Eric J. Topol, MD: Hello. I'm Eric Topol, editor-in-chief of Medscape, and we've got a great conversation today with Dr Jen Gunter. She has a new book and we're going to be talking about her career, which has been rich. Jen, welcome.
Jennifer Gunter, MD: Thank you for having me.
From Canada to California by Way of Kansas and Colorado
Topol: I thought I'd start out with your time in Canada. You were at University of Manitoba, University of Western Ontario, and then you came to the United States. What was going on back then?
Gunter: I finished my OB/GYN residency at Western in London, Ontario, and I wanted to do a fellowship in infectious diseases and women's health, and that was not available in Canada. I think there were only two programs at the time in the States, and only the University of Kansas was willing to help me with my visa, so that is where I went and how I ended up in Kansas City.
Topol: You also trained in pain medicine?
Gunter: Yes. I thought when I was going to do infectious diseases that it would all be toxic shock syndrome and HIV, and maybe HPV-related conditions. But what turns out is that everybody sends you their patients with vaginal discharge. So when you are able to help those patients and make them better, your referring providers say, "Oh, since you fixed my patients with vaginitis, I'm going to send you my patients with vulvar pain." You figure out how to help those patients and then they start sending you their patients with pelvic pain.
Along the way, I decided that I should do some courses in pain management. I was really lucky that my anesthesia department was very receptive to me coming down and learning how to do blocks. They were really great. They were like, "You're a surgeon. Of course you can learn this." I was like, "You're right. I am a surgeon. I can learn this." Then I did the boards for pain medicine. I felt that I should try to get myself sort of legitimized in that way. There was a need there. No one was looking after these patients, and as you know, pain is not taught well in medical school or really residency—I think across the board. I'm boarded now in both OB/GYN and pain medicine, and that is how I got into pain medicine.
Topol: Then you went into practice in OB/GYN in California?
Gunter: I was at the University of Kansas for about 6 years. Then I moved to Colorado and we were there for about 4 to 5 years. My sons were born there and they were really suffering from being extremely premature and having lung disease of prematurity. Oliver also had a complex atrial septal defect and a critical pulmonary valve stenosis, because it's not enough to be 743 grams. After those were repaired, he was still on and off oxygen because of his lung disease. Every time he was admitted with pneumonia, he'd be on oxygen again for 2 or 3 weeks. It was ridiculous, so I decided that I needed to get to sea level. That is how I ended up here.
Helping Parents Navigate the System
Topol: Got you. Back 16 years ago with your triplets and the problems with your two sons who were born, you found that there was not much good information out there so you wrote a book [on preemies]. Is that right?
Gunter: I remembered sitting in the neonatal intensive care unit with other moms, who you get to know very well because their babies are also there for months on end. I would hear them having difficult interactions with healthcare providers. I'd be sitting in the lounge saying, "Why don't you say this?" or "Use this word." [And as they grow,] these kids need to have their eyes checked and they go to all these specialists for follow-up visits, so you really get to know these moms and dads. I just started giving people tips and tricks. I started realizing that when my kids had health problems that medicine didn't have answers for, I got sucked down the rabbit hole of misinformation on the Internet. I have always been "Miss Evidence-Based Medicine." I've always been the person who is the nuisance sitting at the back of grand rounds, throwing my hand up and going, "That's not quite what that study shows." I thought if that could happen to me, it could happen to every person, so that is why I decided to write the [ The Preemie Primer ].
Topol: Do you think your [focus on] evidence-based medicine (EBM) is from your Canadian background? There is quite a bit of emphasis in Canada on that.
Gunter: I think so. I feel that I had fantastic medical training at the University of Manitoba. We had a focus on evidence, but also a focus on empathy and the patient experience. I had a really strong clinical and medicine background. At the University of Western Ontario, since we were so close to McMaster, which is such a seat of EBM, we had a lot of cross-pollination. It was very emphasized. I went to a very traditional residency. There were no work-hour restrictions and we had to go to Saturday school, where people presented cases. There were no weekends off. It's not how it should be. It can get vicious, but you have to come prepared.
Starting a Blog
Topol: You started a blog around 2011; is that right?
Gunter: Yes. I finished writing the book and I had this chance encounter with a woman in marketing, who was sort of a friend of a friend. I think her kids attended the same school. She said, "You need to start a blog and get on that Twitter thing. You have a book." I was like, "I don't really know what a blog is and I don't really know what Twitter is, but if I can be a surgeon, I think I can do those things." I started the blog myself on WordPress, and if I can set it up, anybody can, because I was hopeless with computers. I started blogging on prematurity and had the Twitter account to support it.
After a couple of years, my kids were growing up and my prematurity-related needs for them were moving away. There is so much bad information out there about vaccines, so I focus a lot on conspiracy theories in vaccines. When you have two kids who are medically vulnerable and a kid who has had influenza and pneumonia twice and has been in the intensive care unit with it, you want everybody to be vaccinated. I thought, "Maybe I can do my little bit to clean up women's healthcare online." It was really that naive. I got my backpack on my back and I'm like, "I'm going to fix the Internet for women."
Countering Misinformation
Topol: You have done a lot more than that; you are well beyond women's health. In June you had this just extraordinary piece in the Lancet: "Medical Misinformation and the Internet: A Call to Arms."[1]
We are all poised in many ways to fix this problem.
I'll just get to the punch line where you say, "[I]t is simply not acceptable to me that quality research that can save lives and reduce suffering could be undone by a medical conspiracy theorist or a celebrity looking to sell supplements. Come join me in building a better medical Internet." That is a culmination of a lot of work that you have been doing over the past 8 years. Tell us more about that.
Gunter: As I mentioned in that piece, as physicians we think, "How can we fix this? It's so hard." Imagine how every premature baby used to die from lung disease and thinking, "We can't fix that; it's too hard." But somebody did. Somebody said, "Maybe it should not be too hard. Maybe we can learn about it." And now I have two 16-year-old children who, 30 years ago, would have been dead. This idea that problems are too big and not fixable just does not work for me. They are only too big and only not fixable if you don't do anything about it. We are all poised in many ways to fix this problem. Some people can research it. You can study how people get attracted to conspiracy theories, how they get sucked down rabbit holes of misinformation. We can study how to teach medical professionals to give information out to patients. We know that if you counter misinformation right away, you can make a difference.
We're all also vulnerable from the news media. Stories about curing cancer in mice become headlines and then your patient is angry because you can't do that. You say, "Well, it's a mouse study and you're not a knockout mouse, so it's a bit different." But that is hard to explain. Even online, just the simple act of not sending traffic to bad articles and sending traffic to good articles tells media that we want more good articles. They are going to produce more of what gets attention. We're all poised to help in big and small ways.
I also think that doctors have to do a better job of communicating with patients, because many people turn to charlatans and snake oil salesmen because they have a veneer of empathy and they have a veneer of listening. Obviously they're selling product, so it's a veneer. I love Ben Goldacre's quote. He is a physician in the United Kingdom. I'm going to paraphrase it: If there is a problem with the airline industry, the answer isn't to invest in magic carpets.
Gunter vs Goop
Topol: Right. Also what you have done so well, I think the exemplar, is taking on celebrities. I know you are really good pals with Gwyneth Paltrow.
Gunter: Everybody needs a nemesis.
Topol: Tell us about the collision you have had with Goop.
Gunter: Right, the collision. A few years ago I didn't really know anything about Goop, but I wasn't spending a lot of time on celebrity misinformation, except in regard to vaccines. Somebody sent me an article from Goop on vaginal steaming. I was like, "What?" I was like, "I'm the expert. I run a clinic for vaginal vulvar diseases. I've run a clinic in this area for 24 years. I've done a fellowship in infectious diseases and women's health." I felt like this was my area of expertise. So I wrote what I thought was going to be a throwaway piece on my blog. Honestly, because I know all the literature, it took me 30 minutes to write and it went nuts. It went crazy and viral. I think I had maybe not realized how much people pay attention to celebrities. When Goop puts out a piece like on vaginal steaming, I liken them to couture in fashion. Chanel might say, "This is what we're putting on the runway," and only a very small percentage of people can afford it. But then all the other designers pick up on it and it trickles down and down and down and becomes the style.
We mistake repetition for truth.
When a celebrity talks about garbage like vaginal steaming, it elevates it. They use this great privilege that they have to elevate it. It shows up in People magazine and everybody writes about it. There is this phenomenon called the illusory truth effect, where the more we hear information, the more we mistake it for validity. We mistake repetition for truth. Then what happens is the little spa down the street opens up vaginal steaming, you can buy a bag of herbs on Etsy to steam in your vagina, and you can go to Amazon and buy a throne to sit on to steam your vagina. It's all based on misinformation, a complete lack of understanding of female anatomy and physiology, and, of course, profiting. I think the trickle-down effect is the most problematic. Also, nobody is improved by learning less about anatomy and physiology. That does not help.
Topol: You are a phenom on Twitter. I think [your account] says, "Come for the sex, stay for the science," or something like that.
Gunter: "Come for the sex, stay for the science. Come for the science, stay for the sex." I think about every great lecture that I've gone to in medical school or residency or just anywhere. If you just talk about dry statistics all the time and don't make it fun, it's hard for people to listen. When you have an engaging speaker that puts in personal anecdotes or has funny slides that are not pejorative in any way, they're just funny for being funny, I believe you are more likely to remember. If you can make knowledge entertaining, isn't that great?
Writing for the New York Times
Topol: No question. You are very good at that. You also started writing for the New York Times. Tell us about that.
Gunter: I've been writing for the New York Times for about 2 years after Goop, and I had a little back-and-forth where their editors called me "strangely confident" about vaginal health. I mean, what do you say to that? No, I'm appropriately confident. The most ultimate misogynistic statement is to decredentialize a woman and say that they don't have value. I think my multiple degrees and my 24 years of experience say otherwise. I'm not one to ever back down from that kind of thing, so I wrote a response that went viral, and that response got me interviewed by a reporter, Katie Rosman, for the Times, who did the profile on me.
Then a few months down the road, I wrote something that got a lot of men upset and they sent me all this nasty hate mail about my vagina. My vagina must be horrible. I'm like, "If you only knew." Apparently all the men in the world had a meeting about me and decided that I have a gross vagina. I was like, "Really? You guys should maybe focus on world peace or something." Anyway, I see a lot of women who have been told horrible things by male partners. That really has an impact. I just started thinking, enough is enough. I wrote this piece and I contacted Katie from the Times and said, "Do you think anyone would like this?" She sent it to her editor, who was a man, and he said, "Oh, my God; this is great and I'm going to publish it." That was the piece "My Vagina Is Terrific. Your Opinion About It Is Not." He came up with that title, which is awesome. Then he offered me a regular column based on that piece. I guess those columns did well enough and I was offered a regular advice column. It's called "You Asked." Anybody can submit questions and I answer them almost once a week.
The Vagina Bible
Topol: That is fantastic. I love it. Now, this book, The Vagina Bible, is exciting. I'm so impressed with it. My wife has read it cover to cover.
Gunter: Wonderful!
Topol: I have only had the chance to read parts of it. It's an amazing book. It's entertaining, it's encyclopedic, it's the evidence. Tell us what led to the culmination of the book.
Gunter: I was writing for the Times and writing my blog and still doing a lot of writing for other venues, like the New Republic and the Guardian. One day I was sitting in the office and I had honestly seen like three or four people in the past day or two that had used garlic in their vagina. Women don't just come up with this idea of sticking random vegetable matter in; they read about it online and they read about it from what look like vetted sources.
Some women said to me, "How could you not know this?" I didn't know. How can I have all this knowledge and how can we have all this great knowledge from science, and yet when you go online, this is what you find? I in no way blame the person doing the research. This is the fault of medicine. It's the fault of the Internet. It's the fault of everything else.
When I research things, I still pull textbooks off the shelves. I still use anatomy books and I still use my Blaustein's Pathology. I got really fixated on the idea of women having a textbook—a practical textbook, not like the boring kind where you are reading and suddenly you fall asleep and drool on the page and wake up with a big page print on your face. That has happened to me many times. I wanted a book that would be entertaining and lively, but also have facts. Fun along with the facts. So the next time someone was researching online or they read a headline, they could say, "What does Gunter say about that?" Then they could [refer to the book and] find [the answer] in an easy, accessible, non-clickbait fashion. That is how I just got obsessed with [the idea]. Initially I thought about doing a whole scope of reproductive healthcare [topics] and I thought that was too broad. We need to sort of separate them, so I just decided to write a book about the lower reproductive tract, and here we are.
Topol: I'm sure it's going to be a big success. There is nothing else like it; you did something that is so unique. How your career has led to this point is a great story. Obviously you have a lot further to go.
Should Doctors Be Bolder?
Topol: Doctors and healthcare professionals on Medscape could learn a lot from your bold and connected world. That is, you don't let stuff slide. You take it on. If it's balderdash or malarkey, you call it out. You do not let BS ride. Should all doctors be on Twitter? Should they all be connected? What is your advice? How do we go from here?
[Y]our patient is going to go out the door and needs more information than you have been able to give...
Gunter: I don't think everybody should be on Twitter unless it appeals to them. Just like not everybody is studying surfactant for premature babies, there are many ways that we can all contribute. But I do think that every single physician should have a list of resources to give their patients about the conditions that they treat. Because when you don't provide patients information about where you would like them to go online, they are going to figure it out themselves. Studies tell us that patients want their physicians to tell them where to go. Find good, curated resources and tell your patients about where they can go. Give them a handout. If patients have "email your doctor," you can email back with the links built in. Patients love that. For every medical condition that I treat, I have my top three links. I give people a handout on how to research online, what to avoid, and lists of red flags. Once you put that list together, you just have to look at it maybe once a year to make sure it's up-to-date.
Also, many different places, like the Journal of the American Medical Association and UpToDate, have premade handouts for patients that are really good. Every single professional society has those. Instead of sending patients out the door to go figure out their own skin condition, pain condition, heart condition, lung condition, arm them with where they should go. Every single doctor should be doing that.
Twitter can be a toxic place. It's not for everybody, and that is okay. There are many parts of medicine I could never do and I'm not suited to do, so we should all play to our strengths. But never neglect the idea that your patient is going to go out the door and needs more information than you have been able to give during your visit, and it's your duty to help them find that information.
Topol: That is where you are a model. It's not just women's health, Jen. You also get into other areas where this is off track, like the antivaxxers.
Gunter: Right.
Topol: This is formidable. We have the measles problem right now and more to come. Do you have any thoughts about how we can take on the wake of Wakefield and all the other conspiracy theorists there?
Gunter: We have to call out what is truly unprofessional. It's funny; a lot of people say, "Don't you think swearing is unprofessional?" I'm like, no, it's just choice of language. What is unprofessional is bad medicine. That is what kills people. It's killing children and adults with measles right now. Doctors who lie about vaccines, naturopaths [who discourage vaccines], and government officials who question [vaccines] are unacceptable. It is a good thing to figure out where that misinformation in your own field is.
There are some things that we cannot let slide. I think I got into vaccines because it was very personal for me, but I wish I just got into it anyway. Even if it didn't matter for my kids, it matters for someone else's. I've taken on other battles too, which in a way is interesting for me as a physician because then I have to research and learn about what I didn't know. That is a great way to grow professionally. I was asked to write about biotin supplements that are out there now for your hair (they don't work). I had to do a lot of reading for that one. It's really fascinating to learn something new. We didn't go into medicine just to care for patients. That is obviously a huge part of it, but I hope we all went into it to learn more as well.
Topol: You bring up the fake, the misinformation, and disinformation that is so pervasive. There are stem cell clinics, hydration rooms, supplements. It's extraordinary times to combat that. I think you are a call to arms. If every doctor were to weigh in, it could help this very distressful, vexing situation. I'm in alignment with you. I try to do my best, but you are so good at it that you are a great example for all of us.
Jen, it has been so much fun to have a conversation with you. We are wishing you great success with The Vagina Bible and your continued efforts. We will follow you on Twitter because there is a lot of rich stuff there. Your comebacks to the critique are as good as the points you are making. You are funny and entertaining; your New York Times columns are always right on. Jen, thank you so much, and the best of luck to you in your continued efforts to get medicine straight, and not just in women's health.
Gunter: Thank you so much for having me. This has been a lot of fun.
Topol: Medscape, we're glad to have you on this One-on-One with Jen Gunter and we're going to be following her along. Thank you.
