Marcela del Carmen, MD: Valuing Your Own Diversity

 
Q: Thank you for being here. On this episode, we're talking with Marcela del Carmen, who is the chief medical officer at Mass General. And I'm wondering if you can just first kind of describe what you do here at the hospital; what's your role?

A: Sure. So I'm a gynecological oncologist by training, and that's how I spend my clinical time. So I'm trained to take care of women, who have gynecological cancers. In our specialty, we are trained to do the surgery, so we take care of their cancer surgically, and then we're also trained to provide treatment beyond surgery, including chemotherapy. For patients who end up not surviving their cancer, we provide care till the end of life. It's a wonderful specialty because you're able to really look out, after a patient for the long term.

And then my administrative job is a job that I've had for two years as the chief medical officer for the physicians' organization. That's the group of doctors at Mass General. It's a little bit under 3,000 doctors the spectrum from primary care to specialty care, both in medicine and also in surgery. That job, I would say, has multiple domains of responsibilities. One of my biggest responsibilities is around physician burden, administrative and burnout. So trying to look for ways to mitigate the impact that we all are facing with the demands of our clinical jobs and looking for ways to restore meaning and joy back into the practice of medicine.

Q: Can you talk a little bit about what administrative burden means?

A: Sure. So when you look at the data, it's been pretty well described, not only in medicine, but across all job specialties back in the 1970s. So basically, it's when you're so fatigued by the work that you're doing that you begin to have physical and emotional, essentially, symptoms of being overworked. And you begin to lose the meaning and sort of perspective in the work that you're doing. There's been also descriptions in the literature that it can manifest across three different degrees; so there's like first degree, second degree and third degree. Third degree is when you really are having some physical and emotional manifestations that include depression, substance abuse, where you really have lost, you know, your ability to engage in your job fully. There are data in medicine that the incidence of burnout among physicians is higher when you control for things like age and gender, part-time status, when you compare medicine to other industries, that our job is a little more vulnerable to this burnout, you know, phenomenon.

I think the concern is that people are leaving medicine to look for other jobs because they're finding that it's not sustainable to continue to practice with this level of demand. There are also data around safety and quality of care that are impacted by physician burnout. And also financial costs to institutions; every time that somebody leaves medicine, there's always an impact in terms of cost. So for all the right reasons, I think that it's something that we have to tend to and try to figure out a way to support clinicians better. It's not only pertinent to doctors. I think I want to be clear that it also affects our nursing colleagues. Basically anyone who is engaged in clinical care is susceptible to, to burnout. So a lot of the work that I do is around looking for initiatives to try to mitigate and how do we support doctors better so that they can find meaning and joy in the work that they do every day. And that being one of our primary missions, it's something that I'm pretty vested in. My job is to advocate for patients and doctors across the institution. So it's a wonderful charge.

Q: It's like you're getting to help the doctors take care of themselves so they can take care of the patients better.

Q: So how did you end up here at Mass General?

A: Yeah, so, you know, I'm originally from Nicaragua. I grew up in Nicaragua. We left in 1979 when I was ten. And my family left during the civil war. We had a 40-year dictatorship under the Somoza regime, and so we left a few weeks before Somoza was ousted. We left literally with a suitcase escorted by the Red Cross Managua at the time that the city was being bombed. And I was very fortunate in that my father's an architect and he had a job in Seattle. So we, our first year of exile we spent in Seattle, Washington. And then my family couldn't go back to Nicaragua for the subsequent 16 years. In fact, I didn't go back to Nicaragua until I was a junior in college when the government changed and I was allowed to go back. So that was how I came to the United States.

Ultimately, we moved to Miami, which is where I finished high school and then went to Emory to do my undergrad, and went to medical school and residency at Hopkins, and then came to the MGH to do my fellowship in GYN oncology. It's interesting because when I was at Hopkins, I really wanted to stay there for fellowship, but the fellowship program had just been shut down for gyn onc, so I really had no choice to stay. And I remember the division director at the time encouraging me and sort of, like, telling me it's actually quite good that you can't stay because it's good to look for diversity in your experience and training. And I think probably it was one of the best things that ever happened to me, was to actually come to a place that was a little different– not too different, but different enough that I think you gain something by being exposed to a different way of practicing medicine, a different institution with sometimes different priorities. So I stayed here for three years. Completed my fellowship. Went back to Baltimore for a year, practiced at Hopkins. And then came back to the MGH in 2003. And I've been on the faculty here since that time

Q: I'm curious, you know, you had this really incredible experience as a young person, coming to this country as an immigrant, being completely uprooted. Do you think that changed the course of the decisions you'd make later in life and in going into medicine?

A: You know, so my mom tells the story that she knew I was going to be a doctor since about I was– since I was about age four. So I think–

Q: Four?

A: Yeah. I think– at least that's what my parents remember. But my first exposure to medicine was through my mom's father, my grandfather. He was a urologist. And he had trained at Hopkins.

And I remember being very young and playing hide-and-seek in their house and being– I would always hide in his library, which made it very easy for my brothers and my cousins to find me. But part of it was the ability or the opportunity to actually spend time in this room where he had pictures from, you know, his residency training. And there was something sort of magical for me about this place that I had never been to, but he talked a lot about Hopkins and his training years. And so, for me, I remember growing up and sometimes going out with him in my hometown. People would stop him and there was always something with an anecdote about how he had helped somebody in their house or in their family as a clinician.

By the time that I remember him, he had obviously retired from being a urologist and he was practicing more in the primary care setting and delivering essentially free care after he retired. And I remember thinking, like, whatever he does, I want to do because people really seem to be grateful. And there was something magical about the way that people connected with him. He was a very serious guy, so it was actually interesting that there was something very gentle about the way that other people interacted with him and the way that he interacted with them. It was almost like seeing a different person compared to sort of my, you know, disciplinarian grandfather.

So when I came to the US, at least as far as I can remember, I always wanted to be a doctor. I think the part of my journey that was very different is that I grew up very closely connected to my family of origin, and I think that that connection was forged by the fact that we moved a lot. And so, I didn't have an opportunity to really make friendships that were long lasting. So I'm very close to my two brothers, very close to my parents, incredibly indebted to my parents for the opportunity to really offer us a space where we could grow up in, you know, in a free society with freedom of speech, a lot of freedoms that we take for granted today that I think for me were not trivial as a young kid. My mom was 33 when they moved to the States with three young children and they had to start from scratch. And so, I think that's a privilege that I will never be able to pay them back.

So I think that part of my journey was different in terms of my connection to my family of origin. I also think I grew up with a very strong sense of community service. And the only thing that my parents ever asked was that we give something back. You know, and I don't know that it would have been the same if I had stayed in Nicaragua and had grown up with maybe more privilege. But certainly I think for my parents, education was very important. I think that they had gone through a civil war as a young couple and understood the value of education, and that, at the end of the day, that's the only thing that you really give your children as a legacy. So my dad didn't really care what we did; he just cared that we reached whatever potential we had and that we try to do good and give something back and pay it forward.

Q: Absolutely. How has it affected your sense of identity, being an immigrant, and not just an immigrant but an immigrant who is really leaving something really terrible behind.

A: Yeah. So you know, again, I was ten when I came, and I think that by the time that you're that age you have maybe not a well-defined, but you have some sense of identity. So I think because I grew up with my parents not knowing that we would ever be able to go back to Nicaragua, they instilled in us a very strong sense of, I would say, pride about being Latin and being from Latin America. So there was never, for me there was never a struggle between am I American or am I from Nicaragua. I think I felt like I was– and they always, I think, appreciated the opportunities that this country afforded us. So we grew up with a self– with a sense of identity that was very mixed, that we were from Nicaragua, but had been given this incredible opportunity and that we were now part of this incredible culture.

And there were all these kind of unwritten rules. Like we spoke Spanish at home. Both of my parents were raised– were educated in the US. They're both bilingual. But my parents strongly preferred that we speak Spanish at home so that we didn't lose our language. Every summer, we had a tutor who came and spent time teaching us about Nicaraguan history. So we grew up with a very strong sense of pride about our background. But also very aware that we may never go back. And so, I think that they really were able to optimize this dual identity of being from a different place of origin but being in a new country was where we were probably going to spend the rest of our lives. And I think it's complicated to the degree that you never have one culture that you take as your own, that defines you, but it's also incredibly enriching in that you're very diverse and you can actually– you're comfortable with different people, with different thoughts, different perspective because in some way they reflect who you are.

And so, I think that for me, until this day, you know, I speak to my brothers in Spanish. And so, I think that there's this very gentle way that they allowed us to not lose, you know, a sense of where we came from, but also not be so caught in that that we were never going to be able to adapt to this, to the US, or this new culture.

Q: Yeah, that's incredible the way they kind of were able to balance it and create value for both. You know, retain your heritage, but also help you appreciate what you had now that you were here.

A: Yeah. You know, my parents moved back to Nicaragua like ten years ago and till this day my mom's favorite holiday is Thanksgiving. And in Nicaragua I think she's like the only Nicaraguan that celebrates Thanksgiving in the middle of like Nicaraguan summer. But I think that they understand the opportunities that they were afforded by having this country open their doors to them, again as a young family with three kids, being able to raise them in a free society I think for them was just an incredible privilege.

Q: Did the turkey and everything for Thanksgiving?

A: Oh, yeah, no. It's like New England [laughter] it's like New England Thanksgiving, except in like 90-degree weather. [laughter]

Q: I'm curious to know a little more about how you ended up in gynecologic oncology as a specialty. Because I imagine it can be a difficult field to work in.

A: So you know, when I started medical school, I definitely, I knew I wanted to be a doctor, but I didn't really know what I wanted to specialize in. I remember that my first clinical rotation was psychiatry and for about two weeks I wanted to be a psychiatrist. And then, I think the gyn oncology experience was informed by two events in my life
My mom's closest friend Nicaragua, her son was diagnosed with leukemia when he was 12, and they moved to Washington, DC; he was getting his care at Hopkins. I was a first-year medical student. And he went to Hopkins to be a recipient of a bone marrow transplant. And Marcos actually stayed; they had to stay in Washington for the remaining duration of his treatment. They moved, and sadly he died from a relapse of his leukemia when I was an intern. And I was doing my residency in OB/GYN. So I think my relationship to that family and essentially being a witness to what he went through as a young cancer patient got me, you know, a perspective or an experience in oncology that was very unique. I was a medical student at the time, but got to see the experience of being treated for a cancer through the eyes of a young kid and through the, being on the other side, which I think is an incredible experience. That can be very formative as you are training to become a clinician. So I knew there was something intense, but also really wonderful about the engagement that I saw between his clinical team and the family that I think was very formative in my decision to go into onc.

And then I think the first time that I stepped into an operating room I knew that whatever I did in medicine had to require or involve being a surgeon. I was always interested in women's health, and so gyn oncology was really the one place where I could do all of that. I could, you know, manage patients or take care of patients with cancer, do it in a field that allowed me to exercise surgical care, and then focus on trying to move women's health forward. I think that there are vulnerable populations in medicine, and I would highlight that women and children are two of those. And so, I think I've always had– again, it's probably going back to the way that I was raised, about trying to really pay it forward and looking for places where you could really make a difference and trying to lift those that really need more lifting. And to me, I think I've found kind of a calling there in the charge to be a gynecologist and think of women's healthcare more broadly than just in medicine.

Q: What was it about surgery that kind of sparked your interest?

A: You know, there was some– it was weird, you know. Like I remember walking in and feeling like I've been a surgeon all my life, although I'd never been in an operating room before. There was something about the culture of just being in that space where things seemed to be very– everything seemed to be timed.There was a schedule, an order, an expectation of like who's– you know, everyone has a role that's very much scripted. And it was like watching like an orchestra assemble and play beautiful music. It sounds kind of cheesy, but when you saw this orchestration of care across time and, you know, there's a patient and then at the end you see the operation successfully executed, it was very interesting to me that it was a very multidisciplinary approach. You have nursing, you have scrub techs, you have anesthesiologists, medical students, you know, residents, you know, surgeons. But everyone is sort of orchestrated to come to the same end. And that there was something really appealing to me about the process. And also the ability to go in and kind of fix something quickly and make somebody, depending on the case, you could potentially make somebody better quickly. And so that was also pretty attractive.

Q: So it's kind of like all the people working together as a machine.

A: Yeah

Q: Everybody plays a role. I think probably when a lot of people think of OB/GYN, they think of it as a women's specialty. It tends to be a lot of women in the field. But I know that gynecologic oncology tends, you know, to be much higher proportion of men. So what has that been like, to go from kind of a very female-heavy part of the field to one that is maybe not quite as concentrated?

A: I don't think that I was conscious about that transition. But certainly as I had grown up as a resident in OB/GYN, most of the faculty, certainly– I mean, I was in a class with six other women, and all seven of us were women. So we only take care of women. So it was, you know, I had no idea that there was this, you know, I think gender difference in medicine. And then when I transitioned into gyn oncology, it was almost the opposite where most of the faculty who trained me, a lot of the leaders in the field are still men. And it was similar to the transition of coming to the US at the age of ten, having come from a country where I was a majority, to be in a minority. It reminded me of the same shift in my own personal life from going, again, in OB/GYN and having women being the majority to now being in a space that was much more– where men were much more predominant.

So I had to do some adjustment and some adaptation. I think that in the early parts of my faculty tenure, certainly I would say it was challenging. When you're young and you're a female, a lot of patients were looking for older men to be their surgeon. And it felt to me often that I was trying to, you know, almost like interview to get the job of being somebody's surgeon. And then it was dually complicated because there were also patients who, you know, heard my accent and, you know, maybe they were not comfortable having an underrepresented minority be the person who was in charge of their care. And you know, I woke up one day and I thought, “You know what, you have to deal with it up front.” And I think that for me, it was actually very liberating to be able to sit with patients and their families and appreciate that there were something– there was something about who I was or the way that I was perceived that made them uncomfortable.

My charge is to take care of patients. And I tell patients, we're meeting quickly. It's like going on a first date. But we have to get married pretty soon because the charge of being a surgeon, you know, people have to trust that you're going to be on their side and do the best, you know, to take good care of them. And if something goes wrong, they can go back and feel like they just, you know, went to the wrong person. Or if they'd gone to somebody else, they would have had a different outcome. So that trust is really critical to the relationship working. And because of the care that we provide being oftentimes longitudinal, it's got to be a relationship that's more than just episodic. In a lot of surgical oncology, you take care of the cancer, but then those positions are transitioned to another member of the team to give chemotherapy. Our field is different and special that way, but it does require an engagement and a level of trust that I think is really unique.

And so, I would say about five years into being here, I just started asking patients up front, you know, just what made them uncomfortable. And you'd be amazed that when you actually have a conversation with people that these barriers really break down. And at the end of the day, we're all human beings. And I tell patients, if you're not comfortable having surgery with me or at Mass General, I'm here to kind of try to find that person or that practice that would be a good fit for you. So, but I would say, going back to your question, I think part of that challenge has been, for patients who assume that the right surgeon is going to be– they have some preconceived notion of who that, what that person looks like, and I think for many patients, that's a male surgeon. So trying to understand where that perspective comes from and trying to break those barriers has been, I would say, a wonderful part of my journey to the degree that I think it's given me more insight into understanding human behavior. I think doctors, you know, if you've been in practice for more than ten years, I think that most of us are actually a little bit of a psychiatrist, right, because you've got to go into a room and get a sense of people pretty quickly to be able to meet them where they are. And hopefully be able to deliver the care that they need.

Q: Do you find that when you kind of open that door to a patient and say, “Are you uncomfortable?” Do you find that, are you often able to take someone from maybe a place of discomfort to a place of being comfortable in having that conversation?

A: I think so. I think that most people– you know, we all have unconscious biases and I think that most of us when we actually have a chance to talk about it, we'll have some insight.

I mean, I'll give you an anecdote. When I was about six or seven years out from training, I was on call for the practice and a patient came in on a Friday with a pelvic mass who needed to have surgery that weekend because she was pretty uncomfortable.

And I used to operate on Friday, so the fellow told me about the patient coming into the hospital and I went up to meet her so that I could talk to her about having surgery the next day, on Saturday. Now, mind you, now, we're getting into the weekend. I'm the only staff on call for the service, so there's really no other surgeon for her within our group because everyone else has the weekend off. And, I was wearing scrubs, not wearing a hat or a mask, but I went into the room and the patient was on the phone and her husband was sitting in a reclining chair. And I went in, I didn't say anything. He basically looked at me and said, "Can you come back later and clean the room later? We're waiting to meet with the surgeon."

And you know, I'm actually, you know, I'm pretty quick with words, but I just didn't have anything witty or funny to say. I was like pretty horrified. So I just left, I didn't say anything. Went back to the operating room. But then thought, you know, my job is to take care of this patient, right? I mean, I've got to put whatever uncomfortable feelings I have around somebody, you know, her spouse or whoever, aside because, you know, that is the core charge that we have, even if it's uncomfortable to you, right? And so, I went back and I said to him, I said, "Sorry, I came earlier." I said, "I think you confused me with one of the cleaning staff." I said, "I'm pretty sure that I could do a great job cleaning the room because I actually have pretty bad OCD around cleanliness." And so, he laughed. And I said, "But I'm actually the surgeon who's on call for the practice." And I said, "So we're going to have to work this out, because the only option that I can offer you if we're not comfortable with this is try to transfer your wife to a different hospital." And we had a wonderful conversation. He felt horrible. He apologized. I mean, and then it's uncomfortable because you don't want the poor guy to feel guilty. You know, he had no idea, that he saw a, you know, short Hispanic woman walking in the room and he assumed that it was somebody from the cleaning staff.

I thought a lot about this. I think that, you know, whether it's bias or racism, I think it's institutional, but it's also personal. Like I think you can decide for yourself if you are less than somebody else in the room because of the– how they've defined you, right. And I think because I grew up in this place where being Nicaraguan was really an asset, you know what I mean, like being Latin was really something that I was proud of, I walked in and I'm like, this guy [laughter], like– you know. So I've never had a problem feeling like– it's never been– and I think that's why I'm able to talk about it, because I don't feel like I'm putting myself in a place that is– that makes me vulnerable. Right? I mean, I really think, you know, it's how I was raised, you know, like not thinking that I was less than or had to explain myself.

One of the challenges I think is that we have to have the courage to have these conversations. They're uncomfortable, but if not, I think you end up assuming that you understand something. Again, I think that this wonderful privilege that I've had of growing up in two cultures, you know, English is my second language and every now and then, you know, there's a word in English that I don't know. And I'll ask because I don't know– and you know, sometimes like somebody will say a joke and I just don't have the cultural context so I can't laugh. And it's obvious. But you know. But I think by definition, to survive, I've had to ask questions about not understanding something. And it's usually around language. But it can be, I think, around, you know, body language or demeanor, you know. And I think because I'm always trying to sort myself out in the middle of two cultures, not wanting to miss anything, it's been– it's a very natural response, I think, to that conundrum. But I think in this country, if we had a broader, I would say more honest dialogue where people didn't feel defensive, they were just willing to really talk about the things that are challenging or difficult or hard to accept in your own domain of culture, because they're different, if we had a dialogue, I think we would find, resolve I think more quickly and probably in a more peaceful way.

Q: Absolutely. Your story about walking into the room and them assuming that you're part of the cleaning staff is sort of reflective of, for a long time, what has been the racial and ethnic makeup of the medical field. So how do we go about changing that and changing those perceptions?

A: Yeah, you know, I think that you have to look at the demographics of the country. And if you think of that, these are the patients that we serve. You know, we know that Hispanics are going to be– we're the fastest-growing minority group in the United States, and I think projected by 2050, we'll be a majority. And we don't have, we don't reflect that in medicine. You know, those numbers are not reflected, certainly in academic medicine.

I think there's a lot of things that we can do to increase the number of women and underrepresented minorities that go into medicine, starting by reaching out to young children or young kids and really giving them opportunities to look at this incredible field and engage them early on. I don't think it's necessarily always a pipeline problem. When you look at, for example, Harvard Medical School, this past year more than 50% of the entering class were women. But then when you look across the academic medical community in the United States, you find that very few women are deans or chairs or even have ascended to the status of being professors at their medical school. So we have to create opportunities once these young people engage in medicine, to make sure that they continue to ascend in the academic track, to get the positions where they will have recognition and be able to sit at the table and begin to create initiatives and programs that will create opportunities for other people.

There's been, I think, wonderful efforts, including some going on at the MGH through the diversity office that Elena Olson leads, where we bring, for example, high school students, college students and medical students to spend the summer. These are all students from underrepresented minority backgrounds. They can spend the summer doing research and really get exposed to the clinical mission, the research mission that is part of our academic charge at a young age so that hopefully those experiences are inspirational and make them want to seek similar experiences as they think about college or they think about medical school.

I think that we have to do more to retain, you know, young trainees who are looking for faculty positions, creating an environment where they feel accepted and comfortable. And until we do that more effectively, I think that there's going to be a gap that we haven't closed in having clinicians that represent the patients they serve.

Q: So we're living in turbulent political times. I imagine it is a scary time to be an immigrant. Having come to this country as an immigrant, if you were to meet a ten-year-old girl today who came here from Nicaragua, what would you say to her? What hope might you offer?

A: You know, I would basically reflect my own experience, and I would say this is an incredibly welcoming country. The majority of Americans I think understand that this country has been founded by immigrants from its conception and that it's welcoming to people of diverse races, ethnicities and backgrounds. So just remind, you know, that young person of that, that it is a welcoming country with many opportunities, including freedoms that other places have not been able to sustain, like freedom of speech. You know, all of the wonderful rights that you have, or that we have as Americans, you know, that young person will be able to afford. And through those channels you can actually become someone who can make a difference. So I would think that's the first thing. I think that everything in life, there's always like an experience that is wonderful, but also that has, I would say, some associated risk that you take, and that risk is always, in this case, I think the risk of being discriminated against. But I would charge that person with the courage to never feel bad or apologize for their background, to bring that forward as something that actually enriches everyone else around them. And this country, remind them that, again, this country was, essentially is a country of immigrants, of the legacy of all the contributions that immigrants have made.

And then I think the charge is to really contribute, to really become a productive member of society. It can continue that legacy of building, being a building block for this country. And you know, to treat others with respect and integrity and dignity, but to also show that in every domain of your life – your personal life, your work life. And I think that when people understand that you bring something productive to the table, you can turn almost everyone, you know, everyone's perception around in terms of, you know, looking at you as somebody that brings value and not that takes something away.

Q: I love that, kind of finding your space and where you can bring value and what your place in the world is.

A: Yeah. I mean, I think at the end of the day, you know, it is everyone's charge to be a member of society and in a way that pays it forward. And I think that those of us that have been fortunate to have a welcoming space in this country have that charge.

Q: All right, so now I have my final five questions. The first one, what is the best piece of advice you think you've ever gotten?

A: You know, I think it's probably– my mom's mom was a very influential person in my life, my grandmother. And probably for her, from her I think we always heard that it's very helpful in life to have a sense of humor. And so, I think that if you go through life not being a clown, but actually being able to look at something and find something that's a little humorous in it, you just won't take yourself too seriously. And I think that helps.

Q: Yeah.

A: It helps with the gray hair. [laughter]

Q: So the name of this podcast is "Charged." So in the context of the work that you do, what does that word mean to you?

A: I would say that we all have a charge, we all have a mission, we all have something that drives or should drive, I would say, our goals or should be aligned with our goals. I think, for me personally, the charge is, you know, how do I advance, you know, clinically the care of the women that I serve. Then take it to the next level: how do I advance the care of women in general. I think there's a social justice piece to medicine that is not often recognized, that it's beyond clinical care. I think it touches on the community service mission that we have at Mass General. So extending that commitment beyond the clinical space to the communities that we serve. And I would include in that advancing, you know– or my charge being advancing the mission and giving a voice to those who are underrepresented and vulnerable patients, students, people in the community.

Q: Surgery is hard work. How do you recharge?

A: I think for me, it is spending some time outside of, you know, what I do Monday through Friday or Monday through Sunday. I majored in Spanish literature, and so one of my passions is to read. I continue to read a lot of Latin American writers. And so, to find the space, something that gives you joy, that brings meaning to your life, that revitalizes you. I think that if you don't do that, whether it's– for me, it can be swimming, it can be reading, spending time with family. I love to travel. But doing something that breaks you away from your routine, that gives you the chance to kind of charge up your batteries again and get back to it with more energy. And sometimes I think you just need to take that break, to come back with a different perspective.

Q: You're a surgeon. I imagine you have a lot of early mornings. Do you have any rituals that help you have a successful day?

A: I have a lot of rituals. [laughter] Yeah, we don't have all day. But basically, I go to bed early. That's one of them. I try to get a good night's sleep almost every day. I'm not, I don't do well being sleep deprived. And then I would say, for example, when I scrub, I try to scrub at the sink alone. Usually sometimes, you know, in other surgical services you'll see the surgeon scrubbing with the medical student, the fellows and the residents. And I ask to actually scrub alone because I find that that's the time that I have to really kind of do a little bit of meditation and get myself ready for going into the operating room. I scrub for five minutes, so that's five minutes of time that I have to really kind of like zero everything to go in, essentially ready to do the best job that I can. And then, I generally eat light on the days that I operate. You know. And then, you know, try to not have anything else going on that day that will be distracting. Because I think there's a level of concentration. Things can go wrong in an operating room fairly quickly. So trying to control that environment so that it's conducive to really focusing on the charge, which is taking care of that patient safely.

Q: And my final question: when and where are you happiest?

A: I would say probably my happiest place at work is the operating room. There's something really special about that experience. I think outside of work, probably when I'm with family and friends. I find that that, you know, they're the people that kind of restore you. They certainly bring joy to my life. Or I would say seeing a patient who's done well and having them come back and either bring pictures or, you know, bring their grandchildren to meet the doctor. I mean, that always feels like really, really special, right. I mean, like you know, they've allowed you to enter into their life and they've given you the privilege of being able to care for them at a time that is very– they're very vulnerable. And that I always, you know, feel a little bit disingenuine because I think that we– We do this I think to some degree because we get more than we give. You know, there's something about when a patient gives you a hug or a patient says "thank you," what you feel, no matter what else you have to do to get through the next day, there's something that– it's never a balance. I feel like they give back more than we give. And so, I think that exchange, to me, is always pretty magical.

Q: Wonderful. All right, well, thank you so much for being here. It's been a pleasure.

A: Thank you very much. Thanks, Amy, thank you so much. Thank you, guys.