EPISODE 352

Navigating Changes, Choices and Challenges Facing Med Students and Faculty - Dr. Kim Tartaglia of Ohio State University Wexner College of Medicine

02-15-2023

There are so many choices to make as an undergrad in med school: selecting which medical field to go into; whether to go down the academic path; and how to use your knowledge and skills to find success and create positive change in the world, to name a few. On today’s episode we’re going to hear from someone who helps students work through all of those questions and also assists faculty colleagues with adjusting to the changing medical education landscape. Dr. Kim Tartaglia does all of this wearing several hats at Ohio State University Wexner College of Medicine including Professor of Medicine, Director of the “IMWell” program for internal medicine residents and Director of Faculty Mentorship. “There are so many different ways to make an impact that there’s not one path to success and there’s not one path to be impactful,” she tells host Michael Carrese. Listen in to this episode as Dr. Tartaglia shares her perspective on how medical education has changed since the pandemic as well as how students and academic leaders are relating to each other differently as they work to improve the med ed system. You’ll also learn how she chose her specialty in med school, what drew her to stay in academics, how she established an enjoyable career in medical academics, and the benefits of attending OSU’s College of Medicine. And stay tuned to the end for an enlightening discussion of the role of lifestyle medicine in treating and reversing disease, and the benefits of coaching and mentorship for med school residents. Mentioned in this episode: https://medicine.osu.edu/

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Transcript

Michael Carrese: Hi everybody, I'm Michael Carrese. As the new semester gets underway, we wanted to turn our focus to undergraduate medical education to get a sense for how students and academic leaders are faring in this very complicated time to be in that environment. I'm delighted to welcome Dr. Kim Tartaglia to Raise the Line today to be our guide. Dr. Tartaglia is a professor of medicine in the Department of Internal Medicine at The Ohio State University Wexner College of Medicine, where she also serves as academic program director for the College of Medicine's med 3-year, director of the IMWell program for internal medicine residents, and director of faculty mentorship. She also serves on the council for clerkship directors in internal medicine. 

 

In addition to internal medicine and pediatrics, she's board certified in health and wellness coaching, and lifestyle medicine. Her research interests include undergraduate medical education, performance coaching and mentorship and physician well-being. Thanks very much for being with us today.

 

Kim Tartaglia: Thank you for having me.

 

Michael Carrese: We have a lot to talk about with all those involvements that you have. But let's start first with learning more about you. What first got you interested in medicine, and then, pediatrics? 

 

Kim Tartaglia: Sure. So, I had no experience with healthcare, my parents didn't go to college, no one in my family is in healthcare. So, as I was thinking about what to do after high school, I found myself in a guidance counselor's office, sitting there looking at books, and I knew I wanted to be in a helping profession but I didn't know within that. I knew I liked science, and so I was literally flipping through pages of what does a physical therapist do, and what is that training? What does a social worker do, and what is that training? I had experience as a patient to know what doctors did, but ultimately, went to college majoring in biology with a sense that I was leaning towards medicine and medical school, but really had to go in and do the work of figuring that out and learning more about it. 

 

So, I think I used college as an exploration time to figure out if medical school was right for me. And, I would say, 90% of the people that I went to college with either went to medical school, or they went to graduate school. And so, not being the creative type that would really thrive in a full research career, I leaned towards medical school.

 

Michael Carrese: When you were in med school, because a lot of students obviously struggle with this, how did you start to narrow down your options for specialty?

 

Kim Tartaglia: Yeah, so I went to medical school, I think, with a bend towards primary care, thinking family medicine, internal medicine, etc. I met a group of residents that were, seemingly, to me, the most compassionate, very intelligent residents, and they happened to be doing a combined residency in both internal medicine and pediatrics, or med-peds for short. To me, that felt like the best of both worlds. I could get robust training in adult medicine, as well as get robust training in pediatric medicine. Like I said, the role modeling that they did, without the intention, really showed me that they are the type of physician I aspire to be. That was the first time in my career where I felt like I had found my people.

 

Michael Carrese: Normally, does somebody with that combo go into family medicine as a practice?

 

Kim Tartaglia: No. You get board certified in both internal medicine and pediatrics, and you have really the full gamut of specialties within internal medicine or pediatrics available to you. Some do want to do outpatient primary care in both fields, and they may work with family medicine doctors, or they may work in a combined practice, or what I did is I went into hospital medicine. I did inpatient care for pediatrics at our local children's hospital, and I did adult care at Ohio State. I went back and forth from adults and pediatrics throughout the years.

 

Michael Carrese: Do you enjoy one more than the other?

 

Kim Tartaglia: No, I think I enjoy them for different reasons. Pediatrics is really refreshing. In the hospital, I tend to have younger patients. So, it's like a bimodal curve actually. The types of kids who get hospitalized are the babies and the young toddlers or the adolescents, and they get hospitalized for different reasons. When I take care of adults, it's a lot of more complexity; chronic disease, severe illness. They use different parts of my brain, they use different parts of my heart. I appreciate the opportunity to have that variety.

 

Michael Carrese: That's a great way to put it. So, the other choice in front of med students is whether to go the academic route or not, and you obviously went the academic route. Do you remember what your thinking was about that? When did you sort of solidify the sense that that was the right path for you?

 

Kim Tartaglia: I think there's probably a bias in medical education training towards the academic route. It's what you see going through residency for the most part. I saw I was in an academic center for my residency, and so that was what I was surrounded with. For me, I think it was kind of like the default mode, especially because I thought that, one, being around a robust training environment would help keep me a strong clinician, but it would also give me the opportunity to teach, to do the quality improvement work I loved, and then, continue to grow as a professional. 

 

And so, I was really drawn to that academic side of things, although if I had wanted to live in an area where I could really serve the underserved in a private focus, I think that would be equally fulfilling. But for me, the academic route was available. I think med-peds is a little bit of a niche field in that it's not accessible in all geographic areas and in all practice environments. One of the places that it tends to be more readily available is the Midwest in academic environments. I think that's probably also what drew me to staying in academics.

 

Michael Carrese: For med students that have the concern about an academic career -- where they've got to do clinical practice and research and teaching, and all of that -- and worry about how they could juggle and manage it all, what are your secrets to success in that regard?

 

Kim Tartaglia: Yeah, I think for healthcare learners in all areas in medicine and nursing and all the other areas, what I've learned throughout my career is there's so many different ways to make an impact that there is not one path to success, and there's not one path to be impactful. For me, clinical research or bench research was not really what sort of drove me. I was able to find academic opportunities within medical education and educational research, as well as within quality improvement and patient safety research. 

 

So, those were the areas that I tended to focus on. They were most meaningful to me. I felt like I had some skills to provide and really was able to develop a career in those areas. For any learners out there that are thinking, “Well, I'm not also interested in medical education,” perhaps you're interested in social justice, or patient advocacy, or a whole host of a number of topics where you can develop a career. I would encourage you to just really think broadly about what it means to have an impact, and we don't need to be so narrowly focused on doing research and publications as the only pathway to success.

 

Michael Carrese: Before we get into some specifics on the various roles you play at OSU Wexner, can you give us an overview of the school itself and what you think are its particular strengths?

 

Kim Tartaglia: Sure. So, I'm at Ohio State University in Columbus. I consider it a fairly large public university, generally speaking, but also, the medical school is rather large as far as medical schools go. We have about 800 students, plus dual degree students. That I think presents some challenges, but one of the strengths is that OSU really tries to make it feel small for the student experience with a lot of personal touches to faculty -- and whether it be in small groups, or one on one -- a number of different programs for learning and for mentorship are really built into the curriculum. So, I consider that a strength. 

 

Also, about 10 years ago, we embarked on a major curriculum revision, at least, implemented it, and it really shifted the focus from not just two years of book learning and then two years of clinical learning, but really integrating early clinical learning six weeks into the curriculum, integrating service learning through community health projects through health coaching, and through their preceptorship. I think it's that combination of things that it's not ‘either, or,’ it's not studying the books or studying the patients, but that we have to integrate that, and that the physician of today and tomorrow needs a broad set of skills in order to help make this healthcare system work. Acknowledging that, and implementing that directly into the curriculum, I think is one of our strengths as well.

 

Michael Carrese: So, as I noted at the beginning, it's an incredibly complicated time for healthcare providers and for medical educators. And with the pandemic not completed, but let's say, with it mostly in our rearview mirror at this point, what's your assessment of how medical education came through that and where things stand today?

 

Kim Tartaglia: I think that a lot of medical education has been changing, like I said, in the last decade or so...this need to look in and innovate and rethink how we do medical education. I think the pandemic accelerated a lot of that even if you weren't quite ready. So certainly, it’s about the delivery of content, the delivery of how we do things and figuring out what things can be done virtually, or asynchronously. But, at the same time, it was not just one pandemic. It was also a pandemic of accessibility for patients, it was a pandemic of social justice. We were grappling with all those issues, so we see a lot of calls coming even from students to say, “We've got to address these topics, we can't pretend they're not there.”

 

A new anti-racism taskforce, social determinants of health, environmental justice and social justice are, I think, themes that have emerged over the last couple of years since the pandemic started that we've been grappling with how to incorporate them into our curriculum. As you said, there's so much there, and so, how can we fit these all in and give the basic science the due that they need -- that foundational science component -- but realize that these other topics are also foundational? I think we're still grappling with that. 

 

There is a nice paper written by Lucy et al, last year in Academic Medicine calling for like a ten-point plan over the next ten years to say that the pandemic exposed a lot of fault lines in the medical education system, and we can take the opportunity to look at those and identify what was exposed and how can we address it moving forward.

 

Michael Carrese: So, what are some early steps for addressing that? Because that is a lot to kind of add to the plate. 

 

Kim Tartaglia: So much of medical education, I think, has been a lot of facts and a lot of faculty being able to present research. Seeing what we can pare down on the bread and butter knowing that concepts are more important than facts, facts may change, or the details of what we know about them may change. So, where can we leave space for these discussion topics that if we don't address, then students are left worrying about them and wandering on their own and spending a lot of energy thinking and learning about them outside of the curriculum. So, why not find space for them in the curriculum? 

 

Our focus is to bring more clinical experiences into the first eighteen months of our student's curriculum. It also means bringing some foundational sciences back into the clinical part of the curriculum. And so, just this week, we're launching a new session on how to care for incarcerated persons because at Ohio State, we do have people who are incarcerated and students may be engaging with those patients, so having a formal curriculum on that is something that we found some space for. 

 

We've also found space for a social determinants of health session. It's one thing to have it in the first two years when you're doing mostly classroom learning and a little bit of patient care, but it's another thing to revisit it when you're seeing patients every day. We found that the students are very hungry for that type of learning. They don't necessarily need or want another lecture on asthma, and there's other resources where they can refresh. Let's have a discussion about how we get healthy food to our patients who have food insecurity. So, yeah, we're making space for it, and really trying to trim down stuff that maybe we don't need to revisit for the third time.

 

Michael Carrese: Aside from that bucket of issues that you just outlined, are there other expectations that have changed on the part of students? Are there other things that they're looking for?

 

Kim Tartaglia: Yeah, I think that's been brewing for a long time. But students, especially when they get to the clinical part of their training, it can feel at times more like a job than school, and struggling with where are their places on the clinical teams? Are they a crucial component of that team? Do their supervisors make them feel that way such that they're engaged and want to be there, or do they feel like there's parts of their day that are wasted, and they'd rather be spent studying from a book or studying from their notes? 

 

So, we're seeing, I think, students just be more vocal advocating for themselves and their time such that we really have to, I think, be able to justify the time that we're bringing them into the in-person learning. It has to be meaningful for them, where they’re not only learning, but they feel like they're helpful. If we can't do that, then we have to rethink if it makes sense to have them in the hospital six days a week mirroring the resident's schedules, or was that a relic of previous times that we can rethink?”

 

Michael Carrese: Speaking of previous times, I'm just wondering to what extent you think this represents a cultural shift...the idea that instead of just going to med school and following the program, that there seems to be more of a two-way street here: more receptivity on the part of the leadership and faculty towards students; and students also feeling more empowered to speak up about it?

 

Kim Tartaglia: Absolutely. I think we have felt that at OSU for the last decade, in part because when we launched a very innovative, disruptive curriculum, it opened the door for students to give feedback about what innovations they thought were useful and which ones they were questioning.  I think sometimes students just wanted it the way it was, but many students have really embraced it, and actually, used that to catalyze. Again, a lot of our initiatives about bias, and how we calculate estimated kidney function in patients of different ethnicities, for example, they are initially student-driven. So, we are seeing students as wanting to be partners in their education, very open to not only giving feedback, but coming up with solutions. I think that's been a fun part of it. 

 

I think the other thing we've been seeing that's a little bit more worrisome is just the level of burnout and anxiety and depression in students.  A study from the late 1980s said students came to medical school no more burnt out or depressed than the general population, but then, they became that way suggesting that medical school made them that way or contributed to those developments. But I think that students are coming, perhaps...the general population is more stressed…

 

Michael Carrese: Oh yeah. There’s much more of that.

 

Kim Tartaglia: ...or more burnt out than ever before, or that student population is because it feels like they're coming to us with much less reserve and resilience to deal with problems. Perhaps that's the pandemic impact to some extent, but I do think that the other thing that we're balancing is acknowledging -- when students are giving feedback -- is it coming from a place of anxiety and burnout, or is it coming from a place of an opportunity to be more innovative to change and to listen to them? I think there'll be a tension we deal with forever, but it's something I've noticed and felt more intensely for the last few years.

 

Michael Carrese: I know you're also concerned about competition increasing in the med-ed landscape, tell us more about that.

 

Kim Tartaglia: This generation of students coming to us has had competition at a higher level than I ever, or my parents, had. And it starts when they are rather young children. As I see them getting into middle school and high school, I see the levels of competition and the expectations put on high school students and university students and beyond. So, I think they've come and they've been living their whole lives this way. It's almost second nature to them to be competitive, to worry about every little thing and how it might impact their future career. 

 

Medical students and healthcare students in general are very driven students. So, it's almost like we're at a tipping point where it's maladaptive, or it has been maladaptive, but it comes to a head in medical school. It's pushed medical schools to be more attuned to that, to increase our Student Affairs presence, to increase our well-being program. But I do think we have to acknowledge that if students are coming to us way more stressed out than they had in previous decades, then adding a little bit of programming here and there is a bit reactive. I think that we need to take a look at studying this more rigorously and deciding that we have to acknowledge there's a difference in medical students of today and healthcare students of today, and to be more proactive in what their needs are and how we can help them get through what could be a very stressful training period.

 

Michael Carrese: So, tell me more about the IMWell program for internal medicine residents. It sounds like that would kind of be along the same lines.

 

Kim Tartaglia: Yeah, so it's similar to wellness programs they have in colleges of medicine for students, but this is geared towards internal medicine residents. At the graduate medical education level -- knowing that residency is a huge increase in stress and work hours and responsibility -- many residents are prone to feeling burnt out, having anxiety, depression, etc. It’s just really meant to be proactive and explicit in our programming to keep residents well more holistically. 

 

We do things like we have sessions to learn about topics like fatigue, or substance use, depression, mental health. But we also have social events. We have a couple of retreats coming up for our residents. They'll have workshops. It's also a place to say, “Where is the system working for you, and where is it not?” So, when I think about wellness for our residents, I think about there's professional well-being, and there's personal well-being and we could create programming and curricula and opportunities to learn more about that, and for individuals to address that. 

 

But, at the same time, we have to address the system and the culture. For example, lactation spaces in the hospital for residents and women who need a place to do that after they've had a baby...figuring out how we can advocate for them to have a system that works for them so that they can get their work done and not be disruptive to their patient care, yet, continue to pump and feed their baby. And then, it's also the cultural part of it: that attending physicians won't negatively react when a resident needs to do something like that, or needs to take an hour off to get to a mental health appointment, for example. My role is to look at all four of those things and to simultaneously help the program address those.

 

Michael Carrese: Do you think, and this is probably too broad of a generalization, but that among the older faculty who perhaps were trained in a more stoic culture -- you just push through and it's all about the work -- do they need some education about how to be more flexible and aware of these other dimensions to the student experience?

 

Kim Tartaglia: Yeah, absolutely. I think they need residents who are in a good space and can advocate for themselves very well, and that is a good learning opportunity for those older faculty who might acknowledge that it was different when they trained, but they can appreciate that maybe this is a better way. I think we've had a very good response to that. But there's another side: for residents or learners who don't feel confident enough, aren't in a good space to advocate for themselves, they need someone to advocate for them. And so, that's where I can step in, or program directors can step in and advocate for them and be the bridge so that if it's going to be a tough conversation with a faculty member who's a little more resistant, the resistance is aimed at me as opposed to the resident who might be struggling. Definitely, a lot of education. It's also a lot of positive role modeling. Then, honest conversations when negative role modeling happens.

 

Michael Carrese: Now, you mentioned mentorship before as a hallmark of OSU Wexner’s medical education. Can you talk some more about how you utilize mentorship? And I also know you have a strong interest in coaching, so maybe you could break down the differences between those.

 

Kim Tartaglia: I think coaching and mentorship, while they may ultimately have the same outcome, they're a very different process. One of the main benefits they provide is that personal connection. It gets a learner, or someone who needs something, connected with another person one-on-one. I think if it's well-matched personality-wise and value-wise, and it's a positive relationship, I think that is really, really beneficial for all levels. 

 

A lot of the mentoring I do is for faculty at this point, but we do have mentoring and coaching programs for our residents and our students. I think when I mentor someone, I'm there to provide perhaps some experience, some wisdom, and to help them with something in the system. So, navigating a quality improvement process to get data, for example. When I was mentoring a faculty member the other day, I took on more of a mentorship role and I could talk her through, “These are the steps we have to take. I can help you get access to this. I can help you break down barriers and be someone to bounce ideas off of.” 

 

As opposed to when I'm coaching someone, it's really more of a coachee-driven process where they're defining the goals they have, what they're trying to achieve, and I walk them through: how are they going to achieve them; how are they going to address the barriers; what's going to motivate them when they're feeling less motivated? And they're coming up with all the answers. I use that really quite heavily when we're thinking about behavior change in someone, whether it be professional behavior change, or with a patient, kind of a personal behavior change. 

 

I think the mentorship has really always been there in medicine, but coaching has not always been there, so that's something we're advocating for at multiple levels. All of our students get a coach, and that coach has eight students that they meet one-on-one with every six to eight weeks, all four years of the curriculum, and they're available in between, of course. But then, when you get to be a resident, or you get to become a faculty member, there is really no coaching program at our institution right now. It's what we're working to develop so that if you need something more of a coach, either short-term or long-term, that you have access to those opportunities.

 

Michael Carrese: I know that one of the other things that you're interested in is lifestyle medicine, and perhaps you could give us a definition of that and also talk about what role that plays in making practicing medicine more enjoyable.

 

Kim Tartaglia: Lifestyle medicine is a field of medicine that really takes the evidence-base behind lifestyle behaviors. They have six pillars: nutrition, exercise, sleep, avoidance of risky substances, stress reduction, and emotional health and community. Looking at those six pillars, and saying, “What is the evidence to not only prevent, but also, treat and reverse disease? It’s taking the field of scientific inquiry that we should have access to in medicine, but perhaps, have not given due attention to, and saying, “How powerful are these things in preventing, treating, and reversing disease?” 

 

It's gotten a lot of steam in the last five to ten years. It's not something I knew about when I was going through my training, or even the first ten years of my faculty career, but I think it's a really exciting opportunity for us to revisit and get back to the basics. There's a wonderful cartoon that I think of every time I think of lifestyle medicine, and it's two men mopping the floor. If you scan out a little bit, you see that they're mopping the floor because a sink is overflowing, and the faucet is turned on full blast. And so, lifestyle medicine is going up there and turning off the faucet. 

 

Michael Carrese: Go upstream.

 

Kim Tartaglia: Yeah, going upstream, exactly, to the root cause and turning off the faucet. While acute care medicine can mop up the floor, lifestyle medicine helps reduce the need to mop up the floor by getting to the root cause.

 

Michael Carrese: Now, is there a connection between the rise of this and the rise of awareness about social determinants of health? Because it seems like there's some overlap there. In other words, if you know that food and nutrition is important, then you’ve got to start asking questions about what the obstacles are to this patient having a healthier diet?

 

Kim Tartaglia: I agree, there's a great overlap. In the American College of Lifestyle Medicine, they have a subgroup called HEAL. Achieving health equity through lifestyle, essentially, is what it means. But it's acknowledging that there's this structural racism that's in medicine that comes from not having access to healthy lifestyle, whether it be green spaces, safe outdoor places to walk or exercise, access to healthy food, food deserts. Those all, I think, play a role into the chronic disease burden and how it plays out into communities of poverty or communities of color. And so, absolutely, I think you can't talk about lifestyle medicine without connecting them with the social determinants of health.

 

Michael Carrese: So much change, but so much of this seems to be heading in the right direction, if I could put my two cents in. (laughs)

 

Kim Tartaglia: Yeah, absolutely.

 

Michael Carrese: I know there's a whole other constellation of problems with how health systems operate, and hospitals operate, and insurance and all the rest of that, but in terms of preparing students to become doctors, it seems to m the consciousness of all these things is going to serve them well.

 

Kim Tartaglia: Yeah. I think the more tools we can have in our tool belt to help patients, the better. Not every patient is ready for behavior change, for example, and that's a huge part of lifestyle medicine. Until they're ready, we may have to rely on some of our conventional tools in medicine. But for those who aren't, I'd hate to presume patients aren't ready, and not have the conversation with them about how powerful these things can be.  I think that's the thing that was missing in my education, and I think is still missing. If you have the skills to have that conversation about behavioral change: motivational interviewing, helping them break down those next steps, getting access to whatever they need -- whether that be a social worker or a nutritionist or access to inexpensive healthy food -- that just expands your opportunity to treat patients.

 

Michael Carrese: Plus, if they're operating in a population health environment, it's also important for them to be focused this way too, right?

 

Kim Tartaglia: Yeah, absolutely. I think that the opportunities are endless whether you think at the individual patient level, or you think on the population health level. Any and all between, there are opportunities to improve health.

 

Michael Carrese: So, as you probably know, Osmosis is a teaching company, and one of our favorite questions is to ask our guests to give us some direction and pick a topic -- it could be related to what you do or could be totally unrelated – and say, “I wish people knew X.” What would that be?

 

Kim Tartaglia: I think, looking through what Osmosis produces, you've got a number of great resources, but educating about the pillars of lifestyle medicine, I think, is one opportunity because that's something that's needed by all types of healthcare workers at all levels in medicine. There's a huge gap. Pick any pillar of lifestyle medicine, and there's an opportunity to focus more on that. And the same with health coaching: what are the skills and the steps of health coaching so that you can walk a patient through a coaching conversation who's ready to make some change? We talk about it with smoking cessation in medical school, and then we stop, and we sort of pretend like it doesn't exist outside of smoking cessation. So, how can we expand that and do that for any type of behavioral change?

 

Michael Carrese: So, that's like the motivational interviewing and that sort of thing?

 

Kim Tartaglia: Yeah, exactly. Not only assessing where a patient is, but having the conversation about meeting them where they are and what are their next steps. Some of it is getting to know our patients at the level of, like, what's important to you? What's going to motivate you? What do you want for your life? Do you want to be able to play with your grandkids on the floor? Well, that would require some more physical mobility. 

 

So, it's like starting there at that vision of what they want, and then walking backwards to say how do you get there and having them come up with the solutions and supporting them through that. It's a skill set that I think we don't talk enough of. I know doctors are limited in time to have this conversation with every patient every time, but there are times when you would, again, want to pull it out of your tool belt because it'll be the most impactful thing you do.

 

Michael Carrese: Right. We’re almost out of time. I wanted to give you one last shot at advice for our audience of learners and early career professionals. You're dealing with students all the time, what are your sort of go-to pieces of advice?

 

Kim Tartaglia: I think it depends on the level of learner, but I definitely encourage students to trust themselves and to trust what they think is right, and to not succumb to maybe the anxiety or the chatter of what they need to be doing or what they should be doing. Trust your gut on what you internally think is right, and then really spend a moment to think about your interests and your strengths and your values, and use that to align with your ultimate career path. What are your next steps in your career? What residency are you going to? What type of training program? Is it urban? Is it community? And then, what do you like to do outside of direct patient care? 

 

All of those should be informed by your values, your interests, and your strengths, and you should expect them to change.  Obviously, I haven't been interested in lifestyle medicine my whole career, and I've shifted from quality improvement to more medical education focused, and now health coaching and mentorship and lifestyle medicine. That expectation that your interests and your strengths will change throughout your career is to be expected. Being open to that, and willing to sort of let your career go where it takes you, I think, is one of the hallmarks or one of the protective factors against burnout and to having a purposeful, really enjoyable career in medicine and healthcare.

 

Michael Carrese: That's great advice. Really wonderful. I really appreciate you being here today to share all of that with us.

 

Kim Tartaglia: Thanks. It was great talking with you, and thanks for having me.

 

Michael Carrese: Sure thing. I’m Michael Carrese. Thanks for checking out today's show and remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.