Intro: Welcome to the Peds Ethics Podcast where we talk to leaders in pediatric bioethics about a hot topic or current controversy. And now, here's your faculty host from the Children's Mercy Bioethics Center in Kansas City.

Stephanie Kukora, MD (Host): Welcome to the Pediatric Ethics Podcast Series sponsored by Children's Mercy Bioethics Center at Children's Mercy Kansas City. I'm your host, Stephanie Kukora, a bioethicist and neonatologist here at Children's Mercy. And today, I'm speaking with Dr. Tanya Arora. Dr. Arora is a physician in pediatric palliative care, consultant in bioethics, and leads efforts to improve health equity through educational and clinical efforts to strengthen skills in communication, cultural humility, and partnership with patients, families, and communities. She works at Children's Hospital Los Angeles. And most of her work is influenced by previous experience in global child health in resource-denied health settings. She has expertise in bioethics, completing the Children's Mercy Bioethics Center Certificate Program in Pediatric Bioethics in the 2021 to 2022 year.

Thank you so much for speaking with us today. First, I am super excited to talk to you about this topic today. For folks listening, Tanya and I are both trained facilitators in medical improv, or the use of improvisational theater techniques to teach communication skills for healthcare clinicians. Tanya, could you start a little bit by telling us more about the concept behind medical improv and how it can be helpful addressing gaps in communication education for bedside clinicians?

Dr. Tanya Arora: Yes. And Stephanie, we've partnered so much on thinking about improv together. So, please jump in if I leave something out or add something and, actually, maybe that gets us to why improv is so helpful in medicine, because it really is about teamwork. So, it's that idea of I come with my ideas, you come with your ideas. And together, when we combine them, it makes for a better idea, a more expansive idea. And partnership is such an important part of how we practice in medicine, whether it's partnership with patients, partnership with their families, partnership with our colleagues. And improv sort of allows you to operationalize those skills of partnership in your body, in your voice, in the way you interact with each other, and also in a way that we don't get to practice a lot when we're in medical school or in residency training.

Host: Yeah, I love that. I think I'm really drawn to it because in real life, these conversations are so hard to guess where they're going. And having practice with sort of flexibility feels like the right way to go into a lot of these complicated conversations.

Dr. Tanya Arora: I agree. And I think so often people hear improv and they think of comedy, like Saturday Night Live, or Whose Line Is It Anyways, which is definitely improv. But improv isn't necessarily about being funny, it is about being authentic. And you're right, in these serious conversations, sometimes I think as healthcare practitioners, we're a little afraid to bring our full selves or our entire humanity into those conversations when in fact that might be the exact thing that's required.

Host: Yeah, absolutely. So, tell me a little bit about your story getting involved in medical improv. What drew you into this and what was your path in pursuing it?

Dr. Tanya Arora: I can tell you it's a little bit of a strange story. So, I had turned 40 and had a mid-career shift towards practicing palliative care. Prior to that, I was working as a hospitalist and I was really active in global healthcare. I went into palliative care because I wanted to be a better listener. And in that mid-career level, you also get asked to teach more and talk more. And I am terrified of public speaking. And so, I was sitting in my therapist's office and I picked up a magazine. And in it, this woman told her story of how she had sort of like a midlife crisis in her 40s and decided to take an improv class. I live in Los Angeles. It seemed like everything was intersecting. I was turning 40. I live in Los Angeles. I was afraid of public speaking. I had read this article. I thought, "Oh, maybe I should take an improv class."

On our palliative care team, I'm really lucky to work with a social worker named Rachel Rusch, and she is a trained actor prior to being a social worker in palliative care. And I said to her, "I'm thinking about this thing, taking an improv class. Do you have any ideas?" She got very excited, referred me to a class. I took a class with a bunch of 20-year-old aspiring actors. And I loved it. The class was on Tuesday night, and I would come in to work on Wednesday morning and I would say, "Everything we just did in class yesterday, all the exercises we do, I feel like that's what we do when we go into patient rooms." and because Rachel is such a wonderful partner, she said, "Absolutely. That's exactly what happens when we go into patient rooms." And then, we started talking about it and then started thinking about how we could apply improv into our clinical work.

And then, I took a course with the great Katie Watson at Northwestern, who offers a course every summer for a week, where you really hone skills in medical improv and do exercise after exercise after exercise with a group of people who are as excited about medical improv as you are. And that's where I really found a lot of partnership in thinking about this work and how it applies to medicine.

Host: So awesome.

Dr. Tanya Arora: Stephanie, can you say your improv origin story? Because I don't know it.

Host: Oh, funny you mention Katie Watson. Although I think we should acknowledge that she truly is the person who really pioneered the idea of medical improv. But I was actually at the American Society for Bioethics and Humanities meeting, I think when I was a senior fellow. And for some reason, I decided not to go to the Neonatal Ethics session that I felt like I probably should have gone to, but like this other session sounded really interesting.

So, I wandered in, and Katie Watson was presenting on the decade of experience she had had teaching medical improv to her medical students. And for everyone in the audience, she had us do a brief exercise of Yes And, Yes But, and No with a partner in the audience. And then, she debriefed it, and she kind of explained that, if you don't know the difference between yes and, yes but, and no, you're not going to be a very good clinician. You might feel like you are supporting, you know, your patients by saying yes. But then, when you say but, it really diminishes their viewpoint. It really changes the conversation that you're denying them. And I was like, "Oh my gosh, what if I'm a bad clinician?" Because I didn't really realize that I was doing this. And I was like, "Wow, like this is great." And also, I felt like so much of the training we do around communication just feels so inauthentic. The standardized patients are great practice, but you go in and you sort of know that it's not real, and you have to have a pretend conversation with a pretend patient, like you imagine a doctor and patient should have this conversation because you're being graded, like they have a script and you have this imaginary good doctor script.

And so when I managed to run into Katie again at a subsequent conference about about a month later, I want to say, where she was speaking on her real job, which is actually like Abortion Ethics. And at the cocktail party, I followed her around until I caught her alone, which I'm pretty sure was in the bathroom. And I was like, "I really want to learn more about medical improv." And she was like, "Oh, thank goodness you're not here to yell at me about my abortion views." And, I got signed up and did the course later that year and just thought it was really, really great. I brought it back to where I was then at the time, University of Michigan, got a small grant to pursue it, and started doing it with all kinds of learners. So, that's kind of my backstory. But I'm asking you the questions.

Dr. Tanya Arora: I will say that Katie Watson and Tina Fey are probably like my biggest role models in how to be good communicators. And it is, I think, because they apply improv principles to everything that they do.

Host: Yeah. No, it's amazing to have gotten to learn from Katie. And I'm pretty sure that she did a previous podcast on abortion ethics. So, if you're listening to this and you're like, "Wow, she's an amazing improviser," you can also look back and hear about her sort of more real job as an ethicist too on this podcast series.

All right, Tanya, are there spaces in medical education that you see improv complementing or even replacing some of the conventional teaching methods?

Dr. Tanya Arora: Yes. As you were talking about your own journey through improv, I was nodding along, even though you all can't see that I was nodding along. And you had said that a lot of the strategies that we use for communication don't feel as real. They feel structured and scripted and you know that you're supposed to role play. And improv is not that. There is a structure to improv in a framework, but it's not scripted. And so, improv sort of requires you to bring yourself into the interaction as you are. And I think In medical school training and in residency training, we do a lot of squashing of who people are, as if the reasons that they brought them into medicine sort of need to be shaped and structured into communication tools that we have approved of in medicine. So like sit down, make eye contact, ask your patient this question, then this next question. I sort of think about it like when I was a medical student and I learned to do a neuro exam and I always started like cranial nerve I, II, III, IV, and I went in order. And what an awkward physical exam that was that I had to go from like the top of the head to the toe.

And over time, I learned, "Oh, I will go in an order that feels natural for me and natural for the patient." I mean, especially working in pediatrics, you listen to the heart when you get a chance to listen to the heart. And it might not be right after you listen to the lungs. And I think improv does that too. We give medical students and residents all of this scaffolding, all of these communication tools. But then, we really need to allow them the space to make it their own, authentic to themselves, and remind them of the very reasons that brought them into medicine in the first place. All those things that they wrote about in their personal statements, that actually is the thing that is needed by patients and families in those moments. So, how can they take everything that they've learned and then sort of push it aside to make space for them as themselves to come into that healthcare interaction? So, I think that's where improv replaces maybe-- not replaces, but complements existing medical education tools is in reminding folks that there is something really special and unique that has brought them to healthcare and how do they bring that compassion, that empathy into the interaction.

Host: Oh, that's so well said. I feel like too, there's like an issue, exactly what you said, that a lot of these communication techniques are like, "Here's the structure for how to do this. Here's how to have this hard conversation correctly." But in real life, there's not really a correct. And when you sort of start down , that framework or that path that you feel like, this is how this conversation should go. And a family totally throws you for a loop, then you have to backtrack and say, "Okay. This is clearly not the conversation that they're having. So, I better get on board with their conversation because they're not getting on board with mine." And I think having the skills, not only to sort of know what could these conversations look like ideally, but how to redirect if it's just not going to go that way is really a key piece.

Dr. Tanya Arora: Yeah, how to pivot. Or even in improv, we would call it how to receive the gifts that are given to you. So if you go in and you say to a patient or a family, "I'm thinking that the plan should be this," and they say, "Well, I was thinking that the plan should be this." How do we receive that difference as information, as a gift, as something to build on together? Because oftentimes, I think in medicine, because of the way the hierarchy is, we feel that we need to figure it out and then present something to a patient or family. But I learned really through my global health work and then re-emphasized through improv that the people closest to the problem likely have done the most thinking about their problem, so likely have the best solutions to their problem. They may not have the resources. They may not have the language to be able to access the solutions, but they likely have really good ideas, both about the problem itself and how to solve for the problem. And so if we allow space for patients and families to change our plans, to co-create plans together, we probably result in a better plan of care than if we just try to figure it all out on our own.

Host: Awesome. So, how are you using medical improv at your institution and beyond? What learners and what skills are you targeting? Please tell me a little bit about that.

Dr. Tanya Arora: I found improv to be really helpful in teaching communication and, in particular, in teaching communication across different lived experiences, so really around that idea of partnership. I use a phrase when thinking about improv in these teaching sessions and particularly using Improv to figure out how to provide more equitable healthcare, is that we are 100% responsible for 50% of the interaction. And when I say that, what I mean is, as clinicians, we want to bring 100% of ourselves into the interaction. Be fully present for whatever that interaction is with a patient, with a family member, with a colleague. So, bringing all of ourselves into that interaction and also, leaving 50% of the space for your partner, whether that be the patient, the family member, or your colleague to bring 100% of themselves into the interaction. So, improv is a partnership between two actors, and healthcare is a partnership between two people as well. And so, how do you be fully responsible for bringing all of yourself and fully responsible for creating space for your partner to bring all of themselves into the interaction. So, 100% responsible for 50% of the partnership.

Host: I love how you phrased that. So, how does the work that you're doing in improv tie into your own clinical practice?

Dr. Tanya Arora: It started with really using improv in palliative care. So, palliative care can be such an intimidating topic. It is serious conversations and sensitive conversations. And I work in a teaching hospital. So as you're teaching residents and fellows to enter into these spaces, it can feel really weighty. Improv does not feel weighty. And so, Rachel Rusch and I initially used improv to teach primary palliative care skills. So, how do you enter into these conversations being authentic to yourself and allow for patients and families to share their lived experiences, their hopes, their worries in conversation with the healthcare clinician so that you can come up with a good plan of care together?

 So, we started that way. And then, as healthcare became both post George Floyd's murder and during the COVID pandemic, I think healthcare in general became more aware of racial and ethnic inequities. And because of my background in cultural humility and learning in global health and my interest in child health equity, we started to think about are there ways in which these same improv exercises can help us communicate when we have a different lived experience with patients and families, and how do we talk about difficult topics like bias and discrimination and recognize challenges and limitations of our own perspective? Can we do that through improv?

And so, maybe it helps if I give an example. There's an exercise by Dan Sipp that we have borrowed and adapted, where what he does is he asks people in this exercise to pick an emotion. And one partner picks an emotion. They don't say it out loud, but they pick an emotion. And the person that they're paired with has to guess that emotion. And the only information that your partner has as they're trying to guess your emotion is you say the word, displaying that emotion. So for example, I'm a woman of Indian descent, and oftentimes I will pick for myself the word angry. And so, in the word hello, I have to, with my body language and my voice, depict the word, how I'm feeling when I feel angry and then say that in the word hello. So, I might say hello, which to many people doesn't sound or look like anger, but it is when I'm feeling angry, that is how I sound. And that is if we were together or if you could see my face, looks quiet and serious, but not necessarily maybe what you would think for anger. I also think that folks don't expect maybe a person who looks like me on the outside to have anger as a primary emotion.

And so, if I'm paired with someone, they might say back to me, because I'll say, "Hello," and they might say back to me, "Hi, Tanya. You seem serious." And then, I'll try it again. I'll say, "Hello." "Hi, Tanya. You seem worried." And I know that my anger isn't being received. And they also know that they haven't guessed the emotion that I'm trying to depict. And we go back and forth a couple of times. And then in the debriefing, I can ask the question of, "Does anyone have any thoughts of why it was challenging to guess that I was displaying angry?" And in that conversation, oftentimes bias will come up. "We didn't expect you to have anger in our emotions that we were thinking of as associated with you." It's also information for me to know that it's sometimes hard for people to read my anger as anger. And so, exercises like that, that we've put a little spin on really to have a longer discussion about our own healthcare clinicians really pride ourselves on our emotional intelligence, but we aren't always going to get it right. And so, to have this space to sort of play around with that and see where do we get it right, where do we not get it right, where are our biases leading us in the wrong direction, or giving us incomplete information. That's been really helpful.

Host: I feel like I've played this game with you and that I definitely did not get anger right when I was guessing for you. So yes, you know, it is really important to see how people interpret your emotions, I think, because even as a clinician, I've had patients who felt like I was angry at them and I am just, you know, stressed for time because I've got to see 50 more people in the next hour, you know, and do all these things and write all the notes. And I try to be conscious of that. But yeah, I think, learning to understand what your body language, voice, you know, what those cues are and how they're interpreted by other people is so important.

Dr. Tanya Arora: Yeah. And oftentimes. You know, anger is also a totally acceptable emotion, but naming it can be so helpful. So, I've used that exercise in clinical care when I've been with a family that it could be a room that I walk into and I'm just meeting the family for the first time or it could be a family that I know really well and I might name, "I'm picking up this emotion. It feels like frustration, but I don't know if I'm getting it right." And in that moment, it invites the family to say, "I'm not frustrated. I'm worried. I'm not frustrated. I'm angry." And that recognition and that opening of that space to discuss emotion has been really helpful.

Otherwise previously, I might have walked into that room and been like, "That family's really angry and they don't want to talk to me." And then, I would have left the room. So having some language to name an emotion, be open to the fact that I might not have gotten it right, allow the family to tell me how I can get it right, how they are feeling in their own words, that's really helped in my own clinical care in my own communication style.

Host: That's awesome.

Dr. Tanya Arora: Stephanie, how are you using improv?

Host: Oh my goodness. Well, I think that like we have kind of paralleling paths in these sorts of things. You know, I work in the neonatal ICU and I've done some studies of parents where we've talked to them about their NICU experience. And what we were really asking them about how they thought about goals of care decision-making. But while they were telling us about their experience in the NICU with decision-making, a lot of parents told us about how really serious news was communicated to them and how it was communicated badly, things like it wasn't very clear, things like it was delayed, things like people tried to downplay it. You know, it was confusing for them or just plain insensitive. And it made me wonder whether clinicians really understand when they're giving bad news, when it's not the sort of anticipated sit down in a conference room with a tissue box sort of a setting, and how we can be more thoughtful around sort of identifying that you're having a bad news conversation, whether you intend it or not, and how to react and be flexible and when parents are understanding this news, right?

So, I would say that the work that I primarily did, and I have to say I did a lot of it at Michigan. I had a great partner there, Brittany Batell, who is also a long-time actor. I also had history of social work, including at a hospice facility, I believe, for a period of time, who really helped partner with me for a lot of these things. And I've been a little slow getting it started again here in Kansas City, but I do have some new folks who are excited to do this in the area and ready to collaborate. So, I'm excited for it. But a lot of the work that Brittany and I did was thinking about how serious news is communicated, and what aspects of these conversations might influence how the conversations go.

So, we actually developed an exercise that's called Hilariously Bad News. And it's a little bit like a modified role play. You have a pair of people and they have to have a conversation about a piece of bad news, and you know who's the giver and who's the receiver and what their roles are and what the news is. And then, we just sort of have people play out these conversations. But the catch is that they're actually really funny. They're not like you have to tell the standardized patient that they have cancer, that's a terrible conversation. Nobody enjoys that kind of, you know, role playing. But these are pretty silly. So, for example, we'll have a parent teacher conference, and the teacher has to tell the parent that the aptitude test show that the child is part dolphin. And usually, a very hilarious conversation ensues about the dolphin. And then, we debrief it and we just sort of say like, "What made that easy? What made that hard? What were some of the challenges?" And the people had the conversation will participate and the other people who are watching it will say, "Well, it took a while for the news to come out." And then, I turned to the news giver and say, "Well, you know, why was that? Was there something that was delaying this?" And they'll say something like, "Well, you know, the parent came in saying stuff like, 'Oh, I'm sure that this is going to be that my child is gifted.' And I didn't really know how to respond to that because that wasn't really what we were talking about. And the more that they pushed that they were sure that this was good news, the harder it was to kind of give the bad news." And we sort of talk about those things.

And then at the end of the conversation, we start talking about how does this relate to clinical practice? And usually, I'll say, "Have you ever had a conversation like this in real life?" And everyone is like, "No, I have never told someone that their child was part dolphin. Thank you." But then, I'll say something like sometimes in the NICU, I will look at a baby and then turn to the parents and say, you know, "I'm seeing some different features in your baby that make me a little bit worried about a condition called trisomy 21." And this conversation is a bad news conversation in that it's a big change in expectations. But you know, their child is not dying, they love their child, you know, it's just a little bit different. And in the same way that people will say, "Well, it was really helpful when the teacher said to the parent don't worry, the part giraffe kid is doing great because we have all these special programs. That was really helpful." Thinking about how saying like, "Don't worry, we're here to support you, we're going to be partnering in your child's health going forward," is really the thing that helps those conversations go forward. So, we draw a lot of analogies and then we have a whole bunch of different scenarios where we vary things like the relationship between the people, the status between the people, what the news is, who's responsible for it, who it's impacting and to what degree. And we just sort of talk about how all of these different aspects of conversations probably impact how it's communicated. So, that's largely what we've done.

Dr. Tanya Arora: I love that you're highlighting that it's not simply about the exercise. It's really in the debriefing that a lot of these connections are being made and you always see it in the participants like light bulbs going off as they are thinking about interactions that they've had in the past, how to carry these skills with them into the future as they're making these connections for themselves.

Host: Awesome. What are some of the challenges you face with medical improv? Is it hard to get institutions, funding sources, or learners to buy into this approach?

Dr. Tanya Arora: Sometimes I think because improv is seen as comedy, that if we call it an improv session, people come to it with all sorts of preconceived notions about what's going to happen in this session. And sometimes we've had people come in and deliberately try to be funny, which really, it's very hard to be funny if you're deliberately trying.

Host: It doesn't work at all, no. It makes it uncomfortable, not funny.

Dr. Tanya Arora: So, I've oftentimes learned to start with like, "I'm not a funny person, and I still engage in these exercises." And there's no need to be funny, there's no need to be performative. Just be yourself. That's all that's needed. So, sometimes we get people who are really excited and really, as all of us in medicine do, trying to get an A by being the funniest person in the room. Sometimes we get folks who say, "Well, improv, that's not a real tool that you can use in medicine. That's something for the humanities. That's something for theater. How's that going to help us be better in medicine?"

Host: Or "Where's the evidence behind this wild technique?" And you're like, "Where's the evidence for like PowerPoint slides?" I don't know. We're working on it. But I feel like, yeah, there's a lot of questions about whether it's really a real approach or validated or, you know, worthwhile and what impact it has. So, yeah...

Dr. Tanya Arora: A hundred percent. The next time I get asked where's the evidence, I'm going to say, "Where's the evidence for the PowerPoint slide?" I love that so much. Thank you.

Host: I'm pretty sure I stole it from Katie.

Dr. Tanya Arora: Where all good improv things come from. And I think it's hard to get funding for this too. And yet I have seen people leave our improv sessions feeling whole, feeling restored, feeling confident in a way that I don't often see. Rachel Rusch and our colleague, Isaac Chua and myself decided to present improv as a way to teach primary palliative communication skills at our National Palliative Care Conference now many years ago. And we were worried that no one would show up, because we had improv in the title, Improv to Teach Primary Palliative Care Skills. And so, we were hoping for at least enough people that we could do a couple of exercises, so at least 10. It ended up being that it was standing-room only, well over a hundred people, and everybody was game to participate, which made it so such a wonderful experience.

So, I think when people are in the room, when you can actually get them there and then they participate, and then it's in the debriefing where people said things like, "I did improv with my partner and it really helped our marriage," "I did improv when I was in college and it helped me form better friendships," "I've never done improv before, and I can see myself now thinking about partnership with patients and families in a different way." And so, I think if you can get people into the room, it's pretty easy to sell them on how great this can be to allow them to interact with patients, families, and colleagues, and in their personal relationships in a renewed way. When you think about how improv can be grown and applied and supported on a larger scale, are there things that you dream about?

Host: Okay. So, this is a really hard question, how are we going to make medical improv more, sort of accessible to everyone, more available to learners of all kinds? It's really kind of challenging right now, right? There are a few folks who have done a lot of work in this sphere, who have, you know, gotten a little bit of momentum going forward, who are using this technique at their own institutions and at, you know, conferences and things like that. But the sort of bottleneck is getting trainers trained. And right now, I feel like place that this generally happens, there are a few people who've entered it from other routes, they're already improvisers and they get into the medical space and use it. But I think, you know, largely a lot of the folks go through Katie Watson's Train the Trainer. And there are just sort of a few folks at many institutions who do it, but it's really hard to get the ball rolling if you're the only person at your place.

So, thinking about how we can train and expand this work, I mean, it's a Train the Trainer course, so I imagine that this means that we should be able to also train other people, because now we're trained to be trainers, right? But I feel like that's also very daunting, you know, of a task to sort of say, "Now you know how to teach this forward." And I think a lot of folks don't feel comfortable doing that. I think it's challenging too, because there is kind of a sweet spot for a number of participants in any improv course or workshop. The hundred people that you said, that's amazing energy, but it's real hard to run a lot of the games for a hundred people at once, especially with like only one or two facilitators. So, while it's less resource-intensive than say one-to-one standardized patient interactions, it is more resource-intensive than the PowerPoint presentation where one person can talk to a hundred people showing off their slides.

You know, I think, for me, about 12 to 15 is around where I like leading a group. Much higher than that, and it starts to fall apart a little bit. So, thinking about how the folks who can do this can sort of reach bigger audiences, do they need some of their time protected? Because you can ask people to do a one-time workshop, and that's fine, but you can't say, "Well, you know, you need to do 10 so that you get all of the learners in the medical school class," or things like that. That's a big time commitment if your effort's not protected to do it.

So, I think just sort of getting the buy in from institutions or getting funders to buy in to sort of support some of this work that can increase opportunities for training for more folks and support them to have the time to do this and to study it and to do more research around what the benefits are and how it impacts learners would be really important.

Dr. Tanya Arora: Yeah. I think about the work that you've been doing with improv and language justice, language equity. Can you talk about that? And then, I'll tell you where I was going.

Host: So right now, our sort of most active project on this is to provide a workshop for clinicians in learning communication skills to use medical interpreters. Because we know, specifically in the NICU, which is where I have most of my background obviously, that for patients who have emerging English proficiency, we are not as good at updating them, that there are a lot of barriers to doing it, and that this really can impact their understanding of their child's illness, their ability to participate in decision-making, and in their child's care overall. So, we've created and curated a series of exercises into a workshop, and we are trying to get it approved by MedEd Portal at the moment. But that's, yeah, upcoming. If anyone's going to be at PAS 2024, we're presenting it there, and Tanya and I will both be facilitating. Yay!

Dr. Tanya Arora: And I think maybe that's where I can see improv going, is as a complement to other existing programs, but where we've hit a roadblock in how to teach communication. So like I had started using it as a communication tool for teaching primary palliative care, and then added in improv exercises into how to teach culturally humble care. You're using it in how to work with interpreters to achieve language equity.

I also think improv exercises can be brought in to help with wellbeing. The comedian Matt Walsh has a wonderful talk that he gave, I think, on Inside the Actor's Studio. And in that, he says, I'm not going to get it entirely right because I'm doing it from memory, but he has this quote that it felt so resonant with healthcare work. He talks about, "You are enough, you don't need to go out there and get a whole lot more knowledge. You as yourself are enough." So in those moments where you are interacting with a patient or a family or a colleague, just use your brain. Respond how you would respond as yourself. You already have plenty of information. It's not about somebody else being there. It is about coming to terms with, "I am here and I am enough," and how do we free ourselves from having it be like totally perfect, but actually recognize that in our imperfections, in our maybe not getting the exact correct guess on the right emotion, that there is a space there for your partner to step in and help support you so that together you can get it right. And I love that because I think we put so much pressure on ourselves in healthcare to not make a mistake. And sometimes we get it wrong and sometimes we do make a mistake. And I'm always wondering if someone smarter than me more capable, someone with different words, if they would have done a better job. And so, how do I make peace with, in that moment, I'm there and I'm enough and partnering with my other colleagues and with patients and families that allows us to do it together, and to get it right together.

Host: Awesome. Well, thank you so much for joining us today. I feel like we could talk about this all day long, you know, but I'll sort of wrap it up here. Thank you, everyone, for listening to the Pediatric Bioethics Podcast. And we hope we'll catch you on a future episode. Thank you so much again, Tanya.

Dr. Tanya Arora: Thank you.