Treating Back Pain and Trending on Tik Tok

Preston: [00:00:00] Um, Margaret figured out that if you just say you want a sound effect, the editors will totally put in a sound effect. And I was like annoyed with her earlier. Cause she'd be like, editors, can we get an Eagle screech in here? And then when you walked, watch the episode back, they'll play all the Eagle screech sounds.

So. Just so you know, like I wouldn't like empty the clip on like all the different sound effects that you can do , but I just want you to know they're at, at your disposal as we go through the episode, 

Margaret: right? Well, no, if your brain rot is as severe as mine that now you think in the sound effects . 

Preston: Okay.

Which it's 

Margaret: exactly. 

Preston: Anyways, um, for those who aren't familiar. This is Betsy Grunch MD or Lady Spine Doc, and we are thrilled to have you on the show with us today. 

Dr. Betsy Grunch: Pleasure to be here. 

Preston: Yeah, we, I think we have a long term mutual parasocial relationship. And then we met recently in person for the first time, which was pretty fun.

Um, so, Margaret, I don't know if I told you the story of how Betsy and I first met and kind of hung out. It was at a fixed photo [00:01:00] shoot a couple months ago. I'm curious how the first meeting was for you. And I'll tell it from my perspective, which I think it was like 4 30 in the morning. We were going to like, drive up to this ice skating rink, or maybe it was like 6 a.

1. It was really early. It felt 

Dr. Betsy Grunch: like 4 

Preston: 30. Yeah, it did. And then you, you come up and you're in like a, like a skull and crossbones t shirt and ripped jeans. And I think you like, dabs me up. You were like, what's up, Preston? I was like, yo, Lady Spawn Dog is a bro. Like, this is awesome. I 

Dr. Betsy Grunch: had my trucker hat on too.

Preston: I didn't even see the trucker hat. So, and then from then on, I think we, we kind of vibed the whole weekend. Um, we made a lot of TikToks together and then. It was just fun to have someone who is excited and wanting to make, make videos or ideas. Um, you can see like the medical side of someone, but I think in you, I saw the like content creation side of someone, which I don't see in a lot of other people [00:02:00] that I'm around usually.

So it was like fun and special for me. 

Dr. Betsy Grunch: Yeah, I love hanging out with people that make videos because I feel like they understand me because my mind is always like, Oh, how can we turn this into a video? Yeah, so like, yeah, no people I like totally vibe with are like ones that like understand me and like are not ashamed to do whatever in the middle public and that's Preston right so like no shame whatever Wants to throw some popcorn down his shirt.

Let it hang out Steal a bunch of snacks, whatever the case is, make himself look like a total fool. He's game. 

Preston: Yeah. And if I'm getting positive reinforcement from Betsy, then like, I'm just going to amplify it. 

Dr. Betsy Grunch: That's right. But no, that was fine. I had a great time. That was like one of the most fun weekends I had in 2024.

Preston: Yeah, I, I really enjoyed that. And then for anyone who's, who's listening, curious, um, lady spine doc is exactly the same in person. She, I think she has like such a good way of, [00:03:00] um, coming through authentically and it was weird. It felt like I was hanging out on your page, but I was like, oh, wait, this is like a human being in person and 

Dr. Betsy Grunch: it's the same.

Preston: So, yeah, 

Margaret: baby. 

Preston: Hey, yeah. Name of the game. What 

Margaret: you get. 

Preston: So, 

Margaret: I think that week, weekend or week, whenever you guys were together, Preston texted me and was like, I think we're going to get ladies fine. Doc. I was like, do it. Do it. Do it. He did. He did. 

Dr. Betsy Grunch: He asked me, he hit me up. I'm like, of course. 

Preston: Yeah. Margaret's in my ear the whole time.

She's like, be cool. Preston. Whatever you do, don't make an idiot of yourself. And I'm like, 

Margaret: I'm doing so well, 

Preston: bags of popcorn stuffed in my shirt. Like, okay. Yeah. I'm on it. Margaret. Like this is working. This is working. This is working. So today, um, we are going to be talking a little bit about pain, but before we get into that, and it's a rare opportunity to have someone else who creates content on this pod.

And so Margaret, if you're not aware, also makes content. She's a 4th year psychiatry resident, and she does a lot of kind of like [00:04:00] blogging. Um, and like inspirational things. So you can probably speak more to what you do. 

Margaret: I like I write about creativity basically and like pop culture and mine has been very different because I purposely made it to escape medicine not to leave it, but to be like, this is the time where I get to play with creativity that I don't have to try and help clarify it.

I like love psychiatry, but it was my it started my like intern year, but is. Mostly writing and not video, but yes, yeah, 

Preston: and I think that's what a 

Dr. Betsy Grunch: lot of content creation does for a lot of health care providers. It allows us to, like, be creative, incorporating what we know, but also, like, just letting us do our thing.

And it's it's fun. 

Preston: It's an outlet. So funnily enough, we've all, I think, had our viral moments and possibly some controversial ones. So our icebreaker today is what was the story of your first viral video? Or, or when that felt viral to you, like, what was that [00:05:00] experience like, and then we'll talk about a time that we've dealt with controversy.

Dr. Betsy Grunch: Okay, so it's funny you ask that because I was actually searching just about an hour ago through all my old content and the whole like, tick tock band looming above us. I don't know when this episode will air, but, um, this was this today is 2 days before the supposed tick tock band. And so. Just been like feeling myself and feeling very sad and reminiscing because TikTok has really changed my life.

I mean, yeah, I'm on all the platforms now, Instagram and Facebook and YouTube and all those, but really like TikTok is where I went quote unquote viral and where I really grew my love of social media because, um, it just had such a unique algorithm at the time I started in 2020. Um, and my first viral video, I just use it for fun during the pandemic.

Um, my PA and I were generating some content, really like creating stuff in TikTok because it's super easy to film inside. And then I would import it and like put it on [00:06:00] Instagram just so people, I didn't have any followers on TikTok. I'd like to my cousin and my best friend and, uh, but it was easy to film.

So I filmed in there and then downloaded it and posted Instagram. So we did a video. About telehealth and how it's important during the pandemic like you still get health care blah blah blah So I came home We had you know I learned a lot about filming over the past few days and so i'm like i'm gonna film a video about being a female Neurosurgeon and it was that magic bomb trend.

It's like You know and then you do whatever 

Preston: Yeah, like dispelling facts. Okay. I got you. 

Dr. Betsy Grunch: That's right. And you're like putting facts on the screen, right? So i'm I just put up, you know, a bunch of stuff about like things that you get asked as a, as a female surgeon and, um, posted it and tick tock. So you could then download it and put it in the Instagram.

So post it in there. Um, put it in instead, never opened my tick tock app for a few days. And, um, then I opened it back up and I had like, you know, 100, 000, 200, [00:07:00] 000 views, which for me at the time, that's pretty viral. And, um, just, it was, it was, it was very. Wild like the variety of different comments you got like it was great comments negative comments uh, but it was all like just it was super inquisitive about what it was like to be a female in surgery and it was You know, people that commiserated with what I said, and also people that were like, Oh, I've never seen a female neurosurgeon.

So it really inspired me to, um, start content creation to be quite honest. I mean, I had done some videos, but so I started looking up cause I was extremely bored because it's during the pandemic and we cannot operate. We're bored. So being a type a personality, I needed something to do, so why not learn how to do content?

So I, um, uh, followed some creators and really like kind of. Balanced off of that. And, and that's kind of where it started. So it was, it was fun and I never. I haven't, I haven't stopped since 

Preston: that's so funny that tick tock was functionally a video editing [00:08:00] tool for you and you're like, Oh, here's my dumping ground to get to the real place.

I want to post instagram and then almost by happenstance the video takes off on that platform, which I think is a story for a lot of people on tick tock and how they were able to get discovered way better than instagram or youtube. 

Dr. Betsy Grunch: Yeah. Yeah, the way the algorithm works is kind of, you know, it's, it's kind of interesting and it really allows you to share content with more people.

Um, it's changed, you know, obviously, over the years, the algorithms on the other platforms, but, um, it's, it's just a really cool, uh, ability in some good ways and bad, you know, controversial stuff to maybe, 

Preston: so I made a post, um, the other day, kind of my goodbyes to tick tock because we are 2 days out from the.

Yeah. Supposed ban, as you said, and I recall that tick tock just kind of feels like a 3rd space to me, like going here and sharing stuff. It feels like hanging out with my friends at the park [00:09:00] or the coffee shop, the way that it can, the algorithm can kind of make a community feel tighten. It is so different than.

Instagram or YouTube, which kind of feel like TV or like, it's spoon feeding you stuff. That's being pushed through, whereas tick tock just feels organic. It's hard to describe. 

Margaret: Yeah, I made a video recently that was like viral ish and it was just like, there's this bench that is loved on. I'm in the very much in the like pop culture side of tick tock.

That was my feed and that's where I post and like, there's this bench that's in Central Park that says we were girls together and it's just like a bench inscription from these 2 women who were elderly by the time that bench was built and it's. Yeah. Very popular across like Pinterest and all these things, but the phrase we were girls together has been repeated a lot on tick tock and I posted a video that was like tick tock.

Let women enjoy doing like girl things without it being. A negative like they let them celebrate the Barbie movie. [00:10:00] They let them celebrate Taylor Swift and a whole bunch of other things versus only letting women be there made fun of for liking classically feminine things and all of the comments are like hundreds and hundreds of like girls and women being like I was postpartum during.

This part of my life, like in 2021 and this app, I feel like saved me. Like I learned so much. I got out of an abusive situation and so much of what TikTok has been to people. I think also based on the timing of when it became popular, like during everyone was at home and scared and it wasn't as like kind of masked as maybe some of the other social media platforms are have made it a really incredible place for a lot of people in a third space, Preston.

Preston: So, and. We talked about the ways that it's incredible, but there's also some negatives that we're getting it to. So, um, let's see. I'm curious. Is there a time that you've been the center of a controversy or fear of getting canceled on to talk or or on the Internet? And what does that been [00:11:00] like? 

Dr. Betsy Grunch: Yeah, definitely have had moments where, you know, maybe phrase something incorrectly or, um, You know, maybe talked about something without full acknowledgement of what that really meant.

Um, and even times where I thought something was funny, you know, you, you like to post humorous content. I like to post humorous content. So sometimes the things we think is funny and healthcare can be construed by, you know, a patient or consumer of healthcare as not funny. Um, and I have gotten much better at identifying what can be a trigger and, and, and not posting things like that.

Even things simple as just talking about, you know, sometimes just, I tell I post a lot of content about feminism and being a man, a male, a female in a male dominant field, and that will really ruffle people's feathers. And, you know, last week I did the Shania Twain that don't impress me [00:12:00] much. Trend had like 8 million views.

On Tik TOK, and I had people calling my office asking for me to be, uh, fired, uh, because I shouldn't be, you know, posting stuff like that. And I've had people report me to the hospital and, um, stuff like that. I mean, obviously, you know, the people that are in our department, I mean, they understand what I do and it was just, but just people get so angry.

I've had so many Yelp negative reviews. I mean, they're not my patient, you know, and, and those reviews are really important for. Providers about how patients gauge your interaction. So. It can be a little tough sometimes, but you know what I always say, I mean, if I can survive neurosurgery residency, I can survive content creation.

So I'll, I'll be all right. 

Preston: Yeah, I don't know. It 

Dr. Betsy Grunch: might be harder. 

Preston: Nothing a Yelp review can do. Yeah, it's funny. It always felt disproportionate to me. Like, you saw something you didn't like. So your response is to try to, like, come for my career. You're going to try to, like, disparage me [00:13:00] on Yelp because you didn't like my Shania Twain lip sync video.

Where I talk about being a search, like what? 

Dr. Betsy Grunch: Yeah, there was another one to where I said, like, you know, and in medicine and I'm sure Margaret can commiserate with this comment, but like, you know, I mean, you're a physician, you're a female and you get mistaken for a nurse. I mean, daily. I mean, it's not. You know, and that's not just related to physicians.

I mean, it's physical therapists, occupational therapists, and the whole point of that is gender bias and how we, anything, any female in health care should be a nurse, not saying that I'm any better than a nurse or, um, feel, you know, superior to anybody. It's just more of a kind of accenting or putting that in the spotlight that, hey, we can be doctors.

We can be other health care professionals too. And so, That content tends to also get get people hot for no reason. 

Preston: Yeah, I've I've noticed that I think from the outside where you'll say, like, please don't mistake me for a nurse. I'm a doctor. I went to medical school and then there's all these riled up people saying, like, what's wrong with being a nurse [00:14:00] and I don't know if you're standing on the right hill to try to fight that battle.

Like, I don't think there's anything wrong with hoping to be addressed by your deserved credentials. Because you went into a career, you know what I mean? I, and then I've always been kind of like, curious about that. Like, they view you're trying to kind of stand up for yourself as an insult to other careers or other fields.

Okay, so. Um, if there's a skip, it's because we had some technical difficulties. Uh, a car drove through Betsy's office and she had to perform surgery on them, but now she's back online surgery. I'm back 

Dr. Betsy Grunch: with a better set of headphones. Yeah. Her, 

Preston: her air pods came out in the crash and she had to get the maxes.

Dr. Betsy Grunch: So 

Preston: we've been talking about kind of dealing with controversy on our online presence and Margaret, who tries to shy away from that. I think by [00:15:00] mostly writing and not showing her face, a lot of her content was recently in the seat of controversy. So, Margaret, tell us about what that was like, 

Margaret: which I did do via writing and without showing my face, which is, I think, impressive.

It's hard to do. Yeah, incredible. Yeah. So I really pissed off wellness tick tock and some people I fairly pissed off because you can't have context in some of these. Um, I made a post about an article that I wrote. I write a sub stack like a newsletter and I do a wellness series on it. That's like, where is this coming from?

And what is the literature actually say? Um. And I did one on the marketing around like Pilates and bar to women and the kind of messaging that we get and then the history of exercise and how it's been spoken of to women. Not that long ago in that there's been lots of mythology. I know you're selling. I was looking at some of your videos and I was like, she's going to have thoughts on this.

But, um, and my, I come to this very naturally because I used to teach bar. Yeah. I almost did PM& R [00:16:00] instead of psych and did a lot of pain rotations, um, but had my own like general mild low back pain in med school and intern year and went to PT and then fell down the research rabbit hole of kind of like, wait, why is this happening?

What does this look like? And like fell kind of into the exercise science world. And so I made them very mad because I basically drew the illusion that it's like if men were offered a Like an effective medication for a problem and women were often offered placebo at a system wide level. We would be mad.

Why aren't we with exercise was the title of the article. And that made the mad. I knew it would make some people mad. I didn't realize the extent it would. And I say in the article, like, I think Pilates and bar and like, low impact exercise has a place. But all of this, like, low impact, lower your cortisol does not take into account the actual research around like osteoporosis and prevention.

And like, I'm sure you probably are familiar with, like, the lift more study in terms of, like, this idea of movement, fragility and pain. That [00:17:00] causes people to have more pain, more weakness, and that is a problem for women, especially if they're under BMI, under muscled and would like to have functional lives and not broken hips when they're 60s and 70s.

So I made people mad, but I stand by it. And I, in the comments, I just have said, give me a citation. And I will go read it and I will redact if I'm wrong, 

Dr. Betsy Grunch: I'm sorry. Oh no, you made people more mad by doing that because they know they're wrong. No, a 

Margaret: lot of them actually loved that. They were like, because then I went and read the articles they would cite and be like, this is a poor article or like, this is a fair rebuttal.

But yeah, they didn't like that. 

Preston: I just picture Margaret standing on a hill with the mob and she's like, If one of you has a citation, I dare you to step forward. Any one of you, like she's just pointing around and they're all like, Oh, they're, they're afraid because They all, they're armed with their snake oil and they can't, they can't, 

Margaret: I like, I still do Pilates and bar and I say that in the article.

I'm like, it can be good for pain. It can be good for like first developing muscle or for just like exercise daily, but it's not [00:18:00] going to be as good for your bones and muscle building as like a regular progressive routine. And they hated that. 

Preston: I'm hearing something that never goes over well on the internet and your answer, which is a nuance.

Margaret: Hate that. You 

Preston: shouldn't have tried to include nuance, Margaret. 

Margaret: Yeah, I got a kick out of it. I won't lie. I feel like because I'm like, it was, it was like two weeks ago and I was like, well, the app might be gone soon. 

Preston: Yeah, it's kind 

Dr. Betsy Grunch: of fun to argue with people. So depending on your mood, it's especially when you know you're right and people are dumb.

It's a little satisfying sometimes when you have science. 

Margaret: I can't be like aggressive as a woman in psychiatry and medicine anywhere else. Whereas with this, I'm like, you know what? I am going to cite you and like me being aggressive as me being like, read this paper and get back to me. And it's like PMID 01.

Preston: Boom. 

Margaret: Yeah. 

Preston: She was giving me live updates of this. I'm like, I'm like in clinic and I checked my phone. And it's like, Margaret just goes, I pissed off wellness internet. I'm like, [00:19:00] what? And she's like, she's like, I'm fighting back more to come. 

Margaret: I enjoyed it. I did debate in high school. So like, I did like debates.

So I liked it. 

Preston: She goes, send backup. Nevermind. Don't send backup. I have the situation under control. I'm like, okay, have fun, honey. 

Dr. Betsy Grunch: We actively seek out controversy as surgeons. We love it. Really? You want to argue with us? Bring it. We will win. 

Margaret: I was raising an internal medicine family. So, like, I'm like, let's go this.

Like, we're gonna make dark dark jokes and we're gonna argue about evidence for things. Preston, what's your page note about 

Dr. Betsy Grunch: it? 

Preston: Um, so my, my most recent controversy that I had to think a lot about was, Yeah. Um, kind of knowingly walking into this, so I, I was trying to, like, combine some of my, like, attempted acting chops with, like, teaching.

So I was like, oh, I can do a video where I'll imitate what some aspects of personality disorder look like. So I think I made a video. I [00:20:00] was like, you left a party with your cluster B boyfriend or something. And so I kind of went through a lot of the classic things, the way they externalize and, like, put it together.

Pressure on you, like, look at this. I'm yelling at you. Look at what you're making me do. Like, I hate yelling at you. And now I'm doing this thing to you because of the way you behaved. You know, I'm not responsible for my behavior, but because you didn't talk to me at this party in a certain way, I've I've now.

Understood you to be an evil person, and I thought you were a good person before, but I'm not capable of navigating you being 2 things in my life. So so actually, the mask is off and you're terrible. And then as soon as she starts crying, I kind of like flip and I'm like, oh, never mind. You know, we're in this together.

Like, let me build you up like, it's okay. You know, we're a team. I'm only saying these things to you because I care about communicating openly. You know, and so there's a lot of really nasty, manipulative stuff that I was doing, because these are the things I try to [00:21:00] navigate with my patients. And it was like, not a funny video at all.

It was like, kind of gritty and eerie to watch. And it got a lot of people saying that, like, this only worsens the stigma around personality disorders. And you're like, mocking us and all these things. And some other people, personality disorders said, like, hey, this is like, very important. And like, it was like, looking in a mirror and I was uncomfortable, but I like, I'm glad you did this.

I ultimately took it down. So it was actually kind of like there are a lot of strong forces and support and a lot of forces of criticism. So I was kind of like, okay, how do I feel about this? Because I thought there were good arguments on both sides. And I think that makes the controversy really tough because it's like you said, it's easy to argue with people when you know you're right and they're wrong.

But here I was like, I'm kind of questioning it. Like, I'm not sure who's right in. I took it down because I don't think I'm the right person to be doing that. I guess was the [00:22:00] conclusion I came to. And I think it's because I'm the psychiatrist who's treating someone and I would hate for someone with a personality disorder to ever go online and see their doctor imitating them.

I think that's ultimately how I came to this being the wrong conclusion. And I don't think it means we can't try to point out real life examples of this thing. It just means that I can't be the one to go on stage and do it. So it ended up being, I think, positive experience for me because I was like, okay, the crowd is divided.

And I'm not sure if the crowd's wrong, so I really need to think about this and I kind of, I made a video explaining that and a lot of people are like, you didn't have to apologize. Apology accepted. And I remember kind of like, I don't think I did apologize. Like, I'm not saying I did this terrible thing.

I think I'm just kind of, like, reflecting out loud. 

Dr. Betsy Grunch: Yeah. I think anytime I've learned, you know, when you, I try not to put content where it seems like. You [00:23:00] may be the patient, um, because it's tough. It could be interpreted, you know, from a, or, or make, I wouldn't say making fun of patients, but, you know, just any type of, of content around like that can be difficult because you may intend that 1 way, but it can easily be interpreted a different way.

And it's challenging. So. I've done that many times and it's better to err on the side of taking it down because you just you don't ever want to be that person that seems like you're not compassionate or you know, don't really uh, Quote making fun of a patient that may seek your care for the same problem So if i'm making fun of anybody i'm making fun of the insurance companies everybody hates Yeah, 

Preston: and that's a great point which is you you can't punch down right I think especially if you have a platform And so when I was a med student I love to punch up to the residents or to the attendings or other people, but now that I'm a resident and I was like trying to make these like toxic med student videos that I did when I was like a third year or fourth year.

I was like, it just doesn't [00:24:00] hit the same. Like, I feel like I'm a resident making fun of people below me. So it's almost like as I'm ascending through this ladder. The people I can punch up to get smaller until the only person left is the insurance company. And 

Margaret: I 

Preston: guess, and I guess, yeah, or yourself. So, so now I can, I can make fun of, here's my short list.

Um, Ted, Ted Cruz. The insurance companies, lady spine doc and Margaret. Those are the people I can punch up against. Yeah. And Rob Rob is a producer. If you're listening, Robin, I'm going to make fun of you. 

Margaret: Um, yeah, it's interesting. So we're going to talk in this episode about something that I think is hard to talk about on tech talk, which is chronic pain, particularly.

Chronic, you know, low back pain and some about general brain health, uh, but I, I feel like talking about pain pain is so personal. It's so heavy. People have experienced so many different things as pain patients. Um, and I think as clinicians, [00:25:00] you know, we in psychiatry see a lot. We kind of, I feel like sometimes are the end of the line for pain, so let's just send them to psychiatry because they don't need a surgery.

They don't need an intervention. P. T. and we kind of try and help them cope in some ways, but it's hard to talk about it because I think pain brings up big feelings for people. I don't know if that's been your experience or Preston yours, but I, I think it's also something that there's a lot of misinformation about their about about 

Preston: out there.

Yeah, 

Dr. Betsy Grunch: yeah, the surgeon is, it's hard because, you know, almost exclusively I do mostly spine and inevitably almost every patient that comes to me is dealing with pain of some sort. And they see me as an end to their pain, so they see me as a solution or resolution to their pain. And so it's really easy as a surgeon to, um, look at someone's imaging and be like, it's not that bad.

I don't know why they're in so [00:26:00] much pain, but if you really take a step back and think, okay, well, anything can be a pain generator. And so really just. Trying to understand and navigate what potentially could be the pain source and understand people feel and interpret pain and differently Um, so one person that has one image and the next person that has something 20 times worse I mean you might have 20 times more pain than the you know in the quote unquote not bad mri and uh takes a lot of insight and listening skills and compassion that unfortunately in our profession A lot of us lack and, um, it's really hard.

It's, it's really hard to see patients that come and see me. And I've been like, you know, I've seen 3 other or 4 other surgeons and then automatically people think they're crazy because they're on their 5th opinion, but no one's listened to them. And it's so satisfying for me to have those patients to listen to them and say, yeah, you know, they didn't, [00:27:00] they didn't hear you.

Like, I. I understand and we're going to figure this out together. And sometimes we can offer, you know, a solution. They've never been offered before. Sometimes sometimes we can't. Sometimes it is just a listening and understanding and validation that that can help them, even if we can help with their pain.

So it's very important in our field. And I think we're just raised as being very. Um, distance as surgeons and it's, uh, it can be, it can be challenging. 

Margaret: Yeah. Well, these mind body problems, I think I work in eating disorders and the mind body problem I find really interesting, but I think it ends up being in modern healthcare.

Um, this kind of, if we don't value primary care, if we don't value people's like medical homes, the things that are mind and body don't. They don't locate to any specialty necessarily cleanly. And so they end up, I feel like really going in between different clinicians and people are [00:28:00] people, you know, are there clinicians having conversations?

Is it multidisciplinary? And it makes it so they feel like they're kind of battling it alone. You kind of said, like, I'm going to be in this with you and try in my way to connect you. And I do feel like that's such an important part of pain care that the current model is. And a lot of places and I'm in an academic setting, um, even here, right?

Like, don't necessarily address well, um, which is a shame because I think that's a core part of, as we know now, good pain care. 

Preston: It's easy to let your pain fall through the cracks of the system. 

Margaret: Yeah, 

Preston: and everyone can diffuse it. 1 thing before we go forward that I think I want to have a good definition on.

And I think this is something maybe I've been a little bit too afraid to ask, but what is pain? I think it's something that we think and kind of know about ubiquitously, but like, really, what is the experience of pain? I guess, and that's, yeah, I'm curious what you think as someone who operates on nerves all day.

Dr. Betsy Grunch: Yeah, [00:29:00] I mean, I always explain pain to patients as the way your brain interprets your body and in some ways it's, you know, something quote unquote, pinching it, something pathological, something we can fix, I can go in there and do this and fix this. And sometimes it's more of like the just intrinsic wiring of the way our neurological system is.

Sometimes it's multifactorial. It's the way we're. Uh, cope with certain things from a psychological standpoint, and, um, it can be a combination of all those too. So you can have someone with pathology, but also have some potentially psychological overlay. And then, then you have so much more confounding confusion into how you can offer solutions.

And those are the most difficult patients because it takes a lot of time, right? They've, they've expressed their pain and. It's so like they almost feel like they're crazy because they've been told that by people and they almost believe it themselves kind of and then to try to really get to the [00:30:00] Nuts and bolts of how you can, it takes a lot of time and a lot of relationship building and honesty.

And in this health care model, we just don't have that. And it's, it can be, it can definitely be challenging for sure. 

Preston: How long do you have with a patient?

Dr. Betsy Grunch: I have, I mean, really, like, you know, I see, uh, I see anywhere from 25 to 30 people a day, which is not a lot, you know, time. Uh, but I will say, um, most of the patients I see are follow ups that are pretty quick if they're post op have an incision, you know, they don't have a lot of complaints, but I really try to dedicate as much time to that patient needs.

So if I'm, you know, running an hour late, I mean, I'll just deal with people being mad as long as I'm spending enough time, you know, with the patients that I need, some patients need, you know, five, 30 seconds. Some patients need. You know, 30 minutes or more. Um, and I don't know. I just try to space out the appointments in [00:31:00] which, you know, new patients going to take longer because you need the relationship building type skills.

And, um, you know, I'll, I'll, um, you know, tell them sometimes, hey, you know, we can, we're going to continue to figure this out together and. We're going to, you know, do this test or this test and we'll regroup on it. And if we don't have a solution at that time, we're going to reconvene and try to figure it out.

So, um, I think just, you know, the biggest part is just validation and listening. 

Preston: Yeah. So, so if I come to you and we have, let's say at most 30 minutes to go over my chronic pain and you're my fifth specialist, how do you approach like managing expectations to that person? Who's like, Dr. Grunge, finally, you're here to take away all of my pain.

Your means to an end. 

Dr. Betsy Grunch: Yeah, those are those are heavy. So if I have somebody like that, I definitely attempt to have those identified as being the last appointment of the day. So I have that time. I don't feel rushed as a [00:32:00] provider either because I don't want to have them feel like they're rushed because then they'll close down.

Um, so, you know, a lot of these, we try to even have, you know, I have a PA that's always with me that can maybe go in and get the history before I go in. So we can kind of nail out some of those. Yeah. Find details and clarify some of those things before I even get in the room so we can really divulge into the situation Different ways of doing it, but it can definitely be a challenging.

The biggest thing is just scheduling and identifying when you have those types of patients and how you can best serve them. Yeah, it's 

Margaret: in the psych training for years. Um, so Preston's a second year. I'm a fourth year. Generally speaking, third year is the year you mostly do outpatient care, which is when I feel like this question rises for us.

Um, the most of scheduling and. It's interesting that we both maybe think of the outpatient part of our work similarly, where it's like, if someone's coming in and there's kind of like a lot of things we [00:33:00] need to do together, or maybe it's hard for them to tell their story for any number of reasons, um, and hard to hear responses like I put those patients at certain times so that like the whole day can go well, but that there's emotion at the core of any, you know, from psychiatry, psychiatry to neurosurgery, there is.

A lot of emotion at the center of what we're doing and how do we, I'm curious what you think about your training in, you know, as you've mentioned, as we've talked about on tick tock in some ways to do neurosurgery, like the operating part well, you have to make it through very difficult conditions without any of the, like, malignancy that might be in a program, um, And I wonder, you know, I think you clearly have like a lot of warmth.

Like, how did you, how have you kept that part of yourself? Because my surgeon friends for med school, I think that is been one of their fears or things going through training is like, 

Preston: were you getting the warmth? Margaret, I'm not seeing it.[00:34:00] 

Dr. Betsy Grunch: I 

Preston: smiled for those who are just listening. It was a joke. 

Dr. Betsy Grunch: No, I think, I mean, that's so I think our training is so like. I hate to use the word malignant, but, you know, it's, it's hard, you don't want your brain surgeon not having a tough training because we're dealing with life and death situations every single day, having conversations about cancer, about death, about, you know, very, very hard to talk about things.

So we are trained to be kind of separate. Um, from our patients and to, like, have this boundary and, um, to break down that boundary and to, so we seem cold, um, because you have to separate yourself or else you'll crumble. I mean, during residency, during the hours, during the cases, during the stress, during how you're treated from your attendings.

So, you know, the conditions your patients have, um, it's so challenging. So, yeah, I mean, you, you become accustomed to being cold and short and, um, unfortunately we deal [00:35:00] with patients that don't need that from their provider. So, as I kind of started, I mean, I was, that's how I was taught to be. That's how all my attendings were.

So I thought that's how it's supposed to be. And I realized very quickly that that wasn't the way to really relate to patients. Um, and so I just, you know, learned how to be myself around these people and gain and their trust and, um, just take my time to talk to them and kind of be. Go back to my roots of why I went to medicine to begin with, which, um, you know, it was to help people and to really like take my time to, you know, try to try to figure things out, what I loved about surgery and what I loved about being a doctor.

So it definitely takes a lot of growth over your career. And I think just the toxicity of our training just sucks it out of us sometimes. Um, so I've been out for. Gosh, almost 13 years, 12, 13 years. And, um, I've gotten better at it. I really think social media has helped [00:36:00] me understand people too, because I can see how millions of people will interpret one thing I post versus if I'm talking one on one, I can only see one reaction.

So it's just helped me be a better communicator and. Be a better doctor. I think it's 

Preston: like a crash course in empathy. 

Dr. Betsy Grunch: Exactly. 

Preston: You're gonna, you're gonna get like drink from the fire hose with how people feel about this. 

Dr. Betsy Grunch: Yeah, exactly. 

Preston: So I was, so it sounds like rediscovering empathy was one of the strongest things you did to help your care.

And I don't, I don't mean rediscover, but like kind of Maybe soft compassion. Yeah. Is there evidence that this therapeutic alliance or empathy like helps make a difference for surgery for patients? I think I'm saying this kind of tongue in cheek because I think we've talked about this before. 

Dr. Betsy Grunch: Yeah, definitely.

I mean, patients, you know, have better outcomes when they feel more care for. Um, there's plenty of data that suggests, you know, that, and then also on the same token, like, you're less likely [00:37:00] to, you know, sue your surgeon if you have a bad outcome, if you feel more connected to them and understand them. Um, and, you know, I just think patients in general are happier with their care if they understand where you're coming from.

So, if I have a patient that I've spent a lot of time with explaining, hey, this may not help at all, but we're going to try, we're really going to try hard. And if it doesn't, we're gonna figure it out another way or I'm going to say, we're gonna go in here. We're gonna fix this. We're gonna do this and you'll be fine.

And then they're not, they're gonna be pissed. But if I am more, you know, explanatory about that, um, and take my time with them, they're, they're gonna feel better, even though they both patients may have the same exact outcome. In the end, it's no better. 

Preston: I think when you're managing those expectations, one thing that comes through to me is yeah.

In the 1st scenario, we're saying we're going to try really hard and conquer this together. It feels like you're both on the same side and then the pathologies on the other side. Whereas the second one, I'm going to come in and [00:38:00] rip out your pain. It's like, you're, you're on the opposite side of them and you're, you're just there to serve them.

So, so being able to treat that collaborative relationship is so powerful. And I think I've tried to find that too, with prescribing people medication for the depression or for any kind of mental health disorder at all. It's, it's easy to be like, this pill will take away your sadness. Like you've been depressed for 20 years.

We'll. Have I got news for you like Lexapro 5 milligrams is about to change your life. Like I try to try to avoid those kinds of discussions. I say, you know, you're going to take this pill. Um, it affects serotonin. And about a 3rd of people, it can be like putting on glasses and they see for the 1st time and about a 3rd, it might not work at all.

And if that happens, then we're going to try something else. But these are all the different outcomes that can happen. 

Margaret: And in chronic pain treatment, um, so my 4th year med school was spent during covid mostly in like, chronic pain treatment settings in [00:39:00] Saint Louis. Um, But in, like, the pain psychology approach, and I think the approach for PT and all these things is, like, it's very important for chronic pain to have a, like, patient doctor patient clinician relationship that is co collaborative and also emphasizes not Okay.

Passivity, but activity on both sides versus the kind of the doctor is going to do something to me that is going to get rid of this pain, at least in the chronic pain setting. Um, so I feel like that relationship too, right? If you have a relationship, there can be more of the back and forth. Whereas if it's I don't feel connected to you, it's hard, I think, to help a patient find where they can be active around the very real burden that is their pain.

Preston: Like you're not doing surgery to the patient. You're doing surgery with the patient. 

Margaret: Yeah, if that makes sense, it's easier in psychiatry, but it's even in surgery. I mean, what I've known, what I've heard from surgical outcomes like of recovery, um, [00:40:00] is like, well, I wonder, Dr. Grunch, what do you think? Like, when you think of someone who you have feel like, or from the literature, I think that, Their response, their pain response to a back surgery.

Um, when they struggled with pain and it wasn't like an acute accident or something like that. I know there can be many different things, but what are the things that you think are good predictors of being able to move out of chronic pain after a surgery? 

Dr. Betsy Grunch: Yeah, definitely. You know, there's socioeconomic setting is crucial.

So patients that have a lot of support behind them, uh, uh, underlying mental health disease can be. Uh, very important to kind of predict outcomes and what their overall situation is. And there, I think it's just those kind of things of just kind of understanding the situations patients are in, what they deal with every day at home, what their mental health is like.

Plays into so much of our surgical recommendation as actually, you know, [00:41:00] looking at their imaging and figuring it out. And that's where I see a lot of failed back syndrome and failed surgery, spinal surgery. I think that's the major reason why back surgery gets such a bad name is like, we suck as a, as a group of physicians.

At choosing good patient surgical candidates choosing the right surgery for the right patient because I can have a patient with something crazy going on in their back and Do this massive surgery on them and imaging looks great, but they still have pain and it's like well You know, they didn't have time to recover.

They didn't have the resources. Maybe they weren't medically well, or, you know, you made them worse because now they're dealing with other, you know, complications. And so as so much that you really have to divulge into that, we just don't take the time or effort to do. 

Margaret: Yeah, well, and to your to your point, right?

Like, even in medical school, I think about different trainings. Like, there's so many areas like this in medicine. Maybe during the first two years of lectures, you get like a couple hours on pain and during your [00:42:00] clinical time. Maybe I was lucky because I could choose. I will. I will tell you, I was someone who went to med school and was like, I never want to be in the get me to psychiatry as quick as possible.

So I actually did P M and R anesthesia and like rheumatology were like allowed as part of ortho. Uh, the like outside of that kind of yeah. Elective time. I had, I don't know that I would have got another pain. Um, and similar to psychiatry, like Pain isn't across population, across organ systems, and I mean, I don't, Preston, is your experience of medical school different?

Preston: No, we had a paucity of pain training as well, I would say. 

Margaret: We like talk about like the opioid crisis, but we don't actually talk about what are approaches and do like take this really seriously and have us do cases and work through learning. It's just kind of like psychology, PT, Don't fall into the opioid crisis is [00:43:00] like, I don't know.

That's kind of it feels kind of like that's what our education is 

Dr. Betsy Grunch: I don't think we have a lot of, uh, built in lectures around pain and compassion. And, um, for a young medical student, 27 years old, who's probably personally never had any pain in their entire life, to try to understand what that's like for another patient is near impossible.

So, you know, that experience really is what makes us better providers and if we don't get that experience, we don't learn. And, um, I think that's why positions that work in pain get so good at it, just because we know how to, like, just kind of interpret it, um, and, and, and can try to navigate it the best we can.

Some learn, some don't, but, um, it's, it's challenging. 

Preston: Yeah, I think one thing that's interesting that can help people frame their comprehensive treatment of pain is to realize that that therapeutic alliance or your ability to talk with [00:44:00] someone is one of your tools in treating, treating their pain because I think some people like, oh, if I'm nice, this person, they may have better outcomes or something.

But really, like, if you're trying to have a comprehensive treatment of someone's pain, surgery is part of it. Medications are part of it. But compassion like those are all measurable effects. So if you want to be the best pain doctor, You need to be competent in all those categories. 

Margaret: Which, like, makes sense.

Like, I feel like sometimes this comes across like, yeah, obviously connect to your patient, but who has the time? But like, if we think about this as a 

Preston: procedure, a 

Margaret: procedure, yes, but no, I was going to say, if you think about this is like, if someone came up to you and was like, hey, just met you, I'm going to talk to you for 10 minutes.

Um, why don't you put your hand on the stove? Let's just see how that goes. Like that is what it feels like for some people who have chronic pain when we suggest like different things are going to PT. It's kind of being like, well, why don't we just see? And they're like, that hasn't helped before. It's burned me before.

And we're like, this is a special stove that will not burn you. And it's like, we know that. Yeah. Just trust me, bro. Like, [00:45:00] um, and so it like makes a lot of sense. I feel like if you actually go to the mental space, but again, you know, when are you going to have the time to do that? And in your training, when are you going to, Have the time, unless you're forced to have that experience yourself as the patient or as the family member of someone struggling with these things.

Dr. Betsy Grunch: Mm-hmm . I did, I found, I've found it the easiest to communicate with patients when I try to put myself in their shoes. So I try to really just kind of any patient I see, any surgery I recommend, what would I do if I was in their situation? How would I wanna be treated? Uh, or if this was my mom or my dad or my son.

Um, and I just, I think it kind of helps me put some reference back into how I can attack the situation better. Um, but, you know, also it takes a lot of, of, of, of time or, or, uh, put yourself in a situation that may make you uncomfortable. So. [00:46:00] 

Preston: Empathy takes energy. It's it does. It's a lot Sometimes 

Dr. Betsy Grunch: we're not ready to be empathetic.

Let's be honest. Yeah I had a real shitty day at home and you come to work You're like, I just need to get through this day. And then you got somebody that's complaining of pain. You're like, uh, 

Preston: Yeah, it's it's hard So I know you mentioned that your field has a problem matching patients with their correct operations or the operations they should get right, right patient for the right kind of surgery.

And that might be a reason why back surgery gets a bad rap. What are some other misconceptions or think common false beliefs people have around back surgery and pain? 

Dr. Betsy Grunch: I mean, you know, it's, it's, it's that, but on the other side, it's trust, like patients don't want to trust you because they've been wronged before.

Um, I've had patients that have had, you know. [00:47:00] Eight back surgeries and they come into you and they, they're desperately seeking help, but they're also very sus because they have had many surgeries. So what, what am I going to do 

Preston: back surgery? Right, 

Dr. Betsy Grunch: right. How are you going to fix me? Or, um, you know, that, that kind of thing is, is sometimes.

A little challenging or you tell them something completely different than someone else has told them Or offer them a completely different surgery and you have to really invest time into explaining why Surgeon a recommended this but you're recommending this and why that is your opinion Um, those can be hard and you know for someone like me Who doesn't look like any other old white man who's gray in the face and has been doing neurosurgery for 40 years for a young woman to try to explain to You know, Grandpa Joe over here, they don't want to trust me anyway when they walk in the room.

So that can be hard. 

Margaret: Yeah. 

Dr. Betsy Grunch: Yeah. 

Margaret: What do you when you say failed back [00:48:00] syndrome? What does that mean? Just given our listeners might be more psychiatrically inclined. Um, but I feel like this is one of those 

Preston: surgeons pressing who also doesn't know what that means. 

Margaret: And Margaret. Well, I guess, but I feel like I will.

I've had multiple of my patients who, like, go for back surgery and come back. Some of them. Yeah, it's been helpful. I should most mine. It's been helpful. Um, but what do you mean when you say failed back syndrome? 

Dr. Betsy Grunch: It's a cluster diagnosis. I think that just someone that's had back surgery that still has persistent pain, and we don't know why, um, and we localize it and then we're like, exactly, exactly, and it's not necessarily anything specific, but it's just something that we classify as a diagnosis of, of maybe we don't have a pathological region and back surgery didn't help.

Um, and a lot of people get that diagnosis and it's incorrect. They're not failed. They just had the wrong surgery or they didn't have the right, the right surgery for the right reason or the right problem. Um, [00:49:00] the spine is very simple, but it's also very complex because there could be so many different pain generators and to tease through that is, uh, is difficult sometimes because you don't always have a patient that has a normal spine.

It's upper right here. It's abnormal. I usually have somebody that's in their 70s and their whole back is garbage and you're trying to figure out like, well, is it this or is it is the forest or is it the trees, you know, so. It's it's difficult. 

Preston: So I understand that the spine. Because it's a bone is covered somewhat by ortho spine, but also there's the whole spinal cord, which is covered by neurosurgery.

So both ortho and neuro have some jurisdiction over spine surgery, right? Does that contribute to this kind of discrepancy and knowledge that patients get? Or have you kind of seen changes in how or differences in how the cultures of those two specialties approach back surgery? 

Dr. Betsy Grunch: Yeah, I mean, yeah. I think it's definitely [00:50:00] changed over time.

The old school approach. I trained at a very old school type program where we had orthopedics putting in the screws and the neurosurgeons decompressing the nerves, but never did both do is where it is very weird than we, you know, but in this day and age, I mean, most people do a little bit of everything, but the, the differences is how you're, uh, You know, trained orthopedics are trained more to look at the bone structures and neurosurgeons are more trained to look at the nerves.

Um, but you'll have, I think now, I mean, you have more neurosurgeons that do spine because, uh, you know, we'll take orthopedic fellowships or whatever the case may be to try to help, uh, expand our knowledge of bones and things like that outside of the spinal canal. But, um, I think for the most part, there's.

Always get the question, who's better? Who do I go to? I don't know if I should go to Neuro Prosecutor, ortho. Mm-hmm I think you just picked the surgeon. That's right. Uh, for you because once you get on training, I [00:51:00] think all of that kind of dissipates and you just have a background experience in spine period.

And um, and you know, orthos typically have less spine training in residency than neuros. 'cause they spend 18 months on spine and then do a one year fellowship. So they come out with, you know, almost two and a half years of experience. Whereas neurosurgeons do spine, the whole training. They have eight years of experience under their belt coming out.

Um, and depending on the program some are spine heavy some are not I went to a very spine heavy program So I got you know, six years of full spine and felt very comfortable and it didn't do a fellowship I didn't enfold a fellowship, but um reg you'll have some surgeons do six eight years of brain stuff They really just don't even know how to do the most basic things.

They have to go out and do Um, you know, some type of specialized fellowship, but it just depends on your training. Really a program. 

Margaret: What do you think of and you're talking about this? It makes me think of like, you know, a lot of the meds that we are trained to use and understand it to the best [00:52:00] we can of how they work in psychiatry are also double as pain meds in the chronic pain setting.

Um, Versus like, you know, there are certain meds that neurology is the most comfortable with certain meds that anesthesia if they've gone and done kind of a fellowship or more outpatient focused time might be more comfortable with and it. It just, it strikes me. I wonder if there's annoying consults you get.

I mean, I don't think surgery comes like gets consults as easily as we do. Um, but if there are misconceptions, you feel like within the field of people who aren't neurosurgeons will ask this question constantly, like the kind of consult question you get in the hospital that you're like, I wish you guys it's like our version of like, well, capacity is technically this that we talk about is psych.

Is there a neurosurgery version of that? 

Dr. Betsy Grunch: Yes, a little bit. I mean, it has to be more fundamental. Like, like surgery, that's one reason why I really like surgery because it's very black and white. You either need surgery or you don't. There's not [00:53:00] like, like, we need to, like, figure this out when it comes to inpatient stuff.

I mean, outpatient chronic pain stuff is whatever, but inpatient consults are usually related to acute problems or, you know, something that's very black and white, but we will get the like, oh, this patient's got back pain. Mm hmm. So, we got an MRI of their back, and it shows, you know, degenerative disc disease, so we need a consult, it's like, if you MRI'd every single person in this hospital, they will have degenerative disc disease, we don't need to see that, we can see it in the office, uh, so, that's usually the most annoying stuff we get, shunts, we really hate shunts, but Uh, because everyone wants to point to the shine.

That's the problem for anything. Anything. 

Preston: I'm guilty of that. I've pointed to 1 of many shunts my short tenure in the hospital. Sorry. 

Dr. Betsy Grunch: Yep, we, we, we love those consults. 

Margaret: I, I feel like, um, yeah, it's, it's, it's interesting because it's [00:54:00] such a different set of skills to do psychiatry versus like, and like the culture you exist in for the years you're in training is so different.

And so it makes like communicating across these. I feel like. Yeah. Very difficult, even if like what we're all dealing with is someone's having chronic pain. I feel like the thing that made me start being like, why do we do what we do in the hospital? And is that always guaranteed to be like the right thing to do?

Was reading on like a PM& R rotation that like, we took images of people with back pain and people without back pain and we correlated that to if they were going to have like image findings on their spine? And it was like, Not correlated, like you could have a very funky back and no pain and like a perfect spine and pain.

And that made me be like, okay, which I feel we should care about. I mean, that's one of the things Preston and I originally became friends over was like. What should psychiatrists care about or be trained on in terms of, like, which neurons we care about? Um, because historically it's in like psychiatry.

You guys get the illnesses that have something to do with the [00:55:00] brain that we don't really know what's going on. And now, in the modern era, luckily, that's becoming less clear of a distinction. Um, Preston's much better than I am at reading MRIs, I will say. Uh, but, like, this question of, like, what, how, what is a coherent psychiatrist interacting in the system?

Um, But I mean, to put that backwards, like, what do you think? Are there, are there skills that you wish that neurosurgeons had in terms of how they operate within the system? If we think about really good patient care from a systems level that you think in an ideal world, this is something other skills, neurosurgeons would be trained in, in addition to the operating room.

Dr. Betsy Grunch: I mean, it would go back to the things that we've discussed already is just empathy and listening and, um, just being, uh, better. Listeners and engaging. I mean, we talked about Preston talked about the punching up and punching down type, uh, things that we [00:56:00] experience on social media. But I think the same thing goes in the hospital setting is neurosurgeons are often think of like the top of the chain.

Right? And so they're treated like that. And sometimes we. Have that ego of like, oh, no one can talk to me that way. And no, like patients can't do that. This, that, so it's almost this like ego complex that some of us have to, uh, admitting when we're wrong or, uh, don't want to seem weak or don't want to seem soft.

Um, and, um, yeah, I mean, it's, it's just, uh, it's kind of like this, the way we're Darwinism almost. So 

Margaret: you guys scare me of all the brain people, the most, 

Preston: how would that go over? If we tried to incorporate like therapeutic listening didactics in a neurosurgery, I'd love to see 

Margaret: a I'm picturing a glockenspiel like skit right now.

I just 

Preston: I can just picture myself being like on the screen. Okay, guys, here's a validation. And then like groans throughout the crowd, you know, 

Dr. Betsy Grunch: grow to be nice. [00:57:00] 

Preston: Yeah, 

Dr. Betsy Grunch: maybe walking out, I'm 

Preston: just getting yelled with spitballs as I try to explain how to affirm someone's pain 

Margaret: out here with your tweed and your feelings, like, 

Preston: yeah, I think it's, it's 

Dr. Betsy Grunch: becoming more culturally accepted, though, which is great.

Like, we're talking about, that's what I love about this new generation of, of, of. Folks is like, they're making us talk more about the things that we would never talk about back when I, you know, trained and like, are my current generation of providers. It's interesting the shift that you see, you'll see people that are, um, you know, treated 1 way, but realize that was wrong.

And so they're making changes to make it better. And then you'll have some that are still trapped in that very old school. Uh thought process and it's it's getting more Faded out, but there's still so much of that that is ingrained with us and ingrained with within our [00:58:00] personalities because that's the way we were quote unquote raised and it's it'll be Nice to see that type of thought process kind of slowly dissipate out.

And I think the more diversity that we have within our trainees, um, will really help with, you know, with changing that, that, that, that paradigm. So I'm 

Preston: used to drink whiskey. In the psychiatry hospitals. 

Dr. Betsy Grunch: Yeah. 

Preston: Like on the wards. Yeah. 

Margaret: It's that or withdrawal. 

Preston: So whenever, whenever Bessie's talking about the old school way of thinking, she's probably talking about, I just picture this like dark gloomy basement where there's like lightning strikes and then you're, someone's yelling at you while you have a drill in your hands and you're trying to open up a school.

When I think or picture old school psychiatry, I just picture some dude in a tweed jacket ripping a cigar. And like drinking a handle of whiskey, talking to someone about how we have a new medication called Thorazine. [00:59:00] Now it's going to solve all of our problems. 

Margaret: Well, we're not going to get into lobotomies today, but 

Preston: yeah, I skipped right over that.

Margaret: You said we're going to skip that part of our history. 

Preston: The overlap between our specialties. 

Margaret: Yeah, 

Preston: bottomies. 

Margaret: Yeah, the bad time in psychiatry when we tried to play 

Preston: neurosurgery. Is that what we call it? Psychosurgery. Yeah. 

Margaret: Although there are still lobectomies at times in extremely severe cases that are not lobotomies and are much more specific.

So one other topic I want to talk about that I feel like is related to all of this is just the concept of central pain sensitization. Um, and kind of if you talk how you explain that to patients or how you think about it, just because I think it is sort of the concepts in the. Neuroscientific understanding of, of like what makes patients be more at risk, um, for pain.

Are you, are you familiar with this or 

Dr. Betsy Grunch: are you asking me or [01:00:00] Preston? Sorry. Oh, I'm not. 

Margaret: Well, actually, let's start with Preston. Yeah. What's central pain sensitization.

Preston: Next question. 

Margaret: Next question. I asked Preston earlier, I go, what's your clinical experience with treating pain? And he goes, I once sprayed myself with their spray.

And I also, I also 

Preston: broke my arm cause I fell off the course. 

Margaret: Yes.

Okay, Preston, give us a, give us a good faith guess. 

Preston: Central pain sensitization. Yeah. So. It's her 

Dr. Betsy Grunch: cricket sounds. Okay, 

Preston: no, I'm thinking. So now the grinding sound. 

Margaret: Or the car crashes on just like. 

Preston: Yeah, you see, I'm so SpongeBob was like, what's that smells Patrick thinking again? So here's, here's my guess.

Central pain sensitization sounds like there's a difference between central and peripheral pain. So I'm going to imagine that central pain has something to do with your brain's [01:01:00] subjective perception of whatever input comes in from the outside. 

Dr. Betsy Grunch: Exactly what I was gonna say. So 

Preston: if I could become more sensitive to that.

There may be the same level of input coming from my nerves, but it's going to be amplified and how I feel it. And so something like depression, I know, is going to make someone subjectively perceive a higher intensity of pain. So I would say that central pain sensitivity is the subjective experience of amplified pain, despite no other changes in, like, inputs downstream, I guess, downstream.

Margaret: That's, that's pretty close. Yeah. Um, yeah, I think it means cheering sound 

Preston: effects. 

Dr. Betsy Grunch: Yeah.

We've had, um, it's interesting because this type of conceptual understanding of pain in patients is now becoming almost a standard clearance for some back [01:02:00] surgery. So, you know, I'll have patients that need. Lumbar disc replacement, SI joint fusion, uh, these, you know, classically misunderstood pain diagnosis as a patient with spine disorders and their insurance rule will require cognitive behavioral therapy before they can, uh, have surgery and, um, even spinal cord stimulation, which is a pain relief procedure that we perform will almost exclusively require psychological clearance.

Margaret: Yeah, 

Dr. Betsy Grunch: um, so I think I think we're understanding a lot about that, um, in our field, too, and how there's some overlay. 

Margaret: Yeah, I 

Dr. Betsy Grunch: feel like that 

Margaret: was something. So I worked with a pain psychologist, um, in med school and central pain sensitization. Just to come back to it 1. I also want to say anyone listening to this Stanford has really great resources.

They update every year. The Stanford chronic pain guide in particular is a free, like, 90 page PDF. They update it every year. There's illustrations you can use with patients. But the idea of central [01:03:00] pain sensitization is acute pain is helpful, right? Like, we, we all know this, like, if you touch that stove, like we told our patients to in my metaphor earlier, you draw your hand back because you get the acute painful stimuli.

What the way that site kind of comes into pain is in chronic pain, the likelihood, um, Preston, like you're saying of. pain signals basically going on for too long or too much to the point where basically the threshold for different No susceptors or pain receptors throughout your body. Um, and in particular areas under certain pain conditions, functionally are damaged by inflammation and misfire and can be kind of constantly firing, kind of like having alarm clock that won't turn off.

Um. And central pain sensitization is the idea that there is some way in which if someone has acute pain that transitions past the like plus one or two months [01:04:00] after when you would normally think the tissue would heal or the injury would heal that there's a way in which there is a centralizing or kind of like upper higher order brain function happening that makes them more likely to continue to have and maintain that pain signal versus like.

Okay. Kind of being like, okay, the danger is no longer here. We can turn off the alarm. We can turn off the system. One of the things that I think is really interesting and Dr. Grunsch, I'd be curious your thoughts on it, is that we know that if someone has one chronic pain condition, they're more likely to develop another one.

Um, and so this matters a lot. We think about like kids and adolescents are young adults that if they have chronic pain already. Um, obviously that is difficult in and of itself, but wanting to prevent further chronic pain developing. And so central pain sensitization is sort of the term of how does someone's nervous system across the board kind of become more likely to interpret it.

Normal stimuli as painful. [01:05:00] 

Dr. Betsy Grunch: Yeah. I mean, it definitely is something that, that we have to try to try to navigate and deal with. And it's, it's, I think we're understanding more about it, but, um, it's just something that at least in our training, I mean, we're not even remotely talked about that as even a possibility.

It's like, you know, orthopedic surgeons, broke bone must fix telling neurosurgery that MRI must fix. So there's, there's not like a lot of understanding of that, but I think it is. Um, very important to understand that and how our patients may heal and recover from any type of procedure that we may do. So 

Preston: it makes me think about.

Um, targeting nude, like you, like you said, um, CBT being requirement before you pursue a spine stimulator or surgery as a way to kind of adjust someone's subjective perception of their pain. Um, tramadol has been something I see a lot of patients that take. And what's fascinating to me about that is that [01:06:00] terminal functionally is not as strong as an opiate.

It's metabolized into something that has pretty potent opiate effects. But yeah, If you go pound for pound, it's pharma pharmaco dynamically closer to like a fixer or symbol to. And so I've had a lot of people that say like, hey, tramadol did the most for my pain out of any opiate. I've tried. I've been on oxy, I've been on hydrocodone, but tramadol made the difference for me.

And it makes me wonder, like, is this because they were actually getting the mood benefits of tramadol, which has a lot of noradrenergic and serotonergic activity. So it's almost like. We treat your depression to treat your pain has kind of been the approach. I've taken those people and I try to kind of sell it like that.

So we know that can help with pain, but it just makes me wonder if we know that depression changes how we interpret pain and couldn't an SSRI or even like CBT [01:07:00] indirectly be a treatment for pain. And I feel that that kind of that connection gets a little bit lost. 

Margaret: Yeah. I mean, that is standard of care, like, across the board.

Like, one of the things we know I was. Yeah. Reading the kind of like neurobiology chronic pain chapter before this episode and like the standard of care for chronic pain is that we would get them on like an antidepressant in some ways, even if they don't necessarily have depression and like that we would modulate from these kind of top down way versus like surgically is more sort of bottom up modulation.

Um, I, I feel this gets at the point, too, of the system, like, who knows the whole pain system for the amount of people? I mean, I think 100 million people in a recent clinical, like, review the clinical guidelines from 2018. It was like 100 million people. Um, in the U. S. suffer from some form of chronic pain with the most common being low back pain, uh, in the U.

1. alone. And [01:08:00] that, that's such a huge, it's one of the biggest reasons for disability and for missed work and loss of like quality life years. But, you know, I feel like all of us from every different specialty can say like, where do these patients go that they get access to the best and like most studied care?

Dr. Betsy Grunch: Yeah, I don't know. It's It's, it's tough. I, I mean, I think that's why it's so important to kind of understand that it has to be type of a teamwork type approach and that collaborative environment amongst all of the patients on their care team, you know, from psychology to psychiatry to, you know, to, to surgeons, to pain doctors, to therapist and everything, because, um, it can be complex.

Preston: It's muddy. It lasts a long time. And, uh, requires a lot of teamwork. So as we start to wrap up, um, first of all, thank you for your time. Let's see. Really appreciate you coming to chat with us. Hopefully, [01:09:00] um, this podcast wasn't as painful 

Margaret: as I imagined it would 

Preston: be. 

Margaret: We had the tomato just coming on. 

Preston: So, um, we like to end by saying, you know, if you have any, any products or kind of projects, things you're working on that you'd like to use this chance to promote the floor is yours.

Dr. Betsy Grunch: Oh, uh, I, I, no, I, I just, um, I started my own, um, website slash clothing line recently as a, as just like, I don't know, I mean, it sounds kind of cringy if you think about it, like, why is a surgeon making. Hoodies, but it gives me, uh, I really am using my platform obviously for education purposes, there you go.

But I really just enjoy just trying to inspire people, whether it be pain patients to understand their pain or somebody to understand, you know, [01:10:00] what their diagnosis is, or even like a premed student thinking, Hey, you can be a mom and a surgeon and just inspiration has kind of been my underlying, like, um, just, you know, background of.

My platform and um to i'm also I love clothes and you know fashion and so just to kind of translate that Uh to a mode of self expression has been kind of fun and something that i'm delving into so, uh, So yeah, lady spine doc. com. We have some apparel to kind of you know Have that neuroscience love passion of the brain of the spine And translating that into inspirational stuff and even bringing that into other fields of medicine that I've had some other creators, uh, utilize my space as a mode of self expression for them.

What's been fun to connect with people, uh, on that type of adventure. So we'll see 

Preston: and I'm wearing your trucker hat, right? There you go. Looks hot on you. What's this product called? Thank you. That is the, 

Dr. Betsy Grunch: I know, uh, that is the, I think [01:11:00] cranial love trucker. 

Preston: Cranial love. Yeah. I, I wear this to the gym, so I always make sure to lift a ton of weight so people are like, wow, whoever, whoever likes to wear those hats super strong.

Dr. Betsy Grunch: Hell yeah. . 

Preston: Okay. Well thank you so much for coming on to chat with us. We're going to, um, do some outro and other transition things, but I think at this time mm-hmm . I just wanna say. I hope you have a good weekend. It's MLK day. And, you know, us in the future, hopefully this tick tock thing ended up for the better.

Yeah. Yeah. 

Dr. Betsy Grunch: Hopefully that changes, but we'll see. Only time will tell 

Preston: by the 

Dr. Betsy Grunch: time this airs, we'll know. Yeah. for your time. It was great to see 

Preston: you. 

Dr. Betsy Grunch: You too. Y'all have a good one. Okay.

Margaret: So we are doing Our first ever viewer submission questions that we got after our first episode, [01:12:00] Preston. 

Preston: Well, it's it's like we're a community. 

Margaret: It is like the call and 

Preston: response. 

Margaret: We're going to sing these questions actually. Um, okay. So question 1 is from Avery kale 13. Would love to hear your takes on empathy for your patients versus people in your personal life.

I feel guilty anytime. I don't give someone the benefit of the doubt because I'm supposed to be understanding and caring in quotes, but it's just different. I love this question. Preston, what are you? I 

Preston: agree. So I think I went through this phase towards the end of my intern year where I was like, I'm learning how to be this Yeah.

Therapeutic doctor. So I just kind of have to be this at all times in my life. So my close friend, Reggie and I, we would kind of talk after after work and our interactions would be like, almost like we're trying to play therapist to each other sometimes. And then I think people had to correct and say, like, wait, [01:13:00] stop therapizing me.

Like, I don't want a therapist right now. I want a friend. Right. And I think To your point, Avery, I'm always trying to give people the benefit of the doubt in my personal life or in any kind of concept because I have this identity of being understanding and caring. I had to realize that being understanding and caring means different things in different contexts.

Yeah. So, yeah, when you're this kind of soft, open provider for someone. During the day, you don't share any of your personal life with the patient, you're kind of closed off in a lot of ways. You try to reflect back to that patient. But when you leave the hospital, I realized that these are now bidirectional relationships.

I share and then you share and we both. So it's okay to have your own emotions because you're an active party. So I think I want to acknowledge that it is hard, but also it's okay to be human and not have to be this person all the time. 

Margaret: I [01:14:00] think also one of the things that's interesting to think about from like a broader or population almost perspective is that generally speaking, people who go into helping professions take a lot of stock and being helpful and making people around them kind of Feel good, especially maybe people who go into mental health.

Um, there can be a, a proclivity in the population of people who become therapists or mental health workers, or people who talk to people who are not feeling well for a living. Right. And I think knowing that going into or being in the middle of training or beyond training, being like, good by your own definition doesn't always mean making everyone around you feel good.

And sometimes. Part of really letting the people and the relationships in our own lives outside of being a clinician. It is to kind of put down our coping mechanism of being seen as helpful. Um, and [01:15:00] that's a hard, uh, metaphorical pill to swallow. I know it's been hard for me, but honestly, treating patients and being in residency has made me, I think, better at real like relationship because I know what it feels like when I'm.

Okay. Trying to hold a space for someone and make that space really what the therapy space is. And I'm like, oh, I'm doing my job right now. Whereas before residency, I feel like I didn't know when I was not being real in a relationship because I was trying to just tend to the other person exclusively a lot of therapy to get there to realize.

Preston: I think a statement that comes through is I'm I'm a good person because I make other people feel good if that's the way you measure how you're good or or give yourself value that can be really unforgiving framework, right? And people can end up chasing it and become people pleasers without even realizing it.

Margaret: I saw 

Preston: this tweet that was honest either. 

Margaret: Like, it's like, you're not actually letting anyone know you then 

Preston: [01:16:00] you're just trying to allay their unpleasant feelings. I saw a tweet that was like, um, attention all people pleasers name one person who's pleased with you right now.

Margaret: I'm waiting. 

Preston: Yeah, seriously. And it's hard to learn. Like, wait, I'm I'm allowed to have emotions in this relationship. 

Margaret: Yeah. Yeah. 

Preston: And I don't exist to be the caring therapeutic friend. 

Margaret: Yeah. And it's like, I mean, I think you learn this working in health care, like sometimes not giving a medication if it's not indicated, or if I'm really worried about it, clinically speaking for a patient is the good clinician thing to do.

And so, like, if you. We can't be phobic of like other people's pain. That doesn't mean we should push it away and be like, don't talk about it. But like, we also can't absorb it. Um, and I think that that takes a lot of like reps, like a lot of practice and that you [01:17:00] continually have to do that process over and over to find balance.

And also when you're on nights or if you're in like med school and you're on surgery or on whatever, if you're a future surgeon who like really hate psych and you're on psych, like, yeah, It's okay for there to be seasons where your relationships look a little bit different because your capacity is different.

Just like logistically speaking. Hmm. Um, yeah. Okay. So the next 

Preston: question. This is Monica from the pod page, she said, I've been a big fan of both of your contents for a while, and I loved the first 2 episodes of the show. I'm an M4. I would like to hear you all talk more about balancing heavy feelings and strong emotions you run into as medical trainees throughout my M3 and M4 rotations.

I feel like I've been thrown into some of the wildest highs and lows in my professional life. Being yelled at in the OR for not retracting or suctioning properly, having a patient say I was the one person who made them feel heard and validated, doing chest compressions on a patient and feeling their ribs break, watching a baby be born perfectly healthy after a mother struggled with infertility, watching [01:18:00] someone die in the ICU because they have no family, doing a mantle disimpaction and being hit with pressurized diarrhea.

The profession comes with such extreme highs and lows. I feel like medical school doesn't really teach you how to ride these highs and lows, despite the fact that everyone encounters them. I'd love to hear you both discuss how you grapple with these moments in your training and share advice that you'd have for medical and medical students and residents working through these situations, these situations that we all encounter.

Margaret: Well, first I would say, Monica, are you someone who writes? Because this is a Like, beautiful description of the, like, highs and lows. I think that all of us can relate to. And if you are, you should look up Laurel Braitman and see if you if writing is good for you going to one of her free Stanford virtual writing workshops.

I say that just because you sound like a writer. Um, I don't know. I feel like I Preston. I'm curious your answer on this because I feel a little further from this as a 4 just because I think as you get [01:19:00] settled into a specialty. Um, it becomes less of the up and downs, although there are certainly. Or is that in psychiatry as well?

Um, I would say similar to the above question. One of the things that skills or processes that, like, I've had to get better at is not feeling afraid of the emotions that these situations cause in me and, like, having a better reflective stance on myself. Like, A couple days later, I'm still feeling weird after like an interaction or clinical situation saying like, do I need to talk to my friends about this?

Do I need to do I need more sleep? Am I holding too much? Like, what do I need assistance with this or supervision? I think being, I think med school to like, get through it, you often have to like, the culture of medicine is kind of like, you put on the white coat and you disappear. And sometimes even in our interior self, we kind of then [01:20:00] become like, oh, if I'm feeling sad or anxious or grief or just unsure, we react negatively to that or kind of make it it colludes with our imposter syndrome when we're in med school and makes us be like, is this the right career?

Is this this? Like, we don't know how to hold it gently. And for me, a lot of yeah. Growing into being a clinician has been being able to not just hold my patients emotions with gentleness, but also my own, um, Preston. I wonder what you think. 

Preston: I guess what I interpreted from this question is we are on a roller coaster in medicine.

What's your advice on how to survive the roller coaster? And then she kind of goes through some of these stops. And I guess this is going to sound cliche, but like, keep your arms and legs inside the vehicle at all times. Make sure you're the, you're the proper height to get on this ride, which you are, you're in medical school and know that it's going to come into the station.

Um, one thing that like always helped me when I was [01:21:00] Doing stuff and the only way to describe it is it's bananas B. A. N. A. N. A. S. This stuff is wild that you are experienced like no one else is going to go through this in their lifetime, you know, you, you may be the first person to, um, see someone live like, like you witnessed their birth.

That has been bananas experience and then on top of that, you may be the last person in human talks to like, those are things that people in the general population don't deal with. So it is a roller coaster and what I would be comforted by is knowing that, like, I'm on track. There are hundreds, thousands of people that have stood in my shoes before me.

And there are thousands that will stand after and I'm kind of just like in a line to to do what many have done before. And I think that was comforting for me. I had a, I had a mentor tell me, like, when I was nervous about taking the board exams, he said, you know, at [01:22:00] some point, you just got a nut up and walk in there like every other generation of doctors have done before you and take the boards.

And I was like, yeah, Honestly, yeah, like, uh, and I think I kind of like own that. I'm like, Hey, I, I am a part of this club. You know, I am a physician in training and like, this is a part of me and I'm and I'm a part of it. So I think when I took on that identity, then I didn't need to interrogate whether or not my responses were appropriate or inappropriate.

I'm just like, right here I am. Um, so I think that kind of helped me handle some of those high highs and low lows. Yeah. Because they like, I still think about a lot of them. I remember 

Margaret: only so many scripts about our emotions, like about what does it mean to be a doctor and how to doctor react, especially when you're first learning and trying to prove to like the people evaluating you that you're a doctor.

Preston: Yeah, [01:23:00] the first patient death that I recall, um, she, we go in the room and it was like one of my first days wearing like the Patagonia vests, you know, how like the med schools have those and then give them to you. I was so proud. I was like, I look like a resident. I'm like a third year and a third year med student and she's watching Grey's Anatomy in the hospital and she's like, it's so fun.

It's it's just like what you guys are doing all day. And then, um, the patient goes, and I've made up names for you because we're an internal medicine team. We all have, like, six rolling deep every time, you know, and she goes, she was, she was funny. She goes, you're grazing on me one. You're grazing out of me to you're grazing on me three.

She just listed us off down the line. I think I was grazing on me five and she was, she was joking with us and was excited to go home and she had been there for some right heart failure, which is, you know, can be like pretty scary and can tank really fast. Yeah. But she was up and talking to us and happy, and she wasn't my patient.

So I wasn't like really following close [01:24:00] and then about four hours later, we were doing notes. Me heard a code blue called to her room and go back and she was down and she had passed. I guess she maybe had an arrhythmia. Um, maybe she's preload dependent and her heart gave up. We didn't know why. But I remember just kind of standing there in the hallway, like watching this is that was a body.

Yeah. Um, have a code run on them, and I, like, couldn't comprehend that she wasn't going to wake up and talk to me because just hours earlier, I was grazing on me 5 to her, but now she was just kind of just like a husk of where her soul used to inhabit. And I think, like. I was so confused because everyone around me is kind of like going through the motions.

They've done like three rounds of, of Epi. They're kind of like bored. They're like, do you guys want to call it? Like, I don't really feel like calling it [01:25:00] and there's this kind of like blase air because the code team does that like twice a day, you know, and I've never seen it like a body before. I'd seen my cadavers.

So I remember just kind of like sitting with that for a long time and being like, is this The normal response should I respond to this way? Like it's now 30 minutes later and the interns just writing the note like they're like, just updating the note saying like patient deceased. And then they're like, okay, nice.

Now I have like 4 more notes to write. Yeah, it's not to say that anyone was like callous. It was just that this was like a part of life. Like you have patients die on your team and you have to go take care of other people. So I remember sitting with that for a long time. And then I kind of just realized that this is.

Now a part of me. So each one of these high highs and low lows has kind of just formed me in a small way Yeah, and I've [01:26:00] had other patients pass since then I don't remember them in the same way But that first one just kind of sticks with you So so I think you can own the emotions also know that these are formative experiences and that it's making you who you are 

Margaret: I also think it's like there's definitely a problem of like burnout and becoming desensitized But I in medicine like in general, I don't think you're saying that but I think in general that that is true And We can leave space that like there's a way to do this work, though it's difficult.

There's a way to do this work that just because it won't be as hard as the first time doesn't mean you're like, you're bound to become cold and desensitized. Like, there's a way of still finding this meaningful and it not feeling as hard every time it happens. Does that make sense? Because I feel like sometimes like you're either going to like be soft and sensitive and it's going to destroy you every time or it's going to burn you out and you're going to be cold and like not who you once were.

And I do think there's a middle zone that doesn't [01:27:00] have to be true. 

Preston: Yeah. I see a lot of people punish themselves because they say I'm not as sad as I should be right now. 

Margaret: Yeah. 

Preston: I was expecting to break down and I didn't what's wrong with me. Right. And there was nothing that's wrong with you. You're responding like a human.

Margaret: Yeah, you're responding like a human being would. And yeah. 

Preston: Well, that was fun. I kind of like going over the, the questions from the listeners. 

Margaret: Yeah. Ask us them. We like them. Yeah. So we'll read them off. 

Preston: Um, thank you guys so much for listening. Um, at this time that we're talking, the first couple episodes have aired, so we've got to see the reception and everything has been so positive and it just has been a surreal week.

I'm, I'm just filled with gratitude and one thing that we want to try to is there's been a couple of you that reached out to about sharing your stories as patients on the podcast, we would love to be able to kind of incorporate that more. I think at the beginning when it was just us behind the scenes, we were, we were getting [01:28:00] more medical professionals, but now if there's kind of a chance for us to incorporate you to talk, With your first hand experience about your mental illness or or any kind of experience that you think would be relevant.

We're happy to hear it Yeah, and we'll kind of approach it the way case curious journalists would but rather than clinicians because he's in this space It's Preston and Margaret the gang 

Margaret: Yeah, and we want to be we want to be really thoughtful for those of you who Maybe interested in doing this, but also for our other listeners that we, we recognize the complex ethics of on one hand, not wanting mental health and patient stories to be so stigmatized that no one knows about them.

Um, and on the other hand, recognizing that there is stigma and that even outside of stigma, this is like a vulnerable thing to share with, like, who knows how many, at least it's vulnerable to sharing with just me and Preston and Preston's cats. So we want to be thoughtful. We want to think about it really [01:29:00] creatively with people of how to do this in a way that's comfortable for you and, you know, ethically sound while also getting these stories out there.

Preston: And I think we'll figure it out. I'm, I'm optimistic. The other thing, if you have a win in medicine or in the hospital, or just like a little success that you want to share, we want to hear it too. So just leave that in the pod or on a comment somewhere. And then we'll start to try to read off the wins because I think If I can't have a win, I want to live vicariously through you guys.

So I want to hear the little successes you have throughout the day. If you, if you have any other feedback, we're here to hear it. Let us know how the show was come shout with us at our human content podcast family. We're on IG and TikTok at human content pods, or you can contact the team directly over at how to be patient pod.

com. Shout out to all the listeners that left these reviews and the ones we read off today. Thank you as Avery and Monica, Monica, you guys are awesome. And you're the first listeners that we read off. Wow, you, [01:30:00] you're our first. Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan.

Our executive producers are me, Preston Roche, Margaret Duncan, Will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman, and Shanti Brooke. Our editor and engineer is Jason Portizzo. Our music is by Omer Benz V. To learn about our program disclaimer and ethics policy submission, verification and licensing terms, and our HIPAA release terms, go to howtobepatientpod.

com or reach out to us at howtobepatient at human content. com with any questions or concerns. How to be patient as a human content production. Bye bye.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's [01:31:00] gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the background.