Multicultural competence in psychiatry is more than just a buzzword; it is a crucial aspect of patient care that acknowledges the diverse tapestry of human experiences. On this episode of The Menninger Clinic’s Mind Dive Podcast, Dr. Francis Lu shares an enlightening perspective on the intricacies of cultural considerations in psychiatric diagnosis and treatment as well as the five-part framework of Cultural Formulation from the DSM-IV and its refined application in the DSM-V, which now includes social determinants of mental health and the concept of 'structural competency'. The discussion isn't just theoretical; Dr. Lu’s experiences allow for a practical look into the challenges and advancements in weaving these critical elements into the fabric of psychiatric care.
Dr. Lu, often considered a pioneer in cultural psychiatry, speaks with hosts Dr. Kerry Horrell and Dr. Bob Boland about his 36-year journey through the nexus of mental health care, community engagement, and spirituality, offering a treasure trove of insights into culturally competent care. The conversation covers the evolution of psychiatric training and the robust legacy Dr. Lu leaves behind, impacting both the care of patients and the education of mental health professionals.
Dr. Lu's pioneering work in establishing ethnically focused inpatient psychiatric programs is a testament to the need for sensitivity towards a patient's cultural background. His initiatives at San Francisco General Hospital not only enhanced patient care but also set a new standard for inclusivity within psychiatric practice.
The in-depth look of the psychiatric profession over the last four decades allows for a more personal discussion for Dr. Lu and our hosts about their personal journeys and
careers in mental health. Sharing stories and experiences about the lesser-known toll of being mental health clinicians and navigating a profession that is as diverse as the patients. Tune into Mind Dive for a comprehensive understanding of cultural psychiatry and the continuous quest to improve mental health care for all communities.
Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to stay up to date on new Mind Dive episodes. To submit a topic for discussion, email podcast@menninger.edu. If you are a new or regular listener, please leave us a review on your favorite listening platform!
Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.
Multicultural competence in psychiatry is more than just a buzzword; it is a crucial aspect of patient care that acknowledges the diverse tapestry of human experiences. On this episode of The Menninger Clinic’s Mind Dive Podcast, Dr. Francis Lu shares an enlightening perspective on the intricacies of cultural considerations in psychiatric diagnosis and treatment as well as the five-part framework of Cultural Formulation from the DSM-IV and its refined application in the DSM-V, which now includes social determinants of mental health and the concept of 'structural competency'. The discussion isn't just theoretical; Dr. Lu’s experiences allow for a practical look into the challenges and advancements in weaving these critical elements into the fabric of psychiatric care.
Dr. Lu, often considered a pioneer in cultural psychiatry, speaks with hosts Dr. Kerry Horrell and Dr. Bob Boland about his 36-year journey through the nexus of mental health care, community engagement, and spirituality, offering a treasure trove of insights into culturally competent care. The conversation covers the evolution of psychiatric training and the robust legacy Dr. Lu leaves behind, impacting both the care of patients and the education of mental health professionals.
Dr. Lu's pioneering work in establishing ethnically focused inpatient psychiatric programs is a testament to the need for sensitivity towards a patient's cultural background. His initiatives at San Francisco General Hospital not only enhanced patient care but also set a new standard for inclusivity within psychiatric practice.
The in-depth look of the psychiatric profession over the last four decades allows for a more personal discussion for Dr. Lu and our hosts about their personal journeys and
careers in mental health. Sharing stories and experiences about the lesser-known toll of being mental health clinicians and navigating a profession that is as diverse as the patients. Tune into Mind Dive for a comprehensive understanding of cultural psychiatry and the continuous quest to improve mental health care for all communities.
Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to stay up to date on new Mind Dive episodes. To submit a topic for discussion, email podcast@menninger.edu. If you are a new or regular listener, please leave us a review on your favorite listening platform!
Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.
Welcome to the Mind Dive podcast brought to you by the Meninger Clinic, a national leader in mental health care. We're your hosts, Dr Bob Boland and Dr Carrie Harrell Twice monthly.
Speaker 2:We dive into mental health topics that fascinate us as clinical professionals and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives from the minds of distinguished colleagues near and far. Let's dive in.
Speaker 1:We're delighted today we're going to have Dr Francis Luan. We've been trying to get him on for a bit as well. I know this is excellent. Yeah, absolutely, dr Lu. He retired from the University of California After 36 years of providing clinical care, teaching university and public service at UCSF and UC Davis. His career focused on cultural psychiatry, community psychiatry with the severely mentally ill, psychiatric education, diversity, equity and inclusion, and the interface of psychiatry and religion and spirituality. Dr Lu remains involved with professional organizations such as the American Psychiatric Association, the American Association of Directors of Psychiatry, residency Training, the Association for Academic Psychiatry, the Group for the Advancement of Psychiatry, cultural Psychiatry Committee oh my God, all these different groups and the Society for the Study of Psychiatry and Culture, among others. He also reminded me that he's running the American College of Psychiatrists meeting this year. Wow, yeah, that's right. So how's that for retirement?
Speaker 2:It sounds like you're really good at being retired.
Speaker 1:Exactly Along those lines, though. Dr Lu, can you start just by telling us a bit about your career, how you became interested in cultural psychiatry?
Speaker 3:Well, thank you very much for inviting me to join you today. I'm so delighted to share bits and pieces of my career and background and viewpoints with the audience today. Well, back in the 1970s I did my psychiatry residency training at Mount Sinai in New York City, and which was the training director at that time was a very well-known, internationally known psychoanalyst, edward Joseph. I certainly learned a lot from him and the supervisors, I think, consistent with psychiatric training programs. At that time, culture was not even on the radar screen. It wasn't diversity, equity, inclusion terms that I know are controversial in some states these days but these concepts were just not discussed or not even brought up. So when you compare that with what we have now in psychiatry training and in clinical practice, I've lived long enough to have seen, over the course of 50 years, the changes that have happened in our field. When I completed my training, I moved out in 1977 to San Francisco General Hospital, which had a department of psychiatry that was unaffiliated with UCSF but was just becoming affiliated with UCSF.
Speaker 1:That's interesting. That's probably a story of its own, but probably not the point, but that's interesting.
Speaker 3:San Francisco General Hospital was the public hospital for San Francisco for over 100 years. At that point it did have a relationship with UCSF. That started in the late 1800s but the psychiatry department was unaffiliated with UCSF until that time. So I started out as a team leader on an inpatient unit working with very severely mentally ill people that were almost all were involuntarily committed for danger to self or danger to others or grave disability. In 1980, I became the unit chief there of this 30-bed unit.
Speaker 3:I decided to, in conjunction with the Department of Psychiatry Leadership as well as with the Community Mental Health System of San Francisco, to create an Asian focus inpatient unit where we would bring together staff who could speak many Asian languages. Eventually we had 16 Asian languages and dialects of Chinese represented on the staff with the patients, Because at that time there were two inpatient units. Later there became four inpatient units. And to have an Asian focus Because at that time 22 percent of the city were Asian and a number of the lower income or patients with no income, no insurance, would come to our hospital. A number of them had limited English proficiency. So it seemed to make sense to me and also, very importantly, in San Francisco at the time there were already pre-existing outpatient and day treatment programs that had an Asian focus in several parts of the city, and not only Asian focus, but there were focused programs for blacks and Latinos, which seems pretty progressive for that time. Yes, I think so. So eventually it make a very long story short From 1985 until about 2009, we had created six focus programs ethnic minority focus programs on four different inpatient units.
Speaker 3:So we had the Asian focus on one unit. We had a women's focus team and a Latino focus team on a second unit. We had an LGBTQ and a HIV AIDS focus, two focus teams on another unit. Then we had a black focus unit. The idea here again was similar to bring together staff and patients from these backgrounds. Some of them speak with language issues and specific issues like pregnant psychotic patients would be put on that would be admitted preferentially to the women's focus team, and so on.
Speaker 3:In 1987, we did get a APA certificate of significant achievement that was given to us at the fall APA meeting, and that award process still continues at APA and also in 1999, the American College of Psychiatrists awarded us the Creativity and Psychiatric Education Award. And along the way, of course, we became as a training program for UCSF. We had medical students and psychiatry residents who rotated through our units. Their first six months of inpatient psychiatry in their first year was at San Francisco General Hospital. So this became a recruitment tool to bring in diverse residents to our program, and I'm very happy to say that I was on the selection committee for about 20 years and helped to recruit a whole cadre of diverse residents who have become quite prominent in the field, such as Rona Hu with Stanford, q Chang Li at UCSF, descartes-lee at UCSF, and so on, and so it's just wonderful to see these residents grow into faculty who are contributing so much now.
Speaker 2:That is really an incredible story, and I'm not surprised that it happened in San Francisco or like a lot of the started San Francisco, like what in?
Speaker 1:Just being a bit ahead of us.
Speaker 2:Yeah, and again just being such a hub of regression. And I do think this might land as a bit of an obvious question, but I think it's an important one to say out loud. But I wonder if you can say a little bit about why this feels so important, why focusing and noticing and integrating in folks cultural background is important when treating psychiatric illnesses or mental health conditions.
Speaker 3:Well, I think that we are simply acknowledging the importance of understanding cultural issues when working in clinical care. And sometimes when we say that term, cultural issues, you know the eyes glaze over. It's like deer in the headlights. Like what do you mean by the cultural issues? That seems very vague or very fuzzy, or this seems like, this seems like PC. In fact, there was a book written by Sally Sattel, a psychiatrist at Yale, called PCMD, and in fact, in fact in the in that book she writes about her inpatient units quite critically saying that that, as the title implies that this is all, just all, just PC, you know that this is just window dressing and we would argue that that indeed there are cultural issues that are important. And what are they? Okay, well, let's go no further, if you will, than the 1994 DSM, for which did provide in appendix I, the ninth appendix, an outline of cultural formulation.
Speaker 1:I think everyone knows. But DSM is kind of the is the list of diagnoses put out by the American Psychiatric Association. Right the go ahead.
Speaker 3:Yes, right. So this originated, by the way, in that Dolores Perone, who was the director of Office of Special Populations, as it was called at the NIMH at that time, had funding and had convened three meetings of a work group of NIMH that was headed by Juan Mesec, a Peruvian psychiatrist at the University of Pittsburgh at that time, and I was fortunate to attend, I think, the last of the three meetings. This group of psychiat, cultural psychiatrist, formulated this outline for cultural formulation and let me just briefly mention what those, what the outline is, because I do think that this you know, when we say the cultural issues here, they are, as starters, starting points. It consists of five parts. There are four fields of interrelated information and then a fifth part. So the first part is that, and these are questions that we ask the clinicians to gather information about.
Speaker 3:So the first is what is the cultural identity of the person that you're working with? Secondly, what are the cultural concepts of distress that this person might have? Third, what are the cultural stressors and supports that the person is encountering? Fourth, what are the cultural features of the relationship between the clinician and the patient? And in the DSM-5TR that was expanded to cultural relationship between the clinician and the patient, and treatment team and institution. And then fifth is the overall cultural assessment. Meaning, once you have obtained information about these four parts, how do you bring it together to influence your differential diagnosis and your treatment plan, which is something that we do every day with every patient and in terms of the process of the treatment plan.
Speaker 3:How do we negotiate a plan to maximize adherence and compliance? Are you taking your medications? And then the content the biopsychosocial content of a treatment plan, and how is that influenced by what you've learned? So this has been the outline. It was revised for the five in terms of the language, but the five parts essentially remain the same, and also for the DSM-5TR.
Speaker 3:The language and definition of each of these sections have changed significantly over the years and, for example, a major change that happened in the TR, which came out in March of 2022, was for that section on cultural strengths and supports. There is now an explicit sentence about the importance of the social determinants of mental health. That was brand new. I fear that many people are not even aware of that, that we really need to understand things like food insecurity and housing insecurity, as well as experiences of racism and discrimination, because those conditions or problems that people are experiencing can influence diagnosis and treatment, and until you attend to them, one hand is tied behind our back. In other words, to take it at the 30,000-foot level, there are biomedical determinants of mental health and there are psychological determinants of mental health, which I think psychiatry rightly focuses on, and now we need to fully understand and then also incorporate in our assessment and treatment the social determinants of mental health and, as you know, back in 2021 to 2022, vivian Pender, the president of APA, made that her presidential theme and it was the presidential theme. It was the theme of the annual meeting of the American Psychiatric Association in New Orleans in 2022, the social determinants of mental health. In fact, the American Psychiatric Press, the publishing arm of the APA, has published a trilogy of three books, starting with the 2015, the social determinants of mental health, the 2021 social injustice and mental health and finally, in 2022, a book entitled Something Like Struggles in Solidarity Seven Stories of Federal Legislation that Affected Social Determinants of Mental Health.
Speaker 3:Yeah, so with that addition of that sentence, plus other things in the TR, they've brought together cultural and social structural issues. This is very important. I'm sure we've all heard the term cultural competency as a way of what are the attitudes, knowledge and skills that are necessary to work with culturally diverse individuals. Well, the term structural competency was coined by Jonathan Metzl at Vanderbilt and Helena Hansen, now the interim chair at UCLA, to psychiatrists to denote the social economic conditions that may cause health inequalities in the first place. So the upstream factors above the social determinants of mental health, as well as the social determinants of mental health themselves that need to be addressed in our clinical work. So by adding that sentence, the TR has actually helped bring together cultural competency and structural competency, which is what we ultimately really need to do.
Speaker 1:I mean? What do you suppose I mean? The barriers were that I mean because, in a way, when you talk about culture being important to persons with mental health, that this seems obvious and understanding their background, and yet, you know, it wasn't part of my training. I don't know, maybe it was part of yours, carrie.
Speaker 2:Yeah, I was so excited to talk to Dr Luke because I remember, I mean, obviously learning about the CFI is like a really important tool. Corporate, corporate formulation yeah, and then something that I've incorporated into yeah, what took so long, though?
Speaker 1:I mean, obviously it didn't take long for you, you were doing it years ago, but it took a lot of rest of us to catch up. Any thoughts about that?
Speaker 3:Well, it's very interesting as you, as you ask that question because I remember very vividly you know I've been attending the American Association of Directors of Residency Training Programs annual meetings back to the since the early 1990s and I remember very vividly that Barry Morenz from University of Arizona was giving a report at one of these annual meetings that the ACG and me accreditation standards for psychiatry and residency training programs was going through one of its periodic reviews. About every three or four or five years there's a review and updating Basically the study of the residents should be trained, essentially Right right.
Speaker 3:It gives the accreditation standards for the training programs as to what they should be teaching, and I remember that I had the idea of let's look through the accreditation standards and see what's there in terms of culture. This was in about 1992 or 1993. And so I looked through it and I didn't see very much. That's right.
Speaker 3:At that time and so I worked through the APA, through the I was involved, I think, on the Committee of Asian American Psychiatrists at that time but I remember working with the council on what is now the Council on Medical Education and Lifelong Learning to an action item in terms of changes, because they were of course putting together their recommendations that went to the board and eventually approved and sent to the ACGME Residency Review Committee to incorporate to a sentence about that. The curriculum should include issues concerning race, ethnicity, gender, sexual orientation and religion, and that was the very first time that that was added there. And I remember again Carolyn Rabinowitz, who was the director of education at that time and deputy medical director, being very helpful in getting that through. Wow, and so that started the change.
Speaker 3:That started the change and I remember again back in 1995, 1996, working with David Larson, a psychiatrist in Washington DC, and we put together a curriculum on religion and spirituality for psychiatry residency training programs and through his work with the Templeton Foundation we were able to get some seed money for curriculum award program for residency training programs and Jim Lomax at Baylor was one of the very first programs he submitted and got a grant for their curricular program and we presented for about 10 years or maybe eight years. Every year at the AdPort annual meeting and also at the APA annual meeting we would present the four or five curriculum that got awards that year. Yeah, and we began that process and some of those programs continue at Beth Israel with John Petite and I, presumably at Baylor. That program has.
Speaker 1:I'll be thinking and say that John's actually at Brigham, but Brigham and Women's. But, being a former, woman.
Speaker 3:Yes, that's correct. That's correct, brigham and Dana Farber. I misspoke there, dana.
Speaker 1:Farber, which is also switching, but we're not talking about that today.
Speaker 2:All that we look, Jim's been on our podcast before Talking about religion. He's been a mentor.
Speaker 1:Yeah, yeah, so that's like. So you see all the connections now.
Speaker 3:Well, while you're talking about that, if I could maybe this is a bit of a diversion, but I don't think so, because I've always considered you see religion and spirituality under the broad umbrella of cultural issues.
Speaker 3:You see, as a way of making sure that it is not neglected.
Speaker 3:The same thing about sexual orientation. Well, let me say two things, okay, if I could. It's very relevant to cultural issues here, because in 1994, I and two other colleagues, david Lukoff, a clinical psychologist, and Robert Turner, a fellow psychiatrist, we made a proposal in 1992 to the DSM committee of a new diagnostic category which eventually was accepted in January of 1993, eventually became religious and spiritual problem and it exists as a Z code, what is now called a Z code in the section other conditions that may be focus of clinical attention for distressing experiences involving religion or spirituality. So if you ask a patient, well, what brings you here today? And the patient says, well, you know, well I think that God is punishing me for my sins and I've lost my faith in God. And so if a patient comes in with that as an initial complaint and seems to be focused on that, do you just kind of brush it aside because it doesn't seem to meet any diagnostic criteria or you get a hint that this might be very important, related to their patient's cultural background, their religious background.
Speaker 2:Feel better.
Speaker 3:And so you can make a diagnosis of major depression or schizophrenia and religious or spiritual problem. So you can bookmark it for further assessment, if you know, maybe with a pastoral counselor or chaplain, and then possible religious or spiritual intervention to impact on that aspect of the person's distress. And by doing so perhaps the patient would be more willing to, you know, undergo more usual forms of psychiatric treatment. You know medication and psychotherapy, so we can provide holistic care for our patients. And then the second digression, if you will, is that in in 2003 in San Francisco, at the APA annual meeting, the Association of Gay and Lesbian Psychiatrists also have their concurrent meetings and at that meeting I was presented a Distinguished Service Award from HALP and they openly acknowledged that I was the first straight person to get this award. And what they said was that they thanked me for my efforts to include sexual orientation under that rubric of cultural issues. They felt that that was a very big advance in the field and that proved again very important because in 2005 in Atlanta, at the APA assembly meeting just before the annual meeting, there was an action paper that I and Jack Drescher from the I was the chair of the Council on Minority, mental Health and Health Disparities and Jack Drescher from New York, was the chair of the committee of lesbian gay psychiatrist.
Speaker 3:At that time we worked together on an action paper to support the legal recognition of same-sex civil marriage and it was quite a contentious assembly meeting. We went around to work with the area councils and the reference committees and eventually it passed. I remember we had a celebration One evening that a glp had already pre scheduled and I attended it and it was such a happy Room of people that that past yes, that was in. That was in 2005, you know yeah, I know you're right, so we're getting all the big ones.
Speaker 2:Yeah, you, you mentioned like that was such an advancement in the field, and understandably so, and I wonder if that could be a nice segue into thinking about what further advancements do you imagine?
Speaker 1:yeah, we're needed.
Speaker 2:what do you, what directions do you think are?
Speaker 1:Yes, in the current climate and stuff.
Speaker 3:Yeah, well, you know that's, that's such an interesting question that you bring up. And there's another organization that's really at the forefront of cultural security and that is the, the social and trans cultural psychiatry division. At the social and trans cultural psychiatry division at McGill university, this is the preeminent cultural psychiatry department. It's headed by Lawrence Kiermeyer, who was the long time editor of the preeminent journal Trans cultural psychiatry. He stepped down recently after many, many years and he has, for about twenty five years now, a summer program that runs in may and June at McGill, and every year he has and what he calls, an advanced study institute that lasts three days, focused on a particular topic, and this year it's entitled the future of cultural psychiatry colon, virtuality, imagination and community. Oh, wow, yeah, and and so.
Speaker 3:On the website, which is McGill dot c a slash T C Psych, you'll come to a description of the whole summer program, but also specifically of this advanced study institute, which is June twenty six to twenty eight. I just signed up this week. In fact, I won't read you the whole description here, but he he talks about the new technologies remain remaking the human body, mind and ecological niche, gene editing, other biotechnologies, the, the connectivity of the internet and virtual reality, and this brings us into unfamiliar landscapes. This portends a loss of human community. And so here are the questions here how are new technologies remaking our minds, bodies, cultures and communities? Secondly, what new pathologies arise from the predicaments created by these changes? And third, finally, how can cultural psychiatry respond to these challenges through innovations in clinical practice, mental health promotion and advocacy Wow that is.
Speaker 2:I mean, yeah, I feel like my boy, yeah, and that feels so true to the fact that now, especially with the proliferation of the internet and connecting over Time and space, like, of course, so much, are getting right, blended and yeah, I connected and that makes a lot of sense.
Speaker 1:It's so interesting I hate to move from that to something much more mundane but practical is, like you know, like most many of our listeners are clinicians and and what practical advice you have for them when they're counting cultures you know different from theirs, that they don't understand, and if they feel that it's creating kind of a difficulty with rapport like they're not you know, they worry about their ability to treat someone because of that. What advice do you have for them?
Speaker 3:Well, yes, well, thank you very much for that very down to earth question.
Speaker 3:Exactly I think I really, I really would advise people to learn about the two clinical tools that are in the DSM five TR in section three, which is called the emerging measures. There there's a section on cultural and social structural issues and psychiatric diagnosis, and there you'll find the outline for cultural formulation that I just described. It goes into greater detail than I outlined earlier and then again that was innovated for the DSM for, revised for the five and revised again for the DSM five TR. And then also the second tool is the cultural formulation interview, which emerged in the DSM five and is unchanged for the DSM five TR. Now this is a List of sixteen questions for clinicians to use to help you obtain the information for the outline for cultural formulation.
Speaker 3:This was a field tested internationally before the DSM five was published, and there are two books published by appy press one, the clinical manual of cultural psychiatry, second edition, edited by Russell Lim, and I have no disclosures here. I contributed to these books but I receive no royalties. Okay, that's okay, you can put a book anyway and that book neither for the, for the, for the earlier three books that I mentioned. Again, the clinical manual, cultural psychiatry, second edition, edited by Russell Lim and who was a colleague of mine at UC Davis and a former resident of mine, by the way, at UCSF, and then secondly, the DSM five handbook on the cultural formulation interview. Roberto Lewis Fernandez was the lead editor on that book.
Speaker 3:Are those two books really help you understand about the, about the outline and the cfi? There's a great training program at the Columbia center of excellence that Roberto runs. If you just Google cultural formulation interview, columbia, you'll come to it and it's a. It's a about an hour hour and a half training that with with actual interviews of by psychiatrist, of real life patients showing how to ask these questions. And these are related.
Speaker 3:Sometimes there's this feeling like there's the outline and there's the cfi, but but the way I see it is, the cfi is a mechanism, a practical way of asking the questions to get the information for the, the outline, and so for the past three years during the pandemic, I've been doing, and I still do, a zoom grand rounds, and again, I know this is plugging my own, shooting my own horn here, but I I continue to do zoom grand rounds on this topic, on these two clinical tools in which I I go over, go over both the outline and the cfi in great detail and show people what the meaning of all of this is and how one can use these tools.
Speaker 2:Wow, I think you should to the way. I think that that's again and it really important part of training about how we understand patients, and I know for me, like I supervise, now I'll ask my supervisor Is it time to? Are you familiar with the cfi? Have you used it? And a lot of times they're like oh we, we covered it in psychopathology, one of one, anyways and so I'm so glad it exists as a tool.
Speaker 1:Absolutely. Yeah, well, thanks, for I mean, it's wonderful to hear about everything you've done sort of towards this, and thank you for that, by the way. Yeah, so I think we have to wrap up, but it's been a pleasure talking with you. Any any last words for our listeners?
Speaker 3:Well again, thank you very much for your kind invitation and it's it's just wonderful to reminisce over my career of over 50 years in the field and to see all of changes that have happened and how I've played a influential role in in so many ways to make this happen, and I hope that people listening in today will take something from this and be able to use it in their day to day clinical work.
Speaker 2:And gosh, we're grateful for your work. Thank you.
Speaker 1:Yeah, so once again you've been listening to Dr Francis Lou and I'm your host, bob.
Speaker 2:And I'm Dr Kerry Harrell and thanks for diving in. The Mind Dive podcast is presented by the Meninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.
Speaker 1:For more episodes like this, visit wwwmeningerclinicorg.
Speaker 2:To submit a topic for discussion. Send us an email at podcast at meningeredu.