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Leading with Kindness | Quality Time with Dr. Schaal

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In this episode, Dr. Stephen Swensen discusses his work at Mayo Clinic to create thriving, ideal work environments. His most recent book, Mayo Clinic Strategies to Reduce Burnout - 12 Actions to Create the Ideal Workplace, outlines four evidence based elements of an ideal workplace: agency, belonging, collective effervescence and positivity.

Dr. Swensen is a recognized expert, speaker and inter-disciplinary researcher in wellbeing, leadership and organizational development. For 35 years, he served patients at Mayo Clinic as a clinician, scientist, educator and leader. He serves as a senior fellow of the Institute for Healthcare Improvement and a transformational fellow at The NARBHA Institute.

Expert: Dr. Stephen Swensen, senior fellow, Institute for Healthcare Improvement; transformational fellow, NARBHA Institute; professor emeritus, Mayo Clinic

Notable topics covered:

  • The role leadership plays in creating healthy, thriving work environments
  • The elements of an ideal workplace: agency, belonging, collective effervescence and positivity
  • How People-Centered Kind Leaders cultivate work communities that allow people to optimize their positive life assessment and healthspan

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DR. SHLOMIT SCHAAL:

Welcome to Quality Time, a Houston Methodist leading medicine podcast. I'm your host Dr. Shlomit Schaal, a Clinician Scientist and a Retina Specialist. And I serve as the Chief Physician Executive of Houston Methodist located in the world renowned Texas Medical Center. I passionately believe that quality is the heart of health care, and a commitment to quality is essential for every health care system. Join us each month as we discuss the latest advancement in quality in health care with clinicians, researchers, physicians, industry experts, and thought leaders who are as passionate as I am. Today I am pleased to welcome Dr. Stephen Swensen. Dr. Swensen is an expert in the field of Physician Wellness and Professional Fulfillment. For 35 years, he served patients at the Mayo Clinic as an Interdisciplinary Collaborative Leader, Clinician, and Scientist. As the Director for Leadership and Organization Development, he co-led their professional fulfillment initiative. He is a prolific author and his most recent book is"Mayo Clinic Strategies to Reduce Burnout: 12 Actions to Create the Ideal Workplace." Welcome Dr. Swensen, may I call you Stephen?

DR. STEPHEN SWENSEN:

Of course. And thank you so much. I look forward to our conversation.

DR. SCHAAL:

So Stephen, tells a little bit about yourself.

DR. SWENSEN:

Well, I've -- I spent most of my career as a practicing physician in a physician led organization, so I had leadership roles all along. And I look back, all of those roles contributed to where I'm at today. Today my focus is on the wellbeing of professionals, largely so that we can have the best possible care for our patients. But I've learned in running large department, running quality, running leadership and organizational development that one of the most important leading indicators of a healthy organization and healthy patients is the staff,

professional staff:

doctors, nurses, social workers, NPs, PAs, is a whole team that is mentally, physically, socially, and spiritually well. And in large part we have that -- As leaders in organizations we have that responsibility, it's a shared responsibility but we largely own responsibility of their wellbeing. Because, if you look at nurses and social workers and managers and doctors before they entered the profession, their mental health is above average. And when they join our teams in health care, we have a tendency through our systems and our leadership roles of squeezing that vitality and ingenuity and excitement out of them. And so, what we need to do is step back and say,"What is it -- How do we lead? How do we organize ourselves? What are our systems?" Address those first before we say we're done with our work.

DR. SCHAAL:

So how did you come to this realization? I don't remember anybody taught me this in medical school and I doubt that they taught you this in your medical school. So when did you come to this realization?

DR. SWENSEN:

I think the culture probably, when both of us were in medical school, was, "This is the way it is. You need to work harder and get the job done because we're here to serve patients." And we're still and always will be here to serve patients. But, I think over the last decades, the understanding is that we can't best serve them unless we're well. Decades of research has taught us that organizations function best when staff are engaged, their values are aligned with the leaders and the organizational values, and that each take care of each other for the best outcomes for the organization. So it's been an evolving understanding and I think, historically, maybe we thought it was all about sacrifice. I guess I -- The way I look at it now is what Roger Ingersoll said, he said,"We rise by lifting others." And so, when I look at my role and our role as leaders the first thing we should do is lift the people around us. They aren't there to serve us, they're to serve the mission, and my role as a leader is to serve them because that's the best way to achieve our mission.

DR. SCHAAL:

So you started this work decades ago. Were you a pioneer in this work in this country?

DR. SWENSEN:

Oh, I don't think I was a pioneer at all. What I love as much as anything is learning, and so I've read voraciously. If you look back at the understanding of this, it goes back at least 70, 80 years with anthropologists, and sociologists, and psychologists, and organizational development experts, even physiological biologists looking at the pathways of inflammation and allostatic load. When you think about allostatic load for the social determinants of health, it's the same pathways in workers who are stressed out by their leaders who aren't treating them with respect, or systems that aren't treating their wellbeing with respect. So this is really built on dozens and dozens of leaders over at least seven decades that have put this together. And one of the fascinating things about this is that it's not just our mental health that is affected by all of these drivers of burnout or moral injury or distress, it affects, equivalently, both our physical and our mental health because the pathways are the same. So we think that well, diet and exercise, well that's good for our body, it is, they are, if we do them the right way they affect our mental health equivalently. And we think about kindness and compassion, and awe, and those emotions that we can experience as humans have an equivalent impact on our physical health just beyond our mental wellbeing. So it's fascinating.

DR. SCHAAL:

So I hear, in my role here, one of my roles here is that I'm the CEO of our physician organization and certainly I would like our physician organization to be the best place that any physician or any other clinician would like to be part of. And part of it is to really focus on wellness of our clinicians. And you authored this book that says there are 12 actions that I can take as a leader, or the organization can take as a leader to create the ideal workplace. And I love the word ideal. Can you tell me a little bit about what it means and what I need to do?

DR. SWENSEN:

So ideal is aspirational and it's like perfection. And we never get to perfection, we never get to ideal, but that should be our North Star, that should be what we aspire to. And so we wanna always be in that space between excellence and perfection and ideal, understanding what ideal would be. Because we work in a system with human beings and with man-made, human-made structures it will necessarily be imperfect. But the ideal would be some combination of four elements that have been described and validated over the last 70 years. Agency. Agency means having some control over one's life and specifically our work life. You know, we spend -- Except for sleeping, we spend more time in our lives at work than we do any other activity, so we should be as well and have ideal characteristics of our work life as we do in the rest of our life. So agency is a key. One large epidemiology study including Marmot in Great Britain showed that people who had control over their lives they live longer and they had a positive and more positive life assessment. So that's one that we can certainly work with in how we make decisions and how we govern and how we select our leaders and how those leaders work with staff to make decisions together, and it's not just a top-down deal. You know, if you were designing the ideal symphonic orchestra, you'd want an outstanding conductor. But could you imagine what it would be like that conductor never played the violin? So part of agency is feeling -- you look up and you work with someone and you have trust in them and you can do that if you never played the violin, but it's a lot easier and better if a practicing nurse is leading nurses and a practicing physician is, or at least someone who's had experience as a physician is leading physicians. And that's one of the first foundational stones of agency.

DR. SCHAAL:

And what are the other three?

DR. SWENSEN:

So, belongingness is a -- I love that word, belongingness. And it's basically -- Humans are social animals and creatures and beings and having -- being part of a community that accepts you for who you are and loves you and cares for you in spite of who you are or what you did is a very important piece of wellbeing in life and specifically at work. And leader behaviors play a central role in having all of our staff, regardless of phenome or genome feel like they belong. Third is -- You could -- I say this different ways, but my favorite way is a term from Emile Durkheim, he's one of the founders of sociology 100 years ago in France. It talked about this feeling of collective effervescence, collective effervescence. Isn't it beautiful?

DR. SCHAAL:

I love the word effervescence. It's bubbly, right?

DR. SWENSEN:

It is bubbly, yeah, and that's how we want to all feel at work and we wanna -- And at work, the collective piece is it's part of a team. So collective effervescence is the harmony, the energy, the meaning when a group of people come together with a shared purpose. And that's what we want our work in hospitals and clinics and home care and community care to feel like, that we're a team, we have a shared purpose, we have this energy and excitement and we have this meaning in our work from the shared purpose we do together. And you could experience that by yourself but the ideal at work and in life is we experience it with our family or a loved one, or our work team. And such collective effervescence. And the fourth of these ideal work conditions or traits that all of them are evidence based. All of them have large epidemiology studies, some experimental studies, some observation studies. And so positivity is the fourth. And a lot of people roll their eyes when they think about, well positivity."Well, yeah, let's just get the work done and enough of this Pollyanna stuff." There are four very large epidemiology studies. One with nuns, one with nurses, one with veterans of wars, one at Mayo Clinic cross sectional, epidemiology study at Mayo Clinic. All four of them showed that people who in their lives had a positive life environment their affect tended towards positivity, their disposition was predisposed to optimism, they live longer. And their life assessment, through their own assessment, was more positive. They're subjective. So, like all four of these traits, they affect our physical and mental health, and there are ways that we as leaders can help nurture and cultivate each of these four ideal work attributes.

DR. SCHAAL:

So let's talk a little bit more, kind of in depth about that. So, let's start with agency and control. You know, I'm a clinician scientist and in science you actually have more control over your schedule, you know. You can start experiments at 9:00, you know, instead of 7 a.m. You can decide, you know, I'm going -- Yes there are deadlines but you can decide what, you know, grant you're gonna submit and what grant you're not going to submit. But for physicians and specifically for surgeons, you know, the OR starts a specific hour. There's, you know, patients that are waiting for you and you gotta see them all. And there's this continuous monitoring of actually what you're doing that you can't just say,"You know what? I'm gonna change the clinic and I'm gonna see only four patients today." There are 20 waiting for you today. You have to see them all. You can't just take off. It's not under your control. So how do we as organizations that employ physicians and think, obviously, about our patients who need to be served, how do we insert a little bit more agency and a little bit more control into our clinicians lives?

DR. SWENSEN:

So, I think some elements of the ideal decision making and governance is a model that engages all the staff in that work group. So we're talking about physicians. Ideally they would -- most of the decisions that affect that group's practice in this OR or that clinic would be some element of collective decision-making in an organizational democracy. And so, instead of the leader of those clinics or those work groups saying,"This is, what I figured out is the best way to do it so we're gonna do it that way." You first seek to understand, you listen, and you open the books with transparency so that people -- so you're not hiding anything unless it's, you know, confidential information. You build trust by being transparent, you build trust by first seeking to understand and to listen, and have the group, whenever it's appropriate, make the decisions together. So even if it's not 100% always consensus, everyone at least feels respected and their opinions and input was valued and they had an opportunity to make a, you know, decision, you know, be part of the decision-making. Most people will understand intuitively or after conversation that there probably needs to be some standard work, and if we need to start the ORs at 7:30 every morning, well then that's fine. That's not really negotiable. But there are -- But how can we have the group be informed and make decisions and -- It also includes for having the groups be physician led, and ideally they -- In some models they would have control or some input in who their next leader of this surgical group is, or this group of family docs is, so that it's a leader among peers. And so, I think those are some elements of organizational development that can help staff feel like they have some control over their work life because they're just not showing up and being told what to do. They have an opportunity to inform the decision or make the decision as a group.

DR. SCHAAL:

Yes, and I think this is actually very pertinent because I just read an article this morning that the employment status of a physician, specifically, is changing. The majority of physicians were self-employed just a decade ago and now 76% of physicians are employed in some shape or form in a bigger, larger organization. So these organizations, including ours, the Houston Methodist Physician Organization have responsibility to make sure that this agency, this control, this guidance, I would say, of physicians still exists in order to maintain, really, the best performance and the best wellbeing and happiness of our physicians. So this is really pertinent. The second thing you talked about is belonging. And, you know, it strikes me. I'm an immigrant, right? So I'm kind of, "Okay, well where do I belong? And where is home?" I lived in -- Only the United States I lived in three different states, which are very different from each other. So, you know, where do I belong? Where do people accept me? Where do I find my voice? And I think in health care, we have people that come for the mission, right, of caring for others, for advancing science, for advancing health. People come from all over the world, and specifically to the United States, and specifically here to the Texas Medical Center. You know, we are attracting people from all over the world. How can we make sure that they feel that they belong?

DR. SWENSEN:

Well, thank you for that story and that's exciting to hear that. The, I think -- In large part it starts with the leader of the smaller groups. The CEOs are really important and probably the most important leader in any organization for the… wellbeing of staff and particularly the belongingness of staff is the immediate direct report. There was a survey that Gallup did in 155 different countries and -- across the world, different cultures. And across all those cultures there was the same basic answer. If staff felt that their immediate report leader cared about them as a person, cared about them as a person, they thrived. They were much less likely to look for a different job, to leave, to -- they're much more likely to be engaged and productive, and happy. And so, the behaviors and the culture that that group leader sets, which is in large part set from the CEO down, but most of the staff, docs and nurses, don't interact with the CEO as much in large groups. So it's that immediate direct report leader making sure that they feel, staff feel welcome regardless of phenome or genome or how many states they've lived in their last ten years or whatever. And that's really important. There are ways you -- There are other programs you can put in place or practices. One of the important parts of being a human and well is sharing conversations and meals with other people.

DR. SCHAAL:

Oh I'm a big proponent of food. And meetings over lunch, and food.

DR. SWENSEN:

Yeah. DR. SCHAAL: Yes. Okay, I'm glad you're saying that so when we publish this episode I can actually quote you. Let's talk about this effervescence, collective effervescence and this notion of harmony, energy. I think that's the easiest on your list because we are all driven by mission here in health care. I mean, people don't just choose health care as a career. They are somewhat, you know, deep inside passionate about it and feel very proud for making a difference in people's life. And sometimes taking care of the most vulnerable and the sickest patients that we have. Talk about how we propagate that shared purpose and really remind people what we do and not become, you know, not develop a callus around it. Thank you. I agree with you entirely. The -- This ikigai, this reason for being, this collective effervescence where we have this energy and harmony from working with other people with a shared purpose, it fits in this category of a calling with the work. And in health care I think, like you say, we have more of that intrinsic connection to the purpose at work than maybe other professions. It's also one of the -- It's one of those attributes of ideal work that can be eroded by misalignment of values with an organization or all the distractions that we put up with that weren't what you envisioned as this most meaningful job. So there're two things that I think are worth exploring here. One is when we look at drivers of burnout or moral distress, they vary dozens and dozens of ways depending on the individual. So the best way to find out about them is to ask them. You know, "What is your best day like, and what gets in between you and your best day?" And then you can address those systematically for that individual or the group. And it gets to this idea of job crafting and the literature is called job crafting, I like to call it life crafting. And it's basically -- First I was -- First learned about this when I was Department Chair and Chet Rihal was also the Chair of Cardiology at the time. And what He did when He visited with his staff on a regular basis, at least once a year he would ask them,"What brings you joy at work?" And everyone had an answer right away but most people came back, couple of them rolled their eyes, but most of them came back at their next meeting or in a couple weeks and said, "You know, Chet, I really appreciated that question. I thought about it and what really brings me joy at work is doing this type of surgery and this type of patient. Or, I love teaching, or I love my role as clinician investigator. Or I love quality improvement work." Whatever. And so, this encompasses the agency idea too where you have some control over your work life. What he would do and what the job crafting literature would suggest is that, well let's find a way that we can have you teach more or research, spend a little more time doing your research, or seeing this certain type of patient. And so, collectively the whole organization needs to do patient care, then we need to work on patience experience, we need to work on quality, we need to work on, you know, efficiency. We need to do elements of research and education. But everybody doesn't do -- So a clinician investigator, I was the same thing for my career. To have that balance it gives you some agency and, I think, increases your immunity to professional burnout. And so, what Tate and others found in a study of docs at Mayo was when a physician had spent about 20% of their time doing what they had self-declared as most meaningful to them, they had half the rates of burnout as doctors who weren't doing at least 20%. So -- and part of it is, you know, you actually change your allocation of what you're doing. Part of it's changing your perspective of what you're doing. And the third element or variable would be you could change with whom you are doing the work. And you have to be careful with that. But if I really enjoy doing research with you then let's figure out a way that we can do that together, and if I get to my 20%, I have half the rates of burnout of others. So job crafting is worth thinking about because then it's driven by individual docs saying this is what really brings me joy. And then as leaders we could help craft their schedules or change their perspective on how important the work they're doing is.

DR. SCHAAL:

And the forth thing you mentioned about ideal work environment, work place, is positivity. And I have to ask you, you know, in an era where health care is attacked and science is attacked, and on the other hand, the day-to-day life we have to take care of very sick patients. And, you know, sometimes we do our best and despite our best effort we are not successful, how does one maintain that positivity, that positive outlook, that sense that we're gonna be optimistic about the future? And more and more people would like to join us and, you know, become physicians, become nurses, become caregivers. How do we maintain that optimism as a profession?

DR. SWENSEN:

Well, two thoughts. So, I'll talk about Viktor Frankl then Carol Dweck. So, Viktor Frankl spent a couple years in Auschwitz, an unbelievably terrible place in the Nazi Germany concentration camps. And he saw that the people most likely to live were the ones that had something they were looking forward to, and that connected them with something meaningful and positive even if it wasn't until they got out of the concentration camp. And it turns out, we know, that ends up being true with epidemiology. But he observed that in Auschwitz. The other thing that he said in that regard is that they can take everything away except one thing, the last of the human freedoms to chose one's attitude in any given set of circumstance. So, this is something we all have control of in any set of circumstances. And the leader sets the tone of how terrible everything is or how good it can be. And yes, there are people who are disrespecting science and scientists, and research, and medical care. And they're a minority and we should focus on what we can control about the good stories, about the patients we helped. And I think the best way to keep the more positive work environment which is contagious within groups and between groups is by the leader behaviors of seeking to understand and appreciating and expressing gratitude, taking an interest in your career,"What do you wanna be doing five years from now at our hospital system and how can we work together for your dream to come true?" Fostering belonging so they could see that everybody on the whole team, the whole, beautiful spectrum of humanity is welcome and respected, and then transparency builds trust. So, the leader behaviors like that we studied at Mayo and other places now with over several hundred thousand responses. We started it in physicians and then scaled it to beyond that because it worked. Leaders that have those behaviors, their staff are more fulfilled, they're more satisfied, they're more likely to stay, and they have much lower rates of emotional exhaustion, professional burnout.

DR. SCHAAL:

So, something that dawns on me while we are chatting here is the importance of selecting the leader and then making sure that the leader, him or herself, are not burned out. Because sometimes you know, people seek, you know, leadership role, administrative role because they're burned out. And they say,"Okay, well I'm burned out from my clinical work, let me be a leader." Maybe we do not want these kind of leaders.

DR. SWENSEN:

Right, so I think that is -- that absolutely happens and we certainly wanna help those people but we wouldn't promote them to a leadership role if -- until they're well. So I think leadership selection, there are many ways to do it. I'll share with you one process that works. And it's not the only process that works but -- And so, I think that this model has the staff pick their own leaders in a co-selection process with senior leaders. And so, when Chet Rihal was selected as Chair of Cardiology the organization, doctors and -- outside of cardiology, met with every cardiologist one on one and asked them who they thought would be the best chair, two or three candidates, who would be the best chair to replace who preceded that person.

DR. SCHAAL:

And this is still the process at Mayo Clinic today? DR. SWENSEN: Still the process. And then the second question is, who would not be a good leader? Mm-hmm.

DR. SWENSEN:

And then they'd tally those up, those 100 interviews and the committee, it's a committee of doctors from other departments and administrators, to help out. And then they would get the top three that the staff said,"We have social capital with this relationship." And so they take three or four of the top candidates and then they would do a formal interview process with what's your vision and so and forth. They'd pick one and in -- So this co-selection starts them off on their right feet. The organization, those departments can already trust that leader and the organization says because they had a co-selection process, they say, "This person will also have an organizational view not just a cardiology view." And then the second element is there's a term limit. So no one at Mayo can serve more than 8 years. CEO, Department Chair, Dean. And every physician leader still practices medicine and they can do that because they have a dyad partner, a full time administrator, sometimes administrative team: finance, education, research, that helps in administrative and management tasks. And the physician -- physicians lead physicians and the physicians take care of the leadership aspect of that, and that allows them to lead as a team. There is a clear leader on that team and that's why they can still do surgery and they can still do, you know, bench research or whatever.

DR. SCHAAL:

Yeah, so, this is very unique to Mayo Clinic. I think it's not the case nationwide or worldwide. But one thing that we can learn from it is when we select or try to appoint a new leader over any part of our organization, it's really important to get the input of as many stakeholders as possible through interviews. And we want to attract, I think, not only our own people and make and appoint them, you know, and promote them, which we certainly would like to do, but we also want to attract people from the outside. But then how do we select? Who selects? I think that's, you know, everything that I hear you say point towards the importance of multiple stakeholders that are going to interview and are gonna give their feedback and their feedback is gonna matter. DR. SWENSEN: Exactly. So that's the principle behind it. Make sure I preface this, this is just one way. There are many ways that you can select leader and get out the principle of co-selection and feel like it was the staff that is to be led had a role in that selection process. The big picture goal is social capital. So you wanna build the trust and inter-relationship of all the people in the organization. And if they have some consultative role in selecting their leaders and those leaders listen to them authentically and connect them up over meals, connect them up over decision- making, then social capital grows and there's nothing stopping the organization. One question that I have to ask you about your recent published study,"Leading With Kindness," where you really developed a strategy for people to feel more satisfied in their work and have a meaningful career. And you put a spotlight on kindness there and you mentioned five kindness behaviors. What are those?

DR. SWENSEN:

So the idea behind the whole manuscript was to look at all the research that we know about organizational development and leader development and parse out the most successful systems and behavior, and structures, and processes that would drive us towards organizations with high social capital. It's driven by people respecting and wanting others to do better. And so it's that servant leadership idea of"I'm in this role to serve the staff that I have the privilege of leading so that they can best take care of patients and they're not there to serve me." And so that's the idea. And these fives behaviors are -- We measure them annually. Since 1981, we started our first all staff surveys and there're 12 questions about 5 behaviors that had huge impact in relationship with the wellbeing of staff, their satisfaction, fulfillment, and lower levels of emotional exhaustion, professional burnout. The five behaviors are not rocket science, they're common sense. And if they become common practice, one of the major elements of flourishing is in place for that. So, the five behaviors are first, seeking to understand. So, instead of -- If I know the answer about what we should be doing and I come in and tell the group, there's a -- We'll have a very different result than if we talk about it as a group and come to the same conclusion. DR. SCHAAL: Yeah. Basically listening, listening carefully. Okay. DR. SWENSEN: Yeah that's it. Yeah, listening carefully and authentically. The second is always looking for starting a meeting or weave it into gatherings, some element of appreciation of individuals or teams, and expressing gratitude to them in a way that is meaningful to them.

DR. SCHAAL:

Yeah, not forgetting that people actually work hard to deliver results. Great, what's next? DR. SWENSEN: Exactly. The mentorship piece, where you -- Each -- So the question that gets us,"Does my leader take an interest in my career?" And when you -- if you really care about someone as a person you'll be looking at helping them prepare for, have experiences with, develop for either another position or a different research project, or to be involved in quality improvement work. Whatever it is you -- whatever they would find most meaningful for their career to help them to work with them not do it for them, but with them. The fourth gets, basically, the belongingness. So leader behaviors are very important from body language to words, in having everyone feel accepted, and welcomed, and respected in those groups. And that basically, that's what drives the culture of an organization. And the fifth behavior is basically communicating with transparency. One of the most important things that we can do as leaders is to build trust. And if we open the books, then they can't say we're hiding anything from them. And we're building their respect by saying,"Here's what I know. Here's the information. Let's figure this out together." So this is fascinating, this leadership behavior that actually you track and you track for many years seeking to understand. Which means listening to people, appreciating people, mentoring people, and then accepting and respecting everybody on our team and then communicating, I would say, with honesty and transparency. That's wonderful. You know, I could talk to you all day. I'm learning a lot and really enjoying this but I have to ask you the last question on the podcast. Question that I ask everybody here, everybody that has graciously agreed to be my guest, and that is, what does quality mean to you?

DR. SWENSEN:

Quality has to be viewed through the eyes of the people we're serving, and so that starts with patients and the family. And so they own the definition of quality because they make the decisions about its presence or absence. I was a Chief Quality Officer at Mayo for the eight year term limit in 23 hospitals and I have a long definition. We had 110 metrics that we could measure about quality and safety. But at the end of the day, quality is what this patient with this background and these clothes and this medical condition or… sees and experiences. And so, if we start with the patient and work backwards from there in everything that we do then we will have the highest quality organization and we'll have the highest quality of staff. Because, we can't have the best experience, you know, comes for patients no matter how they define quality unless our staff is mentally, physically, socially, and spiritually well.

DR. SCHAAL:

Wonderful. That's a wonderful summary to this entire conversation. Thank you Dr. Stephen Swensen. I really enjoyed our conversation today.

DR. SWENSEN:

Yeah, I did too. Thank you very much. I appreciate it.

DR. SCHAAL:

And thank you for listening. Quality time is part of Houston Methodist's leading medicine series of physician led podcasts. So that you never miss an episode, subscribe to Quality Time. New episodes will download to your podcast device. If you enjoyed our conversation today please consider rating this episode and sharing it with your colleagues. I appreciate your support, thank you. And until next time, I am always listening.♪ ♪