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In this episode, we talk with Dr. Carol Burke, Director of the Center for Colon Polyps & Cancer Prevention, and Dr. Natalie Farha, a Gastroenterology fellow, who explore the critical work of overcoming imposter phenomenon and microaggressions. Drs. Burke and Farha describe their initiatives to build a more diverse, equitable and inclusive culture within the field of Gastroenterology.

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Overcoming Impostor Phenomenon and Microaggressions in a Clinical Setting

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast, that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise. 

Dr. Tony Tizzano:

Hello and welcome to today's episode of MedEd Thread. I'm your host, Dr. Tony Tizzano, director of student health here at Cleveland Clinic in Cleveland, Ohio. Today, I'm very pleased to have Dr. Carol Burke a gastroenterologist at Cleveland Clinic, and past president of the American College of Gastroenterology and one of her fellows, Natalie Farha, here to join us. Carol and Natalie, welcome to the podcast. 

Dr. Carol Burke:

Thank you, Tony. It's a pleasure to be here. 

Dr. Tony Tizzano:

So to get started, could you tell us a little bit about yourselves, what brought you to Cleveland and your roles here at Cleveland Clinic? 

Dr. Natalie Farha:

Yeah, so I'm originally from Wichita, Kansas. That's where I grew up went to all my school. I went to college in Fort Worth, Texas at TCU, Texas Christian University, and then came back to Kansas for medical school. After medical school, I matched in internal medicine at Cleveland Clinic and stayed on for GI Fellowship. 

Dr. Tony Tizzano:

Fabulous. Carol?

Dr. Carol Burke:

Yeah, I don't have that much of a trail that goes all over the country, at least in the West and South. I was born in Cleveland, and I went to college at the University of Colorado and then was a colleague of yours, Tony, at the Ohio State University for medical school and did my residency at Riverside Methodist Hospital. Did my GI fellowship here in the early '90s and I've stayed right at the Cleveland Clinic for the last 32 years. Happy to be at home. 

Dr. Tony Tizzano:

Well, we're glad to have you, and I must say I look back with those years of fondness, and Carol there's no doubt you were one of the leaders in our class no question. So in today's segment, we'll explore how Cleveland Clinic's Digestive Disease Institute is working to build a more diverse, equitable and inclusive culture by working to overcome impostor phenomenon and microaggressions in gastroenterology. 

So Carol, to get started, could you help us frame this topic and the importance of it? 

Dr. Carol Burke:

Sure, Tony. So we've realized over the last few decades that the pressure that individuals that are in the medical field are experiencing has been increasing, and it's up to epidemic proportions. It was even made worse with, you know, the COVID pandemic and this includes not only burnout, but unprofessionalism, people that feel like they can't fully engage in the workplace. We have recognized that diversity grows stronger workforces, and if we're not engaging people of all types, including by race, ethnicity, body size, disability, sexual orientation, gender, that we can't build the face of medicine to be able to take great care of our patients that we want.

And there's a lot of data that suggests that patients that don't have providers that look like them are less apt to get providers that look like them are less apt to get high quality healthcare, let alone healthcare at all. So I think all the pressure that's been put upon practitioners in the medical field, not only physicians, but nurses, we're gonna focus on physicians, really has brought to the forefront the need for us to address things in the workplace that could actually make a more diverse, equitable, and inclusion environment and improve professionalism by driving down microaggressions and also for people in the medical field to understand that there's another phenomenon called impostor phenomenon that can impact their ability to feel self-worth and fully engaged. 

So Natalie and I kind of took an interest in this together and have written a few papers with you as a collaborator and the digestive disease has really noted that this is at the forefront as well in our institute, and we've taken measures in order to mitigate some of these phenomenon that we'll be discussing today. 

Dr. Tony Tizzano:

Yeah, well, thanks for that outstanding work, and I was, it was a privilege to be a small part of that. So Natalie, tell us a little bit about what are microaggressions, and who is most affected by these? 

Dr. Natalie Farha:

Microaggressions are verbal, behavioral, environmental actions that stem from implicit bias that devalue or disrespect an individual or a group, and they disproportionately impact people who come from underrepresented minorities, so people of different races, religious preferences, gender identities, people of different size or people with disabilities. 

Dr. Tony Tizzano:

Do you think at the end of the day, Natalie, that when someone suffers these, that they actually get a sense that, you know, "Am I part of this group? Do I belong here?"

Dr. Natalie Farha:

Absolutely, and I think that is kind of the impostor phenomenon that we were talking about. Microaggressions making you feel like you don't belong contributes to impostor phenomenon. 

Dr. Tony Tizzano:

Okay, and Carol, I know these are closely related, but if you were to define impostor phenomenon, w- what would you say? 

Dr. Carol Burke:

Yeah, impostor phenomenon, I want to say it again, impostor phenomenon with an O before the R at the end of the word, and phenomenon. It's not a syndrome, it's not a psychiatric diagnosis, but it was an interesting perception that two PhD psychologists back decades ago noticed when they were having interviews with professional women that were working on their PhD. And these women were very successful in their research and their profession, but still questioning, "Oh, you think I'm smart? Why does someone choose me to, you know, ask me to become the president of a society or to lead a section in a department?" Or, "I feel like my successes I owe to somebody else or to luck," and not understanding that the success is based on their own achievement, their own skills and their own credentials. So it's almost the feeling like, "I'm a fraud, and at some point someone's going to figure out that I'm not as smart as everybody thinks I am." So I think that that is the feeling. 

And, and many of us still today and many actors and politicians and world leaders have experienced impostor phenomenon. And it could be quantitatively validated by the Clance IP Scale. 

Dr. Tony Tizzano:

And so, you know, despite being highly educated, highly accomplished, we still have this sense, and I read somewhere that up to 82% of individuals at one time or another. Is that a number that you believe? 

Dr. Carol Burke:

Oh, we exactly believe that. In fact, you know, Natalie had just presented the results of our analysis in the paper that was just published recently. And I think Natalie was surprised at some of the outcomes, so it's no surprise, as you say, Tony, that younger people might experience this, women might have disproportionately experienced it. But Natalie maybe, you want to share the vast array of individuals when we review the literature who experienced impostor phenomenon. 

Dr. Natalie Farha:

I initially thought it was going to be something exclusively in younger people, people had just started in gastroenterology. But although the degree of impostor phenomenon did decrease with age, it was still highly prevalent in people who have been practicing for 30 years. So when you look at people who you see as really impressive, and there's no way that they're experiencing this. They actually are or have in the past at least. 

Dr. Tony Tizzano:

But we're embarrassed to say so. So I must admit, when we first have this conversation, when you were looking at your paper and I was thinking, "Impostor phenomena, well, I'm not. I don't know the..." And then I started reading what you had to offer. And I thought, "Son of a gun. I've been there. I've been there, I've done that." So, you know, I think it's really important to be transparent about it. So Natalie, why do impostor phenomenon and microaggressions matter in healthcare and how is it impacted? 

Dr. Natalie Farha:

So as Dr. Burke said, I mean, it helps to create a diverse workforce for people to have a sense of belonging, so having feelings of impostor phenomena or experiencing microaggressions creates a sense that you don't belong. It also contributes to poor mental health and burnout, which are a threat to the progression and diversity of gastroenterology or any field, really. And it's related to [inaudible 00:07:51] career progression, the, so there have been a lot of studies about microaggressions, a lot of studies about impostor phenomenon that show that these people don't apply for promotions or don't feel like they would get them, why would I even try?

Dr. Tony Tizzano:

Yeah, well that makes a lot of sense. I think it's important and, you know, we're talking about, you know, in the context of this conversation today looking at the Digestive Disease Institute, persons that are highly accomplished proceduralist still having these sensations. So are their specific data, Carol, around both of these issues within gastroenterology?

Dr. Carol Burke:

Yes, so it was interesting. There was a women's leadership conference that I was asked to attend. about a year and a half ago, and, you know, my area of expertise as hereditary colon cancer, but they asked me to address impostor phenomenon and microaggressions. And so that was my first foray into these topics, and when I went down and presented the lecture, what Natalie and I also did was got the approval by Dr. Clance to utilize her validated and impostor phenomenon scale. And also in the survey of the attendees at this conference, was asked two specific questions, have you ever experienced impostor phenomenon, and have you experienced microaggressions? Two simple questions, and then the majority was related to the, the 20 question validated Clance IP Scale.

And what we found, and these are all, you know, high-powered women in leadership from industry to gastroenterology, including medical residents and trainees and some nurse practitioners. We had very few males at this women's leadership conference, but 93% of them had said they had experienced microaggressions and 88 experienced impostor phenomenon. 69% had said that their score ranked them as frequent or intense impostor phenomenon. Again, impostor phenomenon is a self-perception, but when it becomes intense and severe, those are the people that probably have all the qualifications to become a chairman of a department, to write an RO1 grant, right, to be very successful. And I think that's holding them back. 

And as Natalie said earlier, if imagine growing up, and you are an underrepresented minority and you're always told that, "You don't belong. You're not worth it. You stand out. You're not like the rest of us," that it's almost like death by 1,000 cuts, right? It's like the mosquito bite. One, you can tolerate, ten becomes uncomfortable, but when you're getting it every day, and that also compounds the sense of impostor phenomena. So there is this intersection between MA, microaggressions, and impostor phenomenon that we need to address and untangle. And it starts with mere awareness, which some of the individuals taking the survey, a few, said, "I don't even know what that is," so I think we exposed it. And now that we have data, the Digestive Disease Institute has said, "This is a real problem, and we are now taking the bull by the horns, and we've started a program to address these phenomena for all providers in the Digestive Disease Institute. 

Dr. Tony Tizzano:

Yeah, I love that your institute has done that, and it really shows a kind of, you know, at the level of the organization approach that it's recognized from the very top throughout the or- entire organization, so I applaud you for that. 

So Natalie, clearly what Carol has to say here resonates with us. You know, what are some steps we can take though to begin to mitigate microaggressions and impostor phenomenon from the organizational level?

Dr. Natalie Farha:

So like Dr. Burke, said they've started by doing this workshop f- that's required for all staff gastroenterologists and all nurses in the institute to teach them about microaggressions, teach about how you respond to them, whether you're the person that's been the recipient of a microaggression, the person that did the microaggression, or someone that's observed the microaggression. 

The biggest thing that you can do at an organizational level is talk about it and make sure everyone's aware and have the tools to respond appropriately. So by starting that in our department, that's kind of the first step.

Dr. Tony Tizzano:

So, Carol, would you add to that? 

Dr. Carol Burke:

Yeah, thank you, Tony. I would. If the institution doesn't make it a priority, then it won't be a priority. So I think awareness is the first step. And then measurement, right? Where are we at baseline? And after we institute programming like this, what have we done, right? So to measure to see if the frequency of these incidents are decreasing, if people feel more confident in their ability to handle situations, right? 

What we really want is to make our workforce the most diverse, engaged, and happy. We don't have any room at all to lose employees, to lose nurses, and most of what we did is looking at professional on professional microaggressions. But it could be patient toward provider as well. We have many examples, but I think what you taught me, Tony, is the organization needs to think this is important, make it a priority, do the measurement, change the approach, and re-measure to ensure that we're making progress. 

And what you told me is it's important for those that say, "Oh, I was just kidding," when I said, "Oh, you know, it looks like you've put on 30 pounds of weight," or, "Oh, let's have a Christmas party," when, you know, there's others of other ethnicity or people that don't celebrate Christmas and just not, you know, not addressing it as a holiday party, right? So to make everyone feel engaged. 

And you said that when people make comments, it's their implicit bias, right? That they historically have not been, uh, maybe exposed to these types of concepts, and it may be a hard thing to swallow. There are some people that have gone through our two hour course, and they said, you know, "I'm just not going to say anything anymore." You know, "I'm going to upset one person or another, so I'm not going to say anything." You know, we've got to a place where it's a cancel culture. But I think increasing the awareness and then once people are aware when they're in their day-to-day workplace, they will think twice before they make a comment that might make someone feel uncomfortable, or they may feel more empowered to actually take a step aside to let the recipient of the microaggression know at the right time, psychologically safe space, "I heard what was said. I'm sorry it was said. Is there something that I can do to help you?" 

Or for the one that has actually cause the microaggression, reassuring them, and this is what you taught me that it's not a reflection on their personality necessarily. It's just their implicit bias, and so it is going to take some retraining. And so at the right time, taking them aside and saying, "This was painful for someone in our group, and, you know, maybe you could consider it another way." 

So Natalie actually has surveyed a variety of the residents and has experienced microaggressions as, you know, many women in medicine have over the years, whether they're sexist or gender related, you know, hearing some of the responses or some of the occurrences that we experience frequently would be helpful to the audience.

Dr. Tony Tizzano:

Yeah, I'll get there in a second, but you mentioned psychological safety, and I think that's a key. You know, we can talk about this all day long and it's important to have awareness, but until... You know, there's a hierarchy in medicine. No matter how much we try to flatten, it's there. So the ability for a student to speak up, or for me to speak to my person that I report to is a little tough. And so it really becomes incumbent upon leaders in groups, and I'm not talking about from the very top down. I'm talking about at every level of leadership of which there are many layers to say, "Look, this is something I'm beginning to understand and become aware of, and I want to be more sensitive to it, but that's going to require that you speak up. And you will never be criticized for coming to me, bringing it up in front of a group. We will all learn from this."

And you're right, it's not about one's character because we're wired this way. We make these intrinsic decisions. They're just the way we've been wired for so long and how do you overcome that is not going to be quick and easy, but bringing it to everyone's attention to begin with, and I think those workshops begin to do a good job of that. 

So with that, examples that you've seen Natalie that you think are worth discussing as a matter of example. 

Dr. Natalie Farha:

Yeah, I mean, there are things that happen every day. Commonly in our workplace is the nurses communicating with male and female fellows or male and female staff differently. So everyone knows me as Natalie and our endoscopy suite, and that's great by me, but it's interesting to hear them talk about my male colleagues as Dr. XYZ. And then they're like, "Right, Natalie?" And I'm like, "Oh, okay, that's just a little bit different."

So that's one example that's really common in our workplace. Other things that kind of relate to that as the expectations maybe of male and female fellows in particular or, or attendings, like, expected to be more helpful or help them roll patients back and forth and things like that if you're a female and sometimes they don't expect the same of the males. So those are just a couple of examples that we see really often.

Dr. Tony Tizzano:

Yeah, I could see that, and I could even see that in my training that, you know, working with nurses, maybe the male resident or intern didn't interface with the nurses in the same way that female residents, and, and probably to our detriment. Carol, would you add to that?

Dr. Carol Burke:

Yeah, I, I'd like to. I have a personal experience, so a very close person to me who has been in medical practice for years came from another country, and is a high-quality physician. And a patient walked into the office, and the first thing they said is, "Where are you from?" implying, "Oh, you're not American," which this person is American, came from another country, but is American. And said, "I'm, I'm American. Well, I'm from Cleveland." "But where are you, where are you really from?" And, you know, then was forced to say where they were really from, and then the person said, "Well, I want an American doctor," right? So high-quality physician at the top of their game, and you know, it, it this was overt, right? Not such a microaggression. 

But, you know, there are other things where some female physicians are wearing a hijab, and then someone thinks they're funny in saying, "Oh, don't you have to walk three steps behind, you know, the male staff member, right? Isn't that what's done in your country?" Just things that, that are offensive that really are degrading to people and can ruin the whole experience of a team or a member of a team. 

Dr. Tony Tizzano:

Yeah, that's insightful, and I think that some of our workshops work towards that. But we're talking a organization and enterprise of 82,000 people, and we're talking doing 20 or so at a time. But, you know, you have to start somewhere, and you know, you get some ambassadors and it begins to spread. So Natalie, you know, what do you see? We've got this workshop. What else do you think we need to be looking at as an enterprise to promote an environment that allows us to interface with this problem better? 

Dr. Natalie Farha:

So I think the workshops and educating leadership are very important steps to take just to raise awareness, but it really comes down to a micro level of individuals taking ownership of this as an issue, people in leadership on smaller scale, so, like, an attending on a team that I'm on or me as a fellow on, with a team of residents and medical students making it very clear that this is behavior that won't be tolerated. If anyone says anything that could make you feel like you don't belong or it could be taken offensively, to bring it up and s- and not be scared to say something. And if I as a leader, if I'm the leader, if I say something, please let me know because I'll be contributing to that lack of psychological safety if I'm the person that's making the microaggression. 

Dr. Tony Tizzano:

Sure. And there's the sticky wicket, so if we say, "Will not be tolerated," you know, that is implying that it was done purposefully and that you would have had thought about it before you did it, and it won't be tolerated, but how do you approach the individual and say, "You know, you probably didn't mean it, but this is how it was perceived?" 

And for those of us who are willing to just open our ears and listen for a moment, it hits us like a brick between the eyes, "Darn, I should never have said that, and, but I didn't mean it, but I can see where it could be hurtful." To solve this, you have to make both sides of the equation feel whole. How do you do that? 

Natalie Farha:

That's a hard question to answer. It's a very nuanced thing. I think it depends on the situation when the occurrence happens. If it's something that makes everyone stop in their tracks, then maybe it's something that needs to be addressed in the moment. If it's something that kind of goes by the wayside, but it stood out to you or stood out to someone, they brought it to your attention, could maybe be brought up in a more private setting and then hopefully the person that you talk to goes and addresses the person that was the recipient of the microaggression. 

Dr. Tony Tizzano:

Sure. And I think the first step, you know, your DDI is taking it. I mean, at the level of the institute chair, they must have said, "You know what? We're going to do something about this." And I think this is important and so all the leadership within the department, the institute is going to have the sense that it's important and probably moreover, give them time. Your institute has given you time to do this, and that's what a lot of people don't have. 

And Carol, I can see you've got something good to say, so let's have it. 

Dr. Carol Burke:

Thank you, Tony, so you're right. It wasn't that Natalie and I had an interest in this, and we wrote about it. But at Cleveland Clinic, all caregivers have to fill out satisfaction surveys, and we want to be the best place for people to work. And in Digestive Disease Institute, there was a recognition that the women's scores could be substantially improved. Recruitment and retention can be enhanced. 

So the first step was we created a Women's Leadership Coalition because the men's scores were generally better than the women's scores, and through the WLC, we had some town hall meetings. And we said, "What are the issues? What would make you more professionally satisfied in your job? How could we help?" And some of the things that came out were examples of where the women felt like they weren't given the same level of either support or tools or things that they needed to get their job done. And they saw kind of an inequity between the male physicians and the female physicians. 

So it started with the Women's Leadership Coalition, the town hall meeting, some of these things that have come out that are based in microaggressions, and they can be as subtle as I am in my endoscopy suite at 7:30 AM, ready to do the huddle. The anesthesiologist comes in. We do the huddle. The anesthesiologist leaves, and we're waiting for the anesthesiologist to come back and they're going to start the male chair of the GI department's procedure, but I was ready first. So it's those kind of disparities that we wanted to address with the program. 

And it was interesting when you asked, "Well, you know, how do you address these? When is the right time to do it, and retribution hurts, right?" Having something thrown in your face when you didn't think you did anything wrong is painful, but also when someone in a genuine, caring manner or an educational manner said, "This, you know, this really hurt me," and we, we actually have some language of how people could actually respond to a microaggression when it's leveraged at them. 

But just like teaching rounds. When I start, I like to say, "This is my teaching style. It's important for me t- that, uh, everyone has an opportunity to learn in the way that they want to learn. So I want to enhance, you know, your professional satisfaction during the time that we're together." And at that time when you kind of carpet the microaggression, it doesn't have to be called out specifically, but say, you know, "Our job is to work as a really professional engaging team. We have educational missions. We all want to treat each other professionally."

And so you could kind of slowly roll that out to the team where you say, "Microaggressions won't be tolerated here, but we wanna be sure that everyone feels valued," so you kind of frost the cake.

Dr. Tony Tizzano:

Yeah. 

Dr. Carol Burke:

And then make sure that if there is anything, you know, "And we will be meeting throughout the course of our time together. Please come to me during those times that we have our one-on-one meetings or team meetings or any other time," so to open the door to help people get through it 'cause it is as you said, a difficult concept. It has to be nuanced, and I just think it's reassuring everybody and knowing what to do at the right time, but some of the responses that have been crafted either in the literature that Natalie and I have talked about can be very helpful in having people that are leveraging a microaggression that didn't really understand it. 

So if you asked me if you could touch my hair, right? That wi- (laughs)-

Dr. Tony Tizzano:

Right. 

Dr. Carol Burke:

... that's a common one that some of the women have mentioned, or if I overheard Natalie as maybe being offered to chief GI fellow, and because Natalie is of a certain ethnicity, race, n- gender, whatever it is, and, and then I'm talking to one of the other colleagues saying, "Oh, they only asked her because she's an underrepresented minority," which completely discounts.

And so my colleague could say, "Well, I can com- completely disagree with you because that person is the best thing since sliced bread. It has nothing to do with X, Y, Z characteristic of them. It's because they're accomplished and they're the best person for the job." So we've actually crafted, so n- if you said something to me, I could say, "Oh, I'm s- I'm sorry, Tony. I don't think I understood what you said to me."

Dr. Tony Tizzano:

Yeah. 

Dr. Carol Burke:

"Could you please repeat that again," and when someone takes a pause and thinks about w- "Oh, what the heck did I really say?"

Dr. Tony Tizzano:

Right, it's that point of allyship. 

Dr. Carol Burke:

Mm-hmm. 

Dr. Tony Tizzano:

And, you know, how do you respond with that? But it still wasn't easy. You know, I guess it would be door opening maneuver for the leader to say, "Okay, as..." to the group, it's one thing to say to the person, but to say to the group, "We've talked about this. I've not heard anyone come forward. What's been our experience? Have we encountered things?" To open it up so as a learning experience saying, "I'm willing to hear them right now. What might they be? You know, darn it, you've got a point there."

And I think it's that back and forth that is going to make the difference, and, you know, at the end of the day that intersection between diversity, equity, uh, inclusion is belonging. We do want to be valued. We want to belong. And the Harvard Business Review has actually put some numbers on this. They talk about you have as many as seven days less missed work when you feel that you belong annually, that your chances for promotion are 18 fold greater, and the chance of getting a raise are doubled. And when they looked at all this and we spend about eight billion a year on diversity and inclusion work as industries in the United States, that for a company of 10,000 it means about 51 million to their bottom line improved with lack of turnover, keeping people there. 

So gee, extrapolate that to Cleveland Clinic, your approaching half a billion dollars. I mean, this is really timely stuff, so what's on the horizon? What's the next best thing? What can we do next? 

Dr. Carol Burke:

What I think lies on the horizon is some of what we've instituted and, and Tony, uh, we, we have to start by saying thank you because you actually have been a partner in this program in the medical school. That's where it has started, and some of the other institutes have also taken the microaggression training course as a voluntary thing, but I think we're the first institute that's mandated the microaggression training.

And as I mentioned before, f- the first step is opening the door, letting people know that this is out there. I think the provocative data that you talked about in the Harvard Business Review, right, we know that diverse teams actually have better outcomes, better patient satisfaction, better quality, and so putting a dollar mark on these issues when they're understood, when they're metric set, and when we try to meet the metric and then improve the metric is really important.

So I think, you know, mandating courses, and the, you can't just sit in front of computer and, you know, read and read about this. You can't just hear a lecture. I think what's most important is a role playing that is so key because people don't know how to respond. It's quite embarrassing when you make a remark and someone takes it the wrong way, and you weren't thinking that at all, so as Natalie said, it's very nuanced and I think just having the role playing, the surveys that we have sent out to the participants in the mandated DDI training. We have a post-survey assessment and then we'll have a follow-up assessment to understand at every level, you know, have you experienced less microaggressions? We're not really targeting impostor phenomenon. Have you felt more comfortable in addressing them in real time if you haven't been the one that's been subjected to it, if you've only been a witness?

And then for other people to say, "You know what? I realize that it's not a character flaw. But I think it's this process of making an analysis of where we are now, implementing something and reassessing where you're at and then making another change." So it's the cycle of constant improvement. And if we could get a dollar figure put to this, I think that all other institutes would mandate it. 

Dr. Tony Tizzano:

I always wonder how they get that, but, you know, I have to tell you that I think you guys are spot on and I'd like to thank both of you so much Carol and Natalie. This has been a fabulous podcast. To our listeners, thank you very much for joining, and we look forward to seeing you on our next podcast. Have a wonderful day. 

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes. Google Play, SoundCloud, Stitcher, Spotify or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.

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