Understanding Moral Injury in Healthcare with Wendy Dean, MD

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Automated Transcript:

Mark Graban (2s):
Welcome to Habitual Excellence presented by Value Capture. This podcast, and our firm is all about helping you and your organization achieve habitual excellence via one unifying focus, one value-based structure in one performance system. In other words, it's about helping you capture dramatically more value through achieving perfect care and perfect safety for patients and staff. To learn more about value capture and our services, visit www.valuecapturellc.com. Hi. In today's episode, there's a brief mention of death by suicide, so wanna make sure you're aware, and if that's not something that you want to listen to, we understand.

Mark Graban (47s):
Well, hi everybody. Thank you for joining us on the Habitual Excellence Podcast. I'm Mark Graban, and our guest today is Dr. Wendy Dean. She's the psychiatrist, she's the president and co-founder of Moral In Injury of Healthcare, a non-profit organization focused on alleviating workforce distress. And we're going to be talking about that today. A seminal article she co-authored with Dr. Simon Talbot for STATNews in 2018 began the conversation about moral injury in healthcare. So I'll link to that article in the show notes. Wendy is also the co-author of the upcoming book, available April 4th, If I Betray These Words: Moral Injury and Medicine, and Why It's So Hard for Clinicians to Put Patients First.

Mark Graban (1m 29s):
And so you can learn more about her and her work wendydeanmd.com. So Wendy, thank you for joining us. Welcome to the podcast. How are you? Thank

Wendy Dean, M.D. (1m 39s):
I'm fine, thank you. Thank you so much. It's a pleasure to be with you.

Mark Graban (1m 43s):
Yeah, well, you know, happy to explore, you know, it's, you know, a, a serious topic with, with serious implications for physicians and, and other caregivers, and, you know, happy to explore that today. I hope people will check out the book and, more importantly, you know, kind of look into actions that organizations can take or, or other, you know, we'll, we'll delve into that a little bit in terms of some of your recommendations. But, you know, first off, and to me this is a relatively new term, and, and some of our listeners might not have a definition of their own in mind. So you're, you're the expert here. Tell, tell, tell us, how do you define moral injury?

Wendy Dean, M.D. (2m 23s):
So, mil moral injury is relatively new to healthcare. It's been around, particularly in military circles since the early 1990s, but it really came into healthcare full force in 2018 when Simon Talbot and I sort of posited this thought that this wild thought that we were having, maybe it's not all about burnout. Maybe there's something else going on, which is why we're struggling to address clinician distress with all the treatments that we've tried, things haven't worked. So maybe as good clinicians, we should rethink our diagnosis and wonder whether we hadn't approached something quite right.

Wendy Dean, M.D. (3m 8s):
So the way moral injury is defined, it was, the way it was defined originally in the military was as one of two things. It was betrayal by a legitimate authority in a high stakes situation. And that definition came from Jonathan Shea. And then Brett Litz and his colleagues expanded on that and said, it is perpetrating, bearing witness to, or hearing about acts that transgress your deeply held moral beliefs and expectations. And in medicine, those deeply held moral beliefs and expectations, at least in a professional setting, are the oaths that we took to put our patients first.

Mark Graban (3m 47s):
Right. What's an example of that? Back to the origins in a military setting, and then as sort of progressing through to think in terms of military medicine?

Wendy Dean, M.D. (3m 59s):
So this was, it was not actually, it wasn't started around military medicine actually, right? It was, it was in combat, it was looking at combat veterans, and it was things, for example, one of the most egregious situations where soldiers were asked to, they were, they were asked to go and take out a certain population, and in the morning it was dark. And in the morning they, well, this, this was a separate situation, so it wasn't me lie, but they went to a village and were told that there were insurgents there.

Wendy Dean, M.D. (4m 42s):
They took out the insurgents and in the morning realized that they were actually civilian fishermen. And that was, that was an egregious violation. The, the boots on the ground felt, it felt like a betrayal. I, in good faith, followed your orders. And now I've betrayed the promise that I made not to harm civilians in healthcare. When you look at that, it is, i, in good faith, agreed to work in this environment with the understanding that it is a healthcare environment.

Wendy Dean, M.D. (5m 25s):
Our goal is to make patients better. And yet I find that in, I I'm not always putting my patients first. Sometimes I'm putting the needs of the organization first. Sometimes I'm putting the needs of the bottom line first, and that's really where moral injury comes into medicine.

Mark Graban (5m 44s):
Yeah. And, and this, when we talk about medicine, it's not a matter of whether it's military medicine or civilian medicine. This is a, a medicine healthcare culture issue. Where, where, where, where there these, these deep violations that may feel, let me ask this as a question. I mean, the sense of the, the, the depth of injury is pretty close to thinking of, you know, how you would feel committing a war crime. I mean, it's a serious,

Wendy Dean, M.D. (6m 17s):
Yeah. So in, in medicine, I think the interesting thing, there are significant differences between what we've seen in military moral injury and what we've heard from physicians or actually any other clinician. You know, when we put that first article out, we talked about physicians because that's what we knew, but we quickly heard from nurses, physical therapists, social workers, that it was their language too. So when we, when we look at the differences between the two in, in the military, it's more common that there are egregious violations, that it's a one off, this is a horrible thing.

Wendy Dean, M.D. (7m 5s):
But in medicine, what we hear most often is that people experience death by a thousand cuts. That it is small repeated insults over time that really wear them down.

Mark Graban (7m 21s):
Okay. That makes, that makes sense. And when you think about the word burnout, I mean, how, how would you compare the differences of burnout and why, why moral injury is a more correctly descriptive word of, of the feeling than the, the implication compared to burnout?

Wendy Dean, M.D. (7m 44s):
So I think both are true. I don't think it's one or the other. I mean, let's be, let's be honest, there's plenty of distress to go around, right? Nobody has to have a corner on this market, unfortunately. And what I think is true is that there are circumstances where burnout is quite accurate, where there is simply a resource demand mismatch. I don't have enough hours in the day to do everything you're putting on my plate. That doesn't necessarily mean it translates, it does translate into moral injury. So the difference in moral injury is it's that betrayal, it's that, or it's even betrayal sounds like a, a single occurrence, major thing.

Wendy Dean, M.D. (8m 41s):
But it, but it can also be the subtle undermining of what your professional obligations are, what your professional agreement is, what your covenant with society is going into a profession. When your, when your organization constantly says, you must meet these productivity requirements, you must have this throughput and these patient satisfaction scores without listening and hearing what your objections might be, and then doing their best to address those, that feels like a dismissal.

Wendy Dean, M.D. (9m 23s):
And on some level, a betrayal of what your professional obligations are. Yeah.

Mark Graban (9m 31s):
So from those situations, and like you said, sort of an ongoing chronic repeated sense of betrayal, what, what's the effect on, on individuals who are, are injured in this way? And I, and, and I, I use that, that, that term intentionally because they, they, they're being injured. This is not their fault that they get injured any more than somebody who gets hit by a car in most, I dunno if AJ walked, I don't know, I'm sorry, I'm getting sidetracked, but the focus is on the cause of the injury. But, you know, before we get into that, I guess the question I was trying to ask, I'm sorry, is the, the effect, what did the implications of this moral injury?

Wendy Dean, M.D. (10m 13s):
Yeah. So moral injury is really this sense of I know what my obligations are, I can't meet them. And it's gone on long enough that it's not just an awareness that I have, but it has started to become ingrained. So you've taken it on, you've taken on that, that distress as part of who you are. And it may be as subtle as, I don't know, you know, like it's a disorientation.

Wendy Dean, M.D. (10m 58s):
Can I still think of myself as the physician I thought I was, or the nurse I thought I was or thought I was going to be when I started down this path? Can I still be that person? And if I can't, what does that mean? Like, what does that mean for the sacrifice that I've made to get here? And so that's, that's the inner sort of the, the inner experience. Some of the symptoms, when we look at military moral injury, it looks like shame and guilt.

Wendy Dean, M.D. (11m 38s):
Interestingly, when you look at healthcare, it looks much more like frustration and anger. So the, the experience clearly doesn't translate exactly between those two professions. And it may have something to do with what the professions are intended to do or, and how they're trained.

Mark Graban (11m 58s):
So when this, when these conditions are, are created, and you know, we look at systemic drivers of them, how much success is there in actually reversing burnout and how much hope is there of reversing moral injury? Or is the only, the only hope to prevent injuring more people in the future? Can it, can it be treated in a way?

Wendy Dean, M.D. (12m 27s):
Yeah. So there, I think there's hope to treat both, to treat both burnout and moral injury. The real answer is moral injury has been out for a hot minute. You know, it has really only been out in the lexicon since 2018, which means the first two years we spent asking people if they thought this was really a, a legitimate thing. Turns out it is, we've now char we've got some studies characterizing it as a distinct entity from burnout, from depression. So now we can say, okay, this is its own thing and it deserves more study.

Wendy Dean, M.D. (13m 10s):
So we don't really know how effective we can be in treating it.

Mark Graban (13m 16s):
Hmm, okay. But oh, leads to at least some attempts then to treat for,

Wendy Dean, M.D. (13m 22s):
For sure. And I think I, I honestly believe that once we start combining the, the features that will address moral injury with the approaches that address some of the, the more resource demand mismatches of, of burnout solutions, I think we'll get to a better place overall.

Mark Graban (13m 46s):
Sure. And you know, in the, the stat piece, so from 2018 from STAT News, you know, you, you make some real good points and, and I, and I've seen discussion of this online, people rolling their eyes at worse, at, you know, some of the countermeasures that are offered meditation, like things an organization can spend money on and offer. Is it really getting to anywhere near the root of the problem? Is it, is it effective? And, and to what extent is it blaming people for not being resilient enough? Like, I understand the, the frustration at not only being burned out and then being made to feel like it's your fault for getting burned out.

Mark Graban (14m 34s):
What, what are some other things that you would point to that, that seem clearly to not be a good treatment?

Wendy Dean, M.D. (14m 42s):
Okay. I, I definitely want to clarify what we meant in that too, because we've gotten, you know, fairly, we've, we've gotten some pushback. And what I would say is those things apply to some people, and they really help. Some people feel like their high performance machine is tuned up. I, we think that's great. What we don't think is that saying yoga, mindfulness, meditation are the solution to the challenges people face.

Mark Graban (15m 18s):
Okay, sure.

Wendy Dean, M.D. (15m 19s):
So if they are, if they're deployed in conjunction with true attempts to make the environment better, then we're o that might be great. What I think what I think folks really need to be mindful, you know, mindful of, is making sure we're listening to the folks on the front lines and, and honoring what they're saying their challenges are. Because typically what we hear over and over again is if I could break down the barriers that are between me and patient care, if I could get rid of some of the prior authorizations, if I could get rid of some of the clicks, if I could get rid of some of the, the hoops that I have to jump through to get true collaboration of care going, if I could get my colleague on the phone, my frustration, my anger, my moral injury would abate, it might not be gone, but it might improve.

Mark Graban (16m 21s):
And, you know, you, you touch on systemic causes, broken system, and, and there's no single root cause there. It seems like there are many, many contributing factors. One being, you know, I think this is ironic of, you know, EMR / EHR systems being proposed as a solution to some problems. And then as with many new technologies, it ends up creating other problems including overburden and deepening silos. Can you tell us a little bit more about that and, and may you think, are there recommendations for reforming the use of, of these systems that that can reduce some of the overburden and other causes of moral injury?

Wendy Dean, M.D. (17m 7s):
So I, I love one of the, I really love one of the approaches that the AMA has is a proponent of which is getting rid of stupid stuff. And I love it for what it does, and I love it for its name because everybody understands what that means. And I was talking with Don Berwick a couple of months ago, and he was saying that when they did the initial pilot of this, they asked people at I think 300 different institutions, or at least they asked, they asked folks at different institutions to identify what the stupid stuff was.

Wendy Dean, M.D. (17m 48s):
They came up with 300 examples, 85% of which were not le were not linked to legislation or regulation. Hmm. So they didn't required to be followed. Right. They were, they were at the discretion of that local institution to change. They were either an overread of policy, they an overread of legislation, or they were policy that the institution itself could change. So right there, 85% of the stupid stuff that people perceived as getting in the way could just be wiped away.

Mark Graban (18m 29s):
So how much of it did get wiped away?

Wendy Dean, M.D. (18m 33s):
We didn't follow up on that. They, but there is, you can, there's, there's a link in the AMA to these gross initiatives, which, which does go through some of the outcomes. Okay. And it gives really clear examples of what some of the organizations have done and, and those things that they've taken away.

Mark Graban (18m 54s):
Yeah. I mean, it seems like on one level, not being listened to creates harm to some degree being heard and then feeling ignored could be worse. Yes. What are your thoughts on that?

Wendy Dean, M.D. (19m 12s):
100%. So it is bad when you feel like you're shouting into the void when you finally have somebody who seems like they're listening and then either says, yeah, I don't hear that as valid, or just says, that's not on our priority list. That, that, what that does is it takes people's hope and just dashes it. And so frequently when we, when we go into an organization to consult with them, we'll say, if you don't have the intention to follow through, we wonder whether it's a good exercise for us to be here.

Wendy Dean, M.D. (19m 56s):
Sure,

Mark Graban (19m 57s):
That

Wendy Dean, M.D. (19m 57s):
Makes sense. Because we feel like that that might actually cause harm.

Mark Graban (20m 2s):
Because it's, it's one thing I'd, I'd be curious to hear your thoughts on, on this, you know, discussion around psychological safety and creating conditions in which people feel safe to speak up. That's one thing. But then, you know, there's other research that points to even times when people feel safe to speak up, they think, well, it's just not worth it. And they, they hold their voice back for, for different reasons. But I, I guess the question I, I would pose to you from your background and your experience is the role of psychological safety and, and maybe not that that's a magic solution, but how much of that would be a positive contributor to preventing or solving some of the moral injury?

Wendy Dean, M.D. (20m 44s):
Well, I think it's a setting condition for starting the work. I don't think it's, I don't think it's a solution because all it, it, it is an enabling, it's an enabling environment, but it's not, it's not going to follow through with the solutions, follow through with the culture change, do the hard work of listening and then deciding on what the initiatives are for change.

Mark Graban (21m 13s):
Right. The doing something part of it. Right. During, during Covid times, and I, I, I heard you talking about this on a, a different podcast when you talk about the constant never ending stress and trauma, lack of PPE, just, you know, continual overburden. How, how I, I'm trying to even think how to ask, I mean, the impact clearly would be bad, but how would you describe the impact of the pandemic and, and, and how things are going now here in 2023?

Wendy Dean, M.D. (21m 55s):
So in April of 2020, shortly after Lorna Breen's death by suicide, I wrote a pretty impassioned piece for STAT News and said, if we don't plan an off-ramp for Covid, that allows us, that allows healthcare workers the additional support, the slack they need overscheduling, you know, slightly overscheduling giving them the opportunity to rest and repair, we will see an exodus of healthcare worker, healthcare workers.

Wendy Dean, M.D. (22m 38s):
And here we are, you know, I, I have every empathy for healthcare administrators who also, by the way, faced their own version of moral injury during the pandemic. Healthcare workers were wondering if their patients would survive. Administrators were wondering if their organizations would survive. They were worried about their clinicians. They knew they didn't have the p p e, but they didn't have, their hands were tied. So they had this a similar experience. But I feel like having, rushing back to business as usual, that that urgency to get healthcare business and, and processes rolling back as it was pre pandemic for all the reasons, because patients want it, because clinicians want it because the bottom line needs it was, I understand the intention of it, but I do think it missed the human side of it.

Wendy Dean, M.D. (23m 41s):
Sure.

Mark Graban (23m 44s):
And I guess a different history had it, a different timeline might have seen providers feeling safe to push back on some of that, or if they were pushing back to be heard, to be honored and to maybe they're maybe have some adjustments to what did happen in our last couple years of reality here.

Wendy Dean, M.D. (24m 8s):
Correct. And I think there are, there are pockets of where that happened, and those, those pockets, those healthcare systems are doing slightly better, although I don't think anybody has entirely escaped this. Yeah. I think healthcare workers right now are exhausted, like I've never seen, and these are folks that we know are significantly more resilient than the average employed population, and they're worn out. And I'm, I'm really concerned with what's going to happen in the next couple of years if we don't make a major shift.

Wendy Dean, M.D. (24m 51s):
And it may also require educating patients about what they can expect, helping them understand how to better care for themselves, you know, what is appropriate for urgent care, what's appropriate for the emergency room, how they can help themselves in situations when their healthcare systems in their local area are strained. Sure.

Mark Graban (25m 16s):
And taking yourself as a patient to the appropriate facility with appropriate expectations in terms of waiting time, for example.

Wendy Dean, M.D. (25m 26s):
And also, what are the measures that you can reasonably take at home?

Mark Graban (25m 31s):
Sure,

Wendy Dean, M.D. (25m 32s):
Sure. What do you, what are the steps that you take before you go in? And then once you do go in, which one do you choose? And, and how do you support those clinicians who are trying to care for you? Sure.

Mark Graban (25m 46s):
One other question I was going to ask you, Wendy, and, and, and this might point a little bit to some of your own story of, you know, to, to stop practicing as a, a psychiatrist, you know, talk about the, the con the, the conflicts between obligation to patients and then restrictions or requirements placed on you by, let's say, the payers. So, you know, it's up to you how much, you know, you wanna touch on your own story, but you know, there's, there's sort of a, a follow up question. I'll go ahead and bake in about the levels of moral indu, indu, the mor levels of moral injury in countries that have a different payer system than the US where it's a single payer or government payer.

Mark Graban (26m 27s):
Are there still conflicts that lead to moral injury?

Wendy Dean, M.D. (26m 32s):
My, yeah. My experience in deciding, I decided more than a decade ago to leave clinical practice. I had tried almost every permutation of practice I could think of and couldn't find one that was sustainable. And that I thought was, I couldn't, I couldn't find a way to practice that was sustainable for me and that I thought was good for my patients. And I couldn't in good faith and tr stay, stay true to my own integrity, continue to practice like that. That was my choice. Those were my values.

Wendy Dean, M.D. (27m 12s):
I, I know of plenty of other people who have managed to be, find ways to practice that were okay. I will, as to your, the second part of your question, one of our, one of our best collaborators right now is in the uk. They are desperate. We've heard from almost, we've heard from countries around the world and in, in each different country with each with a different reimbursement strategy.

Wendy Dean, M.D. (27m 53s):
The drivers are different. But typically it comes down to we have not, as a society come together to make the choices and accept the discomfort that comes with those choices of how well we're, we will allocate the scarce resource of healthcare. And I think in the US we've chosen to think that it's not scarce. It will be there whenever, however we need it, whenever, wherever, however we need it, healthcare will be there to do whatever we need it to do. What, unfortunately in the pandemic, we saw that, that just, it is a finite resource that we have taken too much for granted and we really need to start thinking about how, how we go forward.

Wendy Dean, M.D. (28m 41s):
Yeah.

Mark Graban (28m 43s):
So before we wrap up, you want to focus a little more on your thoughts about moving forward. And again, our guest today is Dr. Wendy Dean. Her upcoming book is, If I Betray These Words as, as the title. And actually, so one, one question though, before talking about reforms or improvements, tell us a little more about that phrase there. The, the, it's a snippet of a, a broader phrase. If you, if you could tell us that, and you know, some of that context of what happens if I, if I betray these words.

Wendy Dean, M.D. (29m 17s):
Yeah. So, so it's a funny story. Well, it's kind of a funny story. It's a little painful to relive. When the, when the publisher asked me for a title, it was, it was a very compressed timeline. It was days that we had to choose the perfect title for this book. And so I started, I started, I went back to all the source material because I was like, well, we're talking about oats here, so it has to be in the oath. And putting patients first, it turns out is not in that oath. It is not in most of the oaths it is implied. And so I read everything I could get my hands on, and I came to this one translation of the Hippocratic Oath by Amelia Arenas.

Wendy Dean, M.D. (30m 4s):
And it talked about all the usual things that, that oath, the oath talks about, which is admiration for teachers, respect for your patients, et cetera. But the last line of that translation says, may I be destroyed if I betray these words? And it just, it was so powerful when I read that because that was what I had heard from every clinician I had talked to in, in writing this book, that they felt like a piece of them was lost when they had to betray their oath.

Wendy Dean, M.D. (30m 46s):
It was no longer just words that they spoke or a promise they made. It had become integrated into the very fiber of their identity. And when you asked them, you know, when someone expected them to betray that oath, it felt like they were losing a part of their identity,

Mark Graban (31m 7s):
Or it's destroying careers and in some cases destroying lives, unfortunately.

Wendy Dean, M.D. (31m 15s):
Correct.

Mark Graban (31m 17s):
So to help reverse that or prevent more moral injury, and I know this will be laid out in the book, but can, can you give us at least, you know, kind of a high level summary of, of different reforms, different strategies that you would want to see put in place? And it sounds like there, there, I mean, there's, there's urgency. So we're not talking 10 years from now, like right away. What would you hope to see happening?

Wendy Dean, M.D. (31m 40s):
So I think the first thing that we have to put in place is safeguards so that clinicians can stand up and speak out. Because the first way that you avoid moral injury is there is a, there's a moment when you experience that betrayal or when you're aware of the betrayal, whether it's an intentional betrayal or an unintentional one, somebody has crossed your oath and at that moment you can stand up and speak out and prevent moral injury or reduce your risk of moral injury. Or you can acquiesce and say, I, I, I can't, I can't do anything else. I can't push back. And you transgress your moral, your your moral beliefs and experience moral injury.

Wendy Dean, M.D. (32m 23s):
So that's the first thing that we need to do, put in safeguards for people to speak out and follow through on what they ask you to do. There are, there are bigger changes that can happen within healthcare systems that are a culture of co-production that requires big shifts. It requires mindset shifts for the executive team, but it's recommended not just by us, but also by economists, by historians. Like this is, this is a common theme in the books that I've been reading lately, that giving, approaching the solutions as a community effort.

Wendy Dean, M.D. (33m 12s):
And by the way, not just with the executive team, the administrators, the middle managers and the clinicians, but also bringing patients in to say, what is your experience? What do you need? And how can we, there, you know, that's what we're trying to do is, is heal our patients, let's make sure we're all on the same page, getting them what they need. So those are, those are two things. We can also look at societal shifts, meaning can we ask CMS to make some change in legi legislation or re regulation or reimbursement rules that drive sustainability for clinicians that monitor clinician wellbeing or hold executives accountable for clinician wellbeing, much as is done with patient sat satisfaction now.

Wendy Dean, M.D. (34m 10s):
And there are all, there are all kinds of other efforts that we can put forth, but they'd take a lot. They might, they might take longer to explain.

Mark Graban (34m 19s):
Okay. Well, I, I hope people will check out the book for, for a deeper discussion of that. And I, I hope it does prompt discussion on, on different levels. It seems like there are some things clearly leaders need to be doing within health system organizations, and then there may be some solutions to explore along the lines of regulation or legislation. And I, you know, I always think back to, you know, the, the, the full unwieldy name of the Affordable Care Act was the Patient Protection and Affordable Care Act. I, I, you know, PPACA is, is a mouthful I guess, but you know, but people really focused on the a, the ACA it sounds like we need on some level a provider protection

Wendy Dean, M.D. (35m 4s):
Clinician. Yeah. Cuz when you, because when you talk about

Mark Graban (35m 8s):
I was going for the alliteration of provider protection.

Wendy Dean, M.D. (35m 11s):
Right, right. But the, the interesting thing is when you talk about provider, that also means hospital or the hospital systems. And so that, that's my, that's my objection to the term is just, I, it makes it confusing. But you're right, clinician, a Clinician Protection Act, or at least a Clinician Sustainable Sustainability Act. Although I would like it to be more than sustainable. I would like it to be a place where clinicians can thrive Sure. And flourish

Mark Graban (35m 43s):
From surviving to thriving.

Wendy Dean, M.D. (35m 45s):
Yeah.

Mark Graban (35m 46s):
Well, Wendy, thank you, you know, so much for sharing, you know, serious topic with, you know, really serious implications. But we'll look forward to the book being out again, the title, the full title, If I Betray These Words: Moral Injury and Medicine and Why It's so Hard for cCinicians to Put Patients First. We want to make that easier. Eliminating the waste, the stupid stuff, the systemic problems, the lack of support. It's a lot of work to be done. But to encourage everyone, you, you can find Wendy's website, wendy dean md.com. I want, I wanna thank you again for being here. I'll give you the final word if there's anything you'd like to say to bring this to a close.

Wendy Dean, M.D. (36m 26s):
I think it's really critical that we all think about how we can, we can contribute to making medicine better. That's, that's why I wrote this book, is because we all know that medicine is harder than it should be. And I would love to see that change with all of us working together. But the other place that folks can find information is fixedmoralinjury.org, which is our website has a ton of resources in it. We also have a podcast. Moral Matters.

Mark Graban (36m 57s):
Well, I hope everybody will, will go check out the website and go listen to the podcast wherever. Wherever you're listening to this podcast. Dr. Wendy Dean. Thank you again so much for being here.

Wendy Dean, M.D. (37m 8s):
Thank you so much. I really appreciate your interest.

Mark Graban (37m 12s):
Thanks for listening to Habitual Excellence presented by Value Capture. We hope you'll subscribe to the podcast and please also rate and review it in your favorite podcast directory or app. To learn more about value capture and how we can help your organization on this journey to habitual excellence, visit our website at www.valuecapturellc.com.