38. The Evidence Behind Physician Coaching with Drs. Tyra Fainstad and Adrienne Mann

There is a fair amount of skepticism surrounding the effectiveness of physician coaching, so it’s exciting to share the recently published research demonstrating the efficacy of this incredible tool. Dr. Tyra Fainstad and Dr. Adrienne Mann were the principal investigators of the randomized controlled trial published in JAMA in October 2023. Both practicing physicians are certified professional life coaches and co-directors of the online group coaching initiative known as Better Together Physician Coaching.

Dr. Arpita Gupta DePalma and Dr. Michael Hersh discuss their program and the research efforts that substantiated the effectiveness of physician coaching. They also explore the lingering cynicism associated with coaching. Tune in to discover the profound impact coaching has had on their lives and their shared mission to transform the culture of medicine.

What you'll learn:

  • The results of the recent RCT on physician coaching published in JAMA
  • Quantifying burnout using the Maslach Burnout Index
  • The Better Together program and the benefits of group coaching

Featured in this episode:

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38. The Evidence Behind Physician Coaching with Drs. Tyra Fainstad and Adrienne Mann

Michael: Well, hey everyone, and welcome to another episode of Doctors Living Deliberately. Thank you so much for joining in with us today. And of course, welcome to my co host, Dr. Arpita Gupta DePalma.. How's it going? 

Arpita: It's going amazing. I'm so excited about today. 

Michael: Me too, because You and I, we love to talk about coaching, and there is so much skepticism, right? And I know that I experienced a ton of skepticism before I signed up for coaching. You've talked a little bit about what that was like for you. And now, there are some really amazing studies that show, that prove, that have evidence that coaching works. And we are so excited to have with us today, Dr. Adrienne Mann and Dr. Tyra Fainstad here to talk about their latest research and their latest publication. And so welcome Tyra and Adrienne. How are you? 

Tyra: Thank you so much. So thrilled to be here. Hey, 

Adrienne: That was my favorite introduction ever. We're so excited to be here with you both today. 

Michael: Well, thank you. Well, I'm going to briefly tell our audience a little bit about you guys. And then I want you guys to take it away because you guys have so so much to share. So Dr. Adrienne Mann, she is a, an assistant professor of hospital medicine at the University of Colorado and the Rocky Mountain Regional VA Medical Center. And she's also the associate program director for the CU Internal Medicine Residency Program. And Dr. Tyra Fainstad is her co founder of the coaching program, Better Together. And Dr. Fainstad is the Associate Professor of Medicine at the University of Colorado. She's a primary care physician and the resident clinic director for internal medicine trainees at the Lowry Internal Medicine Clinic.

So welcome again to you both. So tell us all the things. So you guys are co founders of Better Together, which is a coaching program aimed at residents and fellows. And so what brought you guys to coaching? Tyra, let's start with you. How did you find coaching? 

Tyra: Yeah, well, I'm so glad that you already opened with this because I found coaching in just a whirlwind of skepticism. And also a whirlwind of my own personal burnout. So, I found coaching at a time when I was, had made the transition from residency to early attending -hood. I was in the University of Washington at the time, in Seattle, and I was a pretty classic, like, approval addict medical student and resident and I was just bolstering myself with like positive feedback that I was getting. I think as many of us do and then when I made that transition to being an attending all sources of feedback stopped and I had no constant stream of dopamine telling my brain that I was okay and so my brain just did the natural thing and told me that I was totally not okay and doing a terrible job and probably made the wrong choice.

At the same time, I had a couple of kids pretty early after graduation, and they also did a terrible job of telling me that I was okay, and pretty much constantly told me that I was doing a bad job, or that's what I interpreted their very colicky infancy as. And so I was just in this, like, Vortex of pain, thinking that I was bad at work and bad at home, being a bad mom and I did the very doctory thing of trying to fix it by like diving straight into it and I read all the things and I asked all my friends and that wasn't working. I got on an SSRI and that wasn't working. I thought maybe I needed to scale down at work. So I scaled down and that didn't work at all, actually. So I scaled up at work and that wasn't working. Nothing was making me feel better, which is what I was craving until I had a friend going through Coach certification. And she offered me a session in return for feedback for her certification program. And I just like, I rolled my way into that conversation because I was an academic doctor at the university of Washington and life coaching sounded like not a thing, like certainly not a thing. I mean, it was maybe like in the lines of I don't know, cheerleading or something very not evidence based. But she was a dear friend so I agreed to have this conversation. And I mean, I don't think I have to tell you two, because you probably have similar stories. And I know Adrienne does. But even in that one conversation from someone going through certification, my whole life changed in ways that it hadn't in like the prior two decades and the things that she Basically just reflected back to me to allow me to question, like blew up my mind in a way that I just hadn't experienced before.

So I was totally hooked. I invested in coaching for the next couple of years and was very, very grateful and also like a little pissed that no one offered this to me in medical training, like, how in the world are you teaching me how to go into the depths of human experience without armoring me with like easy concepts as like how to name and process an emotion I'm being thrown into like, you know, basically death world without knowing how to recognize my own thought as separate from reality or how to how to process an emotion. So along that same line, Adrienne was having similar epiphanies. And we met up.

Adrienne: Yeah, my path is eerily similar to Tyra's. I have a folder in my inbox that goes all the way back. So I did medical school residency and and have stayed on it to you. And I have a folder in my inbox that goes all the way back to medical school, which I think is not called dopamine, but might as well be called dopamine. And it's just like a repository for anything I can read if I need to feel good about myself, because I'm not going to get from the outside. 

But similar to Tyra, I think I like, you know, My version is a little bit different, but I probably had some dips in with burnout as a medical student, as a resident, and then my thing is, was that I was really good at knowing that people I idolized or people who were mentors to me or something like that, like, probably knew better for me what I should do than I knew for me, like, I think I made it through medical school and residency, like, fully believing that anybody out there probably knows better what I should do than I possibly could. And so in medical school, that looked like an incredible woman who was a surgery resident saying, you should be a surgeon, and I was like, maybe I should be a surgeon. Or you know A fellow who I worked with who I love said, you should really be a cardiologist and I thought, oh, yes, I should be a cardiologist because the hard thing that someone else thinks I might be good at is probably the thing for me.

Also, like Tyra I had two kids, one at the end of residency, one early in my faculty career. And by that point, I had kind of started chasing down all the things that people told me I might be good at at like 100 miles an hour. So I was pursuing, like, I think I'm a big E medical educator and I think maybe I should do institutional leadership and also I'm a mom now and I should be great at that all the time. And the bottom kind of fell out for me after I had my second kid and had some complications related to that pregnancy and the only strategy I think I had ever learned to process any of the uncomfortable emotions that I experienced during this time was eating and shopping. Those were like my go to things. And I, after being treated for some postpartum depression, and after coming out of that phase, I found coaching through Katrina Ubell, who helps women physicians lose weight. And through her program, I, my mind was blown that like eating isn't the only thing I can do to feel better. And I know that feels crazy to say, but I think I just had never learned that I could name and process an emotion I was feeling and that it was normal to be uncomfortable a lot of the time. And that like shopping and eating or drinking or binging on Netflix felt like self care in the version of self care that I had kind of learned about, but that really, really weren't. And what had happened in that time was I had lost any sense of touch with who I was and what was important to me or what I was meant to do. And so coaching helped me figure all that out. 

And Tyra and I kind of reconnected through a medical school colleague who was like, you guys are doing the same thing. Like we had both written nearly identical grants to support the development of a group coaching program. And so she was coming back to Colorado and we decided that we would be better doing it together. And so we created Better Together. I'm going to say real quick, it's not a company, we don't have any you know, financial stake in anything. It's a program we offer through the University of Colorado. 

Arpita: That is amazing. Such a awesome story. Each of your individual stories is amazing for experiencing how we kind of evolved and discovered coaching, but also just how cute with even developing the name, right? That's all. I mean, better together. It's so cute. Well, I, I don't know how much our audience knows in terms of what you guys have done since then. And when you started, I know we know obviously because we're privy to what's going on in the coaching world, but I would love for you guys to give a little bit of insight on what you guys have done in the past, maybe a little bit of information there, but then also expand onto what you've recently come out with that is just been a mind blowing and a great, I would say great leap in moving forward for all of the coaching industry, so 

Tyra: I hope it is that. That is the intention of studying it. And I just want to preface this by saying that three years ago, I fully owned the title of not a research person. Like, I, it's not even that I didn't like research, I think I loathed research. I thought that it was like a bunch of people just padding their resumes with stuff that didn't matter in order to like be in some paradigm that didn't matter and it was hard and I didn't understand it and I was like averse to it. I tried it because you have to in academia and it didn't go well for me. And then I just easily like fixed myself into the, I'm not a research person. And also as Adrienne and I created and then implemented better together, first at CU and then nationally, I did get interested in this idea. You know, we, we talk about it a lot and we laud coaching a lot, and we know that it works in our hearts and in our souls, but there are a lot of people that I wasn't sure if it was going to work for. It's sort of like, are we these special people that are open in just the right way to coaching? Or is it really a tool that anyone can use and improve in whatever way works for them? And I didn't totally know the answer to that question. And so I think I have to believe it's that question wanting to actually know if this was a thing that would work for many people that drove the research of this. It's like, are you doing this thing and you're just in your head thinking it'll be great or is it actually working? And I desperately wanted an answer to that question. 

So we piloted it. We created the program and then piloted it here at the University of Colorado in 2021. That was our first paper. We did a little mini randomized clinical trial with 100 residents. We, for that trial and for this trial have gone where the need is greatest and our main outcome is burnout. We are trying to improve burnout with this program and burnout is much worse in women than it is for men for a whole host of reasons, but especially in the resident and fellow population. So we initially targeted women for our intervention. Piloted it here, gave our program to 50 of them, did not give our program to 50 of them. They were our control group and delivered pre and post surveys with validated instruments of well being, including burnout and our program improved burnout and a couple of other well being metrics. We then delivered the program to the control group after the study was over. So no one was withheld coaching and it went so well that it got published and it kind of put coaching on the academic map. But I think the real thing that Adrienne and I learned during that experience was that while creating the program was a lot of effort and researching the program is a ton of effort, actually implementing it is relatively low hanging fruit for the bang that we were getting. Because what we do as a group coaching program like, I remember Adrian saying to me, you know, we could have 30 people on a call or we could have 30, 000 people on a call and it's the same hour. Like, why don't we go, in this conversation I still remember her saying, why don't we do 3 sites? And I was like, Whoa, 3 sites. Really? A multi site RCT. And she's like, yeah, it doesn't matter how many people are on the call. Okay. 

So then we start talking to other sites now it's 2022 and we're recruiting other sites to maybe be in this multi site randomized control trial. And somehow we had so much fun talking to people that we ended up with 26 sites. This person knows this person knows this person. And all of a sudden we have 26 graduate medical education, so residents and fellow physicians sites across 19 States. We had also collected a whole host of volunteer coaches. Thank you very much to all of them. And we mirrored the study that we did in 2021 with these 26 sites. So we delivered a randomized clinical trial. We now had just over a thousand participants. We put about 500 of them in the intervention arm, 500 of them were in the control arm. The intervention arm got the program in the fall. The control arm did not. We pre posted them. And this time we had an even greater impact in every single outcome that we studied. 

So, like, this is wild. And I think, I think what was happening is that we were not powered to find the full difference in our pilot. We had been told that with a power analysis. We did it anyways as sort of a proof of concept study. And then this was evidence that when you are powered, like, I don't even know what the limit is. We didn't hit a limit. We found a statistically significant improvement in all of our outcomes. So all three subscales of burnout, in moral injury, in imposter syndrome, in self compassion and in flourishing. And also those differences were clinically meaningful. So they weren't just little tiny decimal points. They were full swings, usually from highly burnt out, you know, to moderately or low burnt out or full swings across the spectrum in the intervention compared to the control group. It's the first study done in that way for a coaching program like this in, in so many people, which is important because research is not usually the first thing I think that people do in these spheres. And if they do research, it's usually something like a pre, post study, meaning they study everybody in a certain intervention and just see if they get better rather than comparing it to a control group, to weed out are there any confounders? And so people I'll say, like, kind of tend to disregard or think that that level of evidence is not enough to really substantiate what we're doing. And so, we're thrilled. 

Arpita: I love that. I'm just going to giggle for a minute because it's so much data and so much information that is like, if you understand what we're dealing with to try to prove how the evidence is there, and then we're just like, okay, yeah. It's amazing. And we did it. You know? 

Tyra: It was ridiculous. At the day, I could summarize that by saying it works. We proved it. It works. We knew it worked. And now it works. 

Michael: And so you use for the burnout, you use the Maslach burnout index, is that right? Do you want to tell right? Because I'm imagining that not all of our listeners understand, like, how do you quantify burnout? How do you show that physicians are actually quantitatively and qualitatively experiencing an improvement in burnout? So can one of you maybe shed some light on that? 

Tyra: Yeah, the Maslach burnout inventory is considered the gold standard for measuring burnout. It has three subscales; emotional exhaustion, depersonalization, and personal accomplishment. That last one, it's like the higher you are, the better. And the first two, the higher you are, the worse off you are. And they each have cut points for what's considered high, moderate, and low. And to be honest with you, they are validated, and what I believe that means is that they have been given over and over to a large group of people across cultures, across ages, across races, and over time. And Like if somebody scores this way, they also can substantiate that they're burnt out with many other inventories in a way that they can't with other scales. That's about as like nerd out E as I get around. What does it mean to have like this number on a validated instrument? It just means that it has like internal reliability, if it's delivered over and over again, and the powers that be that like giants that have done this work before us did that. And so then they could say, okay, this scale really works and it works over and over and over again. And so it seems likely that if someone scores up here, they truly are burned out. And it's not just a fluke. They're just having a bad day. Like this is true burnout. So we use that. We had to license it from mindgarden. com if you're curious. And that's how we measured burnout. 

At baseline our group of 1017 residents and physicians were all positive on average for burnout, mostly in the emotional exhaustion and also in the depersonalization scale. It's like 70 around three quarters of them were positive for the high cutoff of burnout, they were doing pretty bad. They were all on average positive for imposter phenomenon, had pretty low self compassion, pretty high moral injury. These are not new numbers, unfortunately, for people who describe wellbeing.

Arpita: Yeah. So I you know, we, I think are lucky because we have experienced the power of coaching and are reaping the benefits of coaching for our own sakes. And so, you know, to talk to somebody who is, has experienced coaching and as a believer, it's easy to understand the data and what you're saying here. So maybe Adrienne can you speak to the naysayers, right? Cause we have all the positive people that are in your court with regards to what this is showing. How do we address the naysayers who still, despite the data maybe don't understand the data, maybe you don't understand how it was done so that we can kind of be kind to them, but say, hey, this shit works. 

Adrienne: Yeah, you know, I think it does. And I, I don't think it necessarily has to work for everybody. And one of the things we'll often say is like, what we offer is one way of getting at some of these problems that we face in the profession that we hold. And if learning how to think about your thinking and develop a practice around that, like, doesn't feel like it's right for you, then that's okay, and it is one way that is evidence based for folks who do want to engage with themselves in that way. And I mean I think we all share anecdotally, like, learning the tools that I've learned in coaching and developing this practice has transformed the way I relate to my work, the way I relate to myself within my work, my relationships outside of work, my relationship with myself outside of work, like all of those domains of my life have changed. Do I still feel burnt out sometimes? Totally. Like, do I have more awareness into myself and where I'm landing? Yes. And so it's okay if folks are naysayers about it. If it doesn't feel right for them, that's okay. And for many, many, many people, it will be a very powerful intervention. 

Michael: Can you, Adrienne, tell us a little bit more about the Better Together intervention? We've been talking about the program, but how is it structured? How do the residents and the fellows benefit? 

Adrienne: Yeah. So what started as a six month program, we shortened after the first two cohorts to be four months. In our four month program, so it's 16 weeks, we cover kind of weekly topics. Those are in self study, like 10 minute kind of video modules that have accompanying worksheets, folks can go through those at their own pace if they wish to. We have between two to five group coaching calls per week, and so what that looks like is a call on Zoom. It's held in webinar format, so all of the participants on the call, anybody who's there is kind of in a room together, but they can't see each other, they don't know who's there, they can't communicate with each other, they're just in this room. And anybody who's there can raise their hand and come up for coaching. And that is with Tyra or me or one of our other, I think, 29 certified coaches who are also clinicians. Those one on one kind of coaching in front of the group lasts for between 15 and 30 minutes. And then we send that person back to the audience and pull somebody else back up. We know that physicians, especially residents are super busy. And so call attendance is not required. They come when they can. And then we save the audio, the call recordings and publish it to a private podcast that's password protected. So only members of the current group can go in and listen later on their way to work or when they're walking on the treadmill or whatever. And that is really the way the majority of folks participate is just by listening to the coaching calls later. They may not even ever raise their hands, but they'll hear other people get coached. 

And then the final way, we have actually two more ways, written coaching on our website. So folks can type in, Hey, I got feedback about this thing. This is what they said. This is what I'm making it mean. We will respond within 24 hours with some coaching prompts and then the final way we've recently added one on one coaching options for a couple of the arms that we're running right now. So we're offering that for GME and for faculty have the options for one on one and that's been another way for folks who maybe feel a little uncomfortable with the group format to get the coaching that they need with a certified coach in a time that works for them.

And I kind of think about that, like, like booking an appointment at a hair salon like they can book maybe with the same coach if they want over and over or maybe they just know that Friday morning's when they're available and they can put Friday morning in the calendar and get scheduled with somebody for Friday morning. So we try to make it as flexible as possible because we know that doctors are busy and so nothing's required. It's very flexible. Folks kind of choose their own adventure. 

Arpita: I love it. I think it's giving so many options and, you know, playing into the fact that it's there for them. It's there to help and whatever you can do with all the you know, exposure as minimal, I think we, one of the original studies said as little as six sessions, right? So six calls that you're listening to hearing other people get coached. If you're able to take some, some nuggets out of that and apply it to your life, you're able to make a change. And that's, that's important.

Adrienne: I have a theory for why the group coaching works, even though it's really uncomfortable. I'm like, I've been in a group coaching session and I have just gotten the sweats and like felt sick to my stomach about to raise my hand in front of a group to get coached. So I know it's really stressful. But what we know is that what I think is happening is the room full of people or the listeners who are listening to the podcast later, they see the person up on the screen and they listen to their story and they see themselves in that story. Like, even if they've never really experienced that thing before, it is so easy to experience empathy and compassion for that other person who's up there. And then when they realize that like that other person is no different from them, or they're no different, that they're not going through this thing in isolation or alone. And when you can offer empathy and compassion to the person on the screen, maybe you can offer empathy and compassion to yourself. Like maybe you're also deserving of that. And over four months, I think that is what we're building, what, what our participants build is a maybe belief that they could be okay and not alone in what they're going through.

Michael: It is a fascinating transition, right? Because I think a lot of medicine is kind of lone wolf type stuff, right? We are all trained that we're kind of on our own and we're supposed to be doing these things on our own. And then you get into a group coaching situation, I know this was my experience as well. I found physician coaching because I was burned out at work and I was trying to figure out all the things and I raised my hand on a group coaching call to talk about work, it was a very, I mean, for lack of a better term, it was a fairly boring topic. But I got off, I kind of got sent back to the, you know, to the land of like, where nobody could see me and I just perseverated. I said all the wrong things, I did all the wrong things, everybody must think that this is dumb. And that was when I realized that that's where the work was. And it was amazing because there is so much resistance to group coaching and So much incredible benefit that comes from it. 

And I heard you guys on a different podcast mentioned how essentially better together is the, you created a program that you wish you had when you were in training, you are gifting this to your younger selves. And I just loved that as a description of, of kind of how you are giving back to medicine and how you are trying to change the culture, starting from training, which for so many of us, was traumatic in so many ways. So I just want to thank you both for so much for the work that you're doing. 

One aspect that I wanted to ask you guys about is, you know, your, your pilot study and your larger randomized controlled trial was done in female residents. And I was wondering if you could speak a little bit to kind of what you've learned from studying female residents and how you think this can be applied to, to male physicians as well. 

Tyra: Yeah I will say so Adrienne alluded to this, we have a couple of arms running right now. And so we are offering this to residents and fellows. It's co ed at this point. We are also offering it to attendings or faculty, staff, physicians, and that's a separate arm. We're also doing a study right now in students and then one in APPs or advanced practice providers. And all of those are co ed and it has been awesome actually to incorporate men into the mix. 

On a data level we actually just finished up our randomized control trial in faculty or attending physicians and it, the intervention works in men also. What I will say is actually there were like a section of what I would call very courageous or very brave men that sort of paved the way on group coaching calls and were really overrepresented in the amount of coaching that they received and asked for in both written and in group calls. And it was awesome. It created a really collegial and vulnerable atmosphere. And I think, you know, in, in that study, we can prove that this works in men also and in older generations of career stages.

But we also have run into I guess, barriers around men not wanting to sign up as much. And I think that's really interesting and sort of speaks to the way that probably the people who identify as men or women are socialized in our culture and what it means about yourself to sign up for a coaching program. We know that there's a real disparity in men utilizing mental health resources that exist. Coaching, of course, is a little less stigmatized than classic therapy or other mental health resources. And so the bar is a little bit lower, but there still might be some stigma around there. I'm curious to hear what you all think.

Michael: Oh, there's definitely stigma. I'll be the the token man in this conversation and say, yeah, for sure. Absolutely. There's stigma, but I think also there's skepticism like we talked about at the top of the episode. And I think there is now evidence that there's a better way of doing all of this. And so, you know, we as coaches know that a lot of times doing the hard thing is uncomfortable. And everything you that you want is on the other side of that uncomfortable feeling right and so if you can lean into the skepticism and recognize, of course, I'm skeptical, right, like that's normal. Skepticism is a normal protective mechanism, and It might be holding me back by not embracing the skepticism and leaning into the discomfort of that there is some stigma around just mental health in general, and that is also uncomfortable and If you don't embrace it, it can't get better. 

And so there are so many reasons why leaning into the discomfort can help to lead to a, you know, ongoing, prosperous career in medicine, right? I, I've seen, when we see the skepticism, we sometimes see that the coaches are there because they're pivoting from a medical career. And I have found that coaching has allowed me to stay a full time physician. Before coaching, I was racing for the doors. I was looking for the exit and now I'm able to stay as a full time physician because of coaching. 

Arpita: I also think a part of it is like we touched on is that until we start overcoming that discomfort of trying something new, we're going to stay stuck in where we are. And so with my husband as my prime example, If you had told me 5 years ago that the man is going to go get coached by some random guy across the world to help him be more emotionally in tuned and be analyzing his thoughts and how I'd be like, you crazy. It ain't going to happen. Right? But what happened was I was exposed to it first and he saw how much I shifted and totally wanted to drink the Kool Aid when he saw that. So it's part of us exposing the world and putting it out there as much as we can continue to keep putting it out there. What this does and be so tenacious about it, like really prideful in what we're creating and knowing for me yeah, I'm giving back to docs. I'm helping women. And when I coach women and I see their aha moments and things start to shift, it's so gratifying. And I know it's not to be selfish for myself, but hell, yeah, I'm going to be selfish. It makes me feel awesome when I know that other women are able to start changing the way they think about things and other men are able to change the way they think about things. So they can show up in a way that serves them better. That's what this is all about. 

Tyra: I think that's right. And I think maybe it is a slow path for some people, and perhaps that's been partly explanatory of the success, especially in a resident population where there's not much time to be had. But what we know from our pilot and from our larger study data is that actually most of our participants never get directly coached. They never even raise their hand for group coaching at all. It's like a stark minority, like in the 11 to 12 percent of participants are even brave enough or willing or able to come up and get directly coached. And then the vast majority of participants are listening on the podcast. This was true for faculty. Also, it's definitely true for medical students. And so there's this phenomenon of like spending. a long time listening to other people do this thing first and perhaps never being brave enough and even just that act is still having an effect on their burnout scores on their well being scores across the spectrum and so there is something to the like butterfly effect.

Arpita: So cool. So amazing. So I, I want to just ask you guys, if you're willing to share what's next? Like, what amazing things are you going to create for us to see next and witness? 

Adrienne: I think so, our honest answer to that right now is we would love to stabilize the, the arms that we have going right now. So we're going to continue to offer twice per year cohorts for medical students. GME trainees, so residents and fellows, MD and DO staff and faculty physicians and also advanced practice providers. And our goal right now is to expand the footprint of the people we're able to reach. And so our model is that we partner with medical groups, schools of medicine, departments, divisions the, the institution, right? We partner with them to provide this resource to their people. And so we want to touch as many people with better together as we can. So that's, I think, our big goal for the next couple of years. While we iteratively continue to assess, gosh, are we hitting the mark? Are we talking about the things that are meaningful to the people we're trying to serve? Like, gosh, the medical students are already coming to this work with so much of a different vocabulary than even the residents just had three years ago when we started. So what do we need to do to make sure we're meeting the needs of the people who come to us where they are? And so we're doing iterative improvement of the programs we're currently offering, trying to expand that to more people and Tyra is the fearless leader of our research enterprise. So making sure we're doing that in a way where we're showing the world that this works. 

Arpita: Well, I have really, really enjoyed my time. Michael Hersh, have we missed anything? Is there anything else that you want to ask or wrap up with today? 

Michael: Yeah, I'll just say, is there anything that we missed that we didn't ask you guys about? I mean, this is such incredible work. We want to highlight all of it. So what didn't we ask you guys today? 

Adrienne: I think you asked great questions. The thing I'm leaving this interview with is any of your listeners who are already here, who are already doing this job, like we collectively, the four of us and anybody listening are doing the work of changing the culture of medicine, which is Tyra and my's big overarching mission, and so I think the more of us who are out there learning how to change the way we relate to this calling that we have or this profession that we hold the better we make it for our future selves for the people who come up behind us. And so I'm just inspired that there are people out there sharing in this work with us. And you two are included in that. 

Arpita: Oh, thank you. It's a secret little society almost, but it's not so secret, right? We welcome everybody to join in and, and participate in this. And I will say I have some of the closest bonds, connections, friendships with the people that I've met doing this work because we are so like minded with what we've been able to create. And there's just an amazing gift in that, that I could not replace anything else. And I wish that upon anybody who has an open mind, who'd be willing to even consider doing the work for themselves. So 

Adrienne: amen. Yes. 

Michael: This has been fantastic. Dr. Adrienne Mann, Dr. Tyra Fainstad, we appreciate you both so much and the work that you're doing and like, Adrienne was just saying, if you got something out of this episode, if you are in this community, go out, share this episode, share this work with other people. The work that we are doing to spread this message is helping to change the culture of medicine. And so we do that by talking about it, by sharing these episodes. And so, again, I just want to thank both of you, from the bottom of our hearts, for the work that you're doing. It really, truly matters. And we also want to thank all of our listeners for tuning in this week to this episode of Doctors Living Deliberately. We will see you all next time. Take care. Bye.

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