insurance company has decided that is financially beneficial for them, you are now restricting care for your patients, and so, like you said, we know that PRP is beneficial. And if you don't talk about this and you don't talk about this natural, super beneficial injection that outperforms cortisone, it outperforms hyaluronic acid, and now you're not allowing them to even make that decision themselves because they didn't even know about it. You neglected to educate them on all of the options. Now you're doing the work of the insurance company and restricting their care for free. You're working for free for the insurance company.

SPEAKER_00 49:36

That is an excellent way to put it.

SPEAKER_01 49:39

Which feels kind of right? Yeah. So, yeah, and then the other piece is it's not sales, this is just education and guidance. This is helping them understand all of their options and what you think knowing all of the pieces of the puzzle would best serve them to get the outcomes they're looking for. That's all.

SPEAKER_00 50:05

And you know, and I went through this evolution as well because I, you know, we as physicians are really not comfortable talking about money. And and we just kind of have to get over it, right? Because, you know, what I've found, and I don't remember who in our our kind of circle of regen people we knew said this, maybe it was you, where if somebody says, Well, how much is it gonna cost? Insurance doesn't cover it, how much is it gonna cost? And I'm just gonna throw a random number out there. Let's say like 5,997, because I like odd numbers. And you just say, Well, it's five thousand nine hundred and ninety-seven dollars. Silence, stop, you know, and you just that is my favorite what it is.

SPEAKER_01 50:54

That is the price, that is the price, and and you don't have to justify the price, and you don't have to like back talk and be like, Well, you know, I ah, I'm so anxious about this, right? Please don't allow your anxiousness about talking about money bleed into how they uh receive this information because if you're anxious about the money piece, they think that the treatment, there's something wrong with the treatment. And those two are not connected, so yeah, just breathe and just give them the price and say, Would you like to book? Please don't justify the pricing, right? So you absolutely that that is that is from me. So I just wanted to put this on the screen. This is my quiz to see where you fall into whether or not you want to incorporate orthobiologics into your practice. Are you ready? Do you have, you know, clinic capital workflow readiness? Do you have the legal freedom? There's a lot of physicians who are currently employed and have non-compete clauses. And this has been a massive issue that we really have run into as physician practices got bought out by hospitals and now that we are employed. But what we didn't do is look at the non-compete clauses before just signing our life away. And this has really started to restrict physicians from escaping out from underneath these big health conglomerates. So everybody go home tonight. Please evaluate read your restrictive covenants uh and see how hard or easy it may be to start a separate cash-based micropractice for your orthobiologic practice. So we have about four more minutes before we are at the top of the hour. If there's any other questions about Dr. Shipley, about her awesome joint span program or her six percent podcast, please, please, please don't hesitate to ask. And if you want to know how and get the the all of the the details done and executed for your 90-day plan, please come to Scottsdale and join us for our cash pay launch pad live practice. If you missed that QR code, it's right here. And I would love, love, love to see you all there. It's gonna be myself, it's gonna be Dr. Colin Rigney with AMSKU teaching ultrasound live to you. It's amazing. He's a master, he makes it look so smooth, so easy, and he can get you up to speed very quickly. And then finally, that entire marketing piece with Atiba Disusa. So please, please, please. This is this is good stuff. This is why we created TrueMD so we could help everybody engineer a cash-based practice that they deserve, and that their patients deserve to have more of you. All right, Nancy, anything else you want to mention about your practice or how to reach you?

SPEAKER_00 54:09

Yeah, you can reach out to me through my website. I'm also on Instagram and social media, and I try to make that part fun. I I think from a business standpoint, I think that's a really great way to kind of reinforce the no like and trust, which will help when your patients come in and you're talking to them about orthobiologics. And so I'm on Instagram as underscore Nancy MD, and YouTube is also Nancy MD. I'm on, I think most of the platforms, but mostly on Instagram and YouTube.

SPEAKER_01 54:42

So awesome. Well, thanks so much for being here. Thanks so much for spending your day. I know you were wondering if you were gonna get out of surgery, and it is it was pretty tight, but I'm glad you're here. Thanks so much for taking time out of your uh busy day and everybody.

SPEAKER_00 54:57

Thanks for having me.

SPEAKER_01 54:58

Thank you so much for joining us. I really appreciate all of the time that you spend with us. Hopefully, this has been helpful. Hopefully, this has piqued your interest. Uh, and please join us in two weeks for conversations in regenerative medicine. We have a really fun time, so please look out on social media for our next guest. I'm gonna keep it a secret, so keep your eyes peeled. This is quite controversial, and I'll give you a little hint that it's our guesses from down under. So I will see you in two weeks, and everybody else take care. Be good to yourself, and you deserve a cash-based practice so that you can practice whole person medicine and do a great job for your patients and have a sustainable practice. All right, everybody. Take care, and we'll see you next time.