Dr. Matt Sherrer (Host 1): Welcome to another edition of the Fresh Flow Podcast. Mitchell, right off the bat, man, I'm going to ask you, I've asked you this before, what are you reading right now? You are the Johnny 5 of the Anesthesia world, you can't get enough input-- if anybody catches that short circuit reference. What is Mitch Tsai reading right now?

Dr. Mitchell Tsai (Host 2): So last week, I just finished, I think it's Le Cunff, but she wrote tiny experiments and she used to work at Google and she decided to step off the hedonistic treadmill and then try to understand and figure out what she wanted to do for the rest of her life. So, she got a graduate degree in Neuroscience. And there's a lot of cognitive psychology in there, but it's a lot of design thinking about what we need to do to move sort of this world forward and all the issues that we have, and it scales down to what we're trying to do in healthcare.

Host 1: Cool. That sounds like Rita McGrath, Discovery-Driven Planning, small bets, checkpoints, right? Little bets and checkpoints, that kind of thing.

Dr. James Cole: Yup. Think ahead.

Host 1: Learn as you go. I have, because of our podcast guest today, picked up one of my Jocko Willink, The Dichotomy of Leadership books and thumbed through it again today. Just an incredible book. We talk about paradoxes on here a lot. So, finding balance right between those two extreme positions.

So, that leads us into something that I'm pretty excited about. It's not often that we get to interview a physician with the background that Dr. Cole is going to bring to us today. So, introducing you guys, Dr. Jim Cole. Dr. Cole is a combat veteran, a trauma surgeon, and now a leader. He is the Chief Medical Officer and vice President of Medical Affairs at the University of Wisconsin. Jim, we're happy to have you, man. Let's do this thing.

Dr. James Cole: And I am really happy to be here. Let's light it.

Host 1: So right off the bat, using that terminology, I just talked about, Jocko. You have experience like nobody that we've ever interviewed on this podcast before, extensive Military experience, and I even see SEAL teams on this CV that you've sent us. I feel like before we do anything, I just need to acknowledge that we're talking to a Navy SEAL and get the heck out of the way, and let you talk about that for a minute.

Dr. James Cole: All right. So, number one, standby. So, I am not a Navy SEAL, but I was a Navy SEAL team member. So, I'm not a Navy SEAL because I never went through BUD/S, right? So, I can never call myself a Navy SEAL. I shouldn't ever call myself a Navy SEAL, but I did go through Combat Dive School, Parachute Infantry Training School. I was on several different SEAL teams, in fact, including in the combat zone. But I'm not a SEAL, I'm never going to do that. And I say that just to be sure I don't mislead anybody, because I don't like wannabes. All right?

But let's talk special operations and so forth. I served on a number of different SEAL teams embedded within them on orders as a part of those teams. I know them well.

Host 1: That's incredibly cool. Well, first off, thank you for your service. Thank you for your service to our country.

Host 2: So, I can't remember what it's called when you put your name in the hat to become a Navy SEAL. And then, when you mess up in what you're doing, you have to become a sugar cookie. So, I'm going to assume that you never had to become a sugar cookie.

Dr. James Cole: Well, don't forget, I didn't go to BUD/S, right? So, I didn't go to formal SEAL training. Now, I did go to combat dive school, and they do try to get you to ring out and to tap out. I could talk about that crazy experience. But obviously, I didn't tap out because I've got my scuba helmet that I wore on my uniform, and I did dive with SEALs, but that was a hellacious experience. But again, I'm not a SEAL, so I didn't go through that same level of training as they did.

Host 1: You went through a heck of a lot more than Mitch and I did, that's for sure.

Host 2: So, with scuba diving, one of the things divers are taught is that you never dive alone and you ascend slowly. For anesthesiologists, we understand respiratory physiology to some degree. How has your experience informed your clinical practice or your administrative responsibilities? 

Dr. James Cole: Yeah, I mean, interesting question. But in addition to diving school to become a diver, I went through dive medical officer training school. And dive medicine is so different from anything else that I've ever done, including working in the ICU. And there are some similarities, especially in the ICU, like occasionally I used to mix gases, the effects of PEEP on the body.

But as I'm pretty sure you know, most diving casualties are due to various forms of compressed gases turning into bubbles, getting into the soft tissues, and causing all kinds of different types of decompression sickness or air gas embolism. But both we treat with rediving them, right? Either in the chamber, you could actually even dive in the ocean, honestly. But it's actually pretty simple. And so, it's very hard for me to say that I'm a better or a different kind of civilian doctor, including my ICU work, just because I was a dive medical officer, because we rarely see anything in most hospitals that has much of any comparison to dive casualties.

Host 1: So, I want to stick with this Military theme. We've had some discussions before this leading up to it. Talk about trust, if you don't mind. We've talked about on this podcast before, I believe, Simon Sinek's book, The Infinite Game. And in that, he talks about how Military especially really emphasizes trust almost sometimes as much as performance with the kind of concept that a high performer of low trust is actually a toxic team member. So, can you tell us just from your Military background the meaning of trust on those Military teams?

Dr. James Cole: Well, I mean, trust is everything. I mean, SEALs and special operations forces like them expect excellence. Weak performers are not allowed. As you may know, some people have criticized that only 70-80% of BUD/S candidates graduate and they wonder if SEAL training should be made easier. But most SEALs would respond to that question by saying, "No, perhaps we need to make it harder because life is hard. Missions are even harder."

So, excellence is overwhelmingly important, but trust is something that you should and cannot ever compromise, especially on small teams. Because if you can't trust one of your teammates, regardless of how excellent he is as an individual, if you can't trust that that person is going to do his or her job well or if if there's any sort of risk, that person may bail on you at the wrong time, that person should not be on the team. And it's not just SEALs who feel that way. I mean, I can tell you Army Special Operation Forces, Marine Recon, I've been in all these teams, they all feel this way. I've been a part of it all. I can attest that trust is of highest importance, but you need excellence as well. And, you know, we can translate that, if you will, to the OR, right? We want excellent surgeons, we want excellent anesthesiologists, we want excellent surgical assistants, et cetera, et cetera. We need excellence. But if you can't trust that your assistant's going to do the right thing, if you can't trust that the anesthesiologist is going to keep the patient in a state of sedation, anesthetized to a level you can do your job, then that whole team falls apart. So, trust is everything.

Host 2: I think you've answered two questions there. You know, one, how do you build trusting teams in the Military? How do you build trusting teams in Medicine, right? I think one of the big differences is that, in the Military, and again, I'm not a Military person, but they operate in different environments, right? They operate in constrained environments in a lot of circumstances. How do we take lessons from the Military and build better teams in medicine? And I don't know if we're circling back on that question, but I agree with you. We need excellent surgeons. We need people excellent at what they do individually. But how do you build that trust between nurses, anesthesiologists, surgeons, and the technicians and the people that help us every day? Because ultimately, we're all there to take care of the patient.

Dr. James Cole: I think the best physicians are the people that worked as say, you know, technicians or EMTs or did some non-physician-like healthcare work. They were basically boots-on-the-ground grunts from the medical perspective, because they get it. They understand the hell that the people that support us as physicians have gone through, because we went through it, right? In the same light in the Military, the best officers are the ones that have been prior-enlisted, or at least senior officers are the ones that have started out as very, very junior officers and worked their way up in various echelons, be it in training or be it in operations.

So, how do we build teams? I think the first thing is through experience. Like if we haven't walked the walk, it's hard for us to talk the talk, right? And lead them, because people aren't going to think that we have credibility. So, credibility is everything. So interestingly, in the Military, when I came back from Parachute Infantry Training School, and I had those silver parachute wings, it instantly gave me credibility with the Reconnaissance Marines when I actually ended up jumping more, more parachuting, and I eventually got my Navy Marine Corps Parachute insignia, it's like a gold set of wings, it changed even more. When I went to scuba school and I got the silver helmet, that combo Force Recon insignia, it changed even more because they knew that I've been there. I've suffered like they've suffered in the past.

So, the first thing is you want to establish some credibility. The next thing is you want to be real, right? You don't want to be this barbaric leader who said, "It's my way to the highway. I'm going to be in for five minutes," and then just make sure you get all the work done. I think when there's work to do and tasks, if the leaders can offer to help in some way, shape or form, pitch in, it doesn't have to be at the same level, and it doesn't even have to be for the same amount of time. But if you can show that you're not such a big deal in your own mind and important that you're not too good to help them out, do the real laborist tasks, that goes a long way.

And then, the other thing is if you can teach people pearls of wisdom, because most people on teams are like sponges waiting to soak up knowledge. The more wisdom you could offer, the more training you can give them, the more grateful they will be and the more likely they will follow you. 

Host 1: So when I hear you talking about that, the word that pops up in my mind is humility. I know I mentioned this at the beginning, the Jocko Willink Dichotomy of Leadership. And it's this idea of be humble but not passive, right? Is that kind what we're talking here being obviously assertive, but in a way that displays humility?

Dr. James Cole: Absolutely. So, imagine that you're in the field, okay? And you're living in a bunch of tents. Let's say we're living in 15 by 18 foot tents, and we know that it's going to be really windy or rainy and so forth, and we got to put sandbags up. You can either tell your team members, "Hey, fill sandbags," or you can go fill some sandbags yourself. You start the train by getting those sandbags, all you got to do is fill about six, seven, eight sandbags, everybody else is going to follow and they are going to be grateful that you started it, okay? Or how about when leaders, PT, physical training with their subordinate teammates and they show that they're not too important to participate in something that we all know is necessary, right, physical training or any other mundane work, it goes a long way, right? If we're willing to step up for them, they'll be willing to step up for us. And oh, by the way, everybody should be more humble, and that's humility.

Host 2: These are great stories. I mean, just a shout out to one of our spine surgeons here, Dr. Monsey, when he tries to help us move the rooms, he'll grab the mops, and he'll sweep the floors, right? You work a little bit harder when you're in that room because you know that the surgeon's also pitching in. In the business world, what I think about is Southwest Airlines, right? They will pay their employees to walk the walk. Pilots will learn how to load baggage. And then when it's crunch time and baggage gets backed up a little bit, the pilot can jump down because they've been cross-trained and what to do. And are you going to work on that plane a little bit faster and harder? Absolutely, right? The guy who's flying is jumping down, helping you load the baggage.

Dr. James Cole: This takes me back to a story when I was in Iraq when we were doing work out of these, 15 by 18 foot tents, but there were only like 10 of us, which means-- oh, by the way, we relied on generator power and other sort of types of equipment. We didn't have any maintenance technicians, so we were the maintenance technicians.

So if you can pitch in back in garrison or back in big base camp to learn how to do that stuff and do it alongside these people, it's not only going to be better for yourself, but it's going to be better for your teammates, because they're not going to be able to figure out how to do it any better than you if nobody is trained in how to do it.

Host 1: I do a talk on this, and I use the sandbag example from Jocko's book. And in our world, in Anesthesia, what he's saying to do is that trust is built in the boring, mundane times in between the action, right? We want to be heroes. And we are in a lot of ways, right? Our jobs are incredibly cool. But we build the trust to perform in those heroic moments, in the boring, mundane times. And I tell people, "Hey, like, can you go give somebody a bathroom break? Can you go give them a lunch break? Can you ask them if you can bring them something you stay in the room and let them go get something?" Just anything that you can do just to show I'm here with you.

So, I'm glad to hear that these stories seem to be something that you guys focus on. You talk to Military folks, and they seem to overwhelmingly talk about these same things. So, it seems like it's something that actually means something to you guys.

Dr. James Cole: Absolutely. It's real. It happens all the time.

Host 2: So, you wrote a book, which is much more than Matt and I have ever done. Trauma, my Life as an Emergency surgeon. Looking back, what thoughts and reflections have sort of stood the test of time? And then, how have your perspectives changed since it's been published?

Dr. James Cole: Yeah. So, all of the content in my book that discussed my training, like when I was a resident, it just doesn't exist anymore, right? Training has completely changed. That is residency training, I think, I'm confident, was a lot harder back then compared to now. Because back then, that was in the '90s, we worked literally 120 hours a week, and we were always sleep-deprived. We never ate, right? At least sometimes, we didn't eat. And there was certainly no built-in family time, no days off.

But I think as everybody knows in 2003, there was this assertion that there were too many medical errors, and too much physician burnout as a result of those long and grueling residency hours. So, suddenly, they, you know, maxed out and decreased the number of hours residents were allowed to train, to no more than 80. And that had some short-term benefits to the residents' lives. But honestly, it just pushed all the work onto those who had already graduated, because there are no rules governing how many hours an anesthesiologist or a surgeon or anybody who just finished yesterday needs to work.

Of course, if somebody trained exclusively in an environment, in a culture where they're no longer expected to work overly hard, most will refuse or not want to do so post-training. So, flash forward 20 plus years, and what are the results? Well, there has been no decrease in medical errors. There's been no long-term improvement in burnout. And there has been a significant decrease in confidence in competencies in newly graduating Medicine and surgeon residents even in the last month, I should say, of the residency.

So, don't forget, in the case of surgery, General Surgery, it's a 33% decrease in patient contact hours over that surgical five-year residency period. Thirty-three percent, that's like almost 10,000 hours. So, what was sacrificed? What was sacrificed was Lung Surgery, Vascular Surgery, Trauma, Surgery, Critical Care, some Pediatric Surgery, things like that. So, these days, it's very hard to find a newly graduated general surgeon who is comfortable outside of the belly or the soft tissues. So, that's definitely changed. But what has not changed, of course, my book is mostly about trauma surgery, right? And I think that those out there that essentially practice trauma surgery full-time can relate to the stories I've told in my book. Obviously, these are the ones that had the greatest impact on me and stayed with me for years and years and years. So, they were pretty substantial. Like I got to even write about softball patients in my book.

But the worst part also of being a trauma surgeon is there's really nothing that's overly standardized about how a patient is wounded, the pattern of injuries, necessarily the complexity of cases, or necessarily the approach needed to solve the immediate threat to life. There's no time to read up on anything in the moment. You have to rely on your training and your experience and your consummate understanding of the human body, the anatomy, especially when it comes to controlling hemorrhage and difficult-to-access parts of the body.

There are times when you literally have to make things up, right? You have to make up an approach or a technique to save a life. And all of those nuances about trauma surgery that I describe in multiple chapters in my book will likely never change, frankly, because human anatomy doesn't change, it doesn't evolve. There's no rule book that the patients read as to how you're supposed to be wounded. And time is also never on your side when somebody's audibly bleeding and trying to die in front of your

Host 2: I think, you know, this circles back to the conversation that we had when we started this with the Navy SEALs, right? Should we increase the percentage of people that passed BUD/S School and the Navy SEALs themselves have said, "No, what about making it harder?" I firmly agree with you with the switch for the 80-hour work week, we switched to night float systems, right? And Sleep Medicine's been around since the 1960s, 1970s. William C. Dement at Stanford, we know what happens when go on night float. And yet, that's the model that physicians adopted to try to backfill the workforce shortage in that sense in terms of not enough people around.

Dr. James Cole: So personally, I think we probably need to find a place somewhere in between where it was in the past and where it is now, right? I think that restricting people to 80 hours when we know that it's not like outside of those 80 hours, they're sleeping the whole time or they're, you know, just sitting and having dinner with their wife or something. They're doing other things, right? So, I think we need to relax those standards a little bit with good intentions to ensure that, if they're going to stay in the hospital longer, that they're actually doing something meaningful, meaningful learning.

And I think, at the same time, we actually may need to increase the length of some of these training programs, because what happens in that final months or final year of that training program, if you're a general surgeon, Internal medicine doctor, whatever, and you don't feel comfortable, confident that you can Independently do your job, what are you going to do? You're going to apply to a fellowship. But what does a fellowship do? Does it make you a much better super subspecialized person of a particular specialty and all of the generalness that flowed up to that specialty? No, in many ways, it just restricted what you have to be responsible for and what you need to do. And therefore, it takes all of those generalists with all those other skill sets and body of knowledge out of the general pool. And that's not good for America, right? It's not good for healthcare in America. So, I think we need to compromise between what we did and what we do now, because honestly, I would never want torepeat the residency I did. It was pure hell. It was really hellacious. I think the culture now needs to be changed as well.

Host 1: I mentioned earlier, Mitch and I love to read lots of books by kind of what I would call Military titans, right? I think the Stanley McChrystal team of teams. A lot of folks look to Military for leadership. Is there anybody in particular, books in particular, heroes of yours in particular, who you've really focused on as you've evolved into a leader and that you can see yourself using in your role as a Chief Medical officer?

Dr. James Cole: So, there are two people. I'm going to tell you, you probably don't know who he is. His name is Mark Donald. Mark Donald. I worked with the guy, okay? He is the most decorated Navy medical person ever. The guy, he was a PA. He was a former Trident-wearing SEAL before. He worked his way up to E-6 and then went to PA school. But just a consummate leader, operational master, medical guy, and good person, right? So, I met him on one of the East Coast SEAL teams, we worked together. He wrote a book called Battle Ready. It's worth reading. And to be honest with you, it does not tell even a fraction of the stuff he has done, but he is amazing, okay?

The other person is also someone I worked for directly, that was Major General at the time, eventually became general, Stan McChrystal. And Stan McChrystal was the commanding general of a unit that took care of the most elite special operations forces. And, you know, I worked for him during a time of war. That guy was amazing, honestly. And he talks about character and leadership. And honestly, I really appreciated working for him, and I still admire the work that he does and publishes.

Host 1: I got books to order. How about you, Mitch? Mitch has probably read them all three times,

Host 2: I've never heard of Mark Donald, but Stan McChrystal, can't remember if it was a TED Talk or a video, but just how he ran operations; making sure that an analyst, that he knew something about an analyst who was presenting information to everybody, the fact that he connected everybody that was not on the battle front, but everybody operating behind it, and he found a way to connect them all.

And when I think about healthcare today, you know, I come from the world of OR management science, and I think we've done a huge disservice. And I think medicine. Does the same thing with all these metrics: length of stay, turnaround, first case on-time starts, because those are just timestamps, right? Because underlying everything that we do is a coordination problem, and the Military understands how to coordinate people even with things don't go to plan, that everybody understands what they need to do and how to get it done.

I was really hoping you were going to say Patton was one of your war heroes, and then the other person would be John Boyd, right? I think the Marine officer that's honored by the Navy, the individual who came up with the idea of modern jet warfare. But no, Stan McChrystal's one of those people that sort of sticks out from my mind.

Dr. James Cole: I mean, there are some other people I could tell you, but I'm not going to because they had a storied past, and people might question me, but I'll just tell you one guy, General Mattis. My God, that guy was a character. But man, did he know how to lead people. Man, did he know how to inspire people to get the job done. Very impressive person.

Host 1: Jim, you're in a leadership role now. Do you still get to go to the operating room? Do you still get to go down and play in the OR and take care of patients or is that something that is in your past?

Dr. James Cole: Very little, you know, I mean very little, because I take trauma call, backup call, but it's really backup call. I round in some weekends. I. And it's sad, but it is what it is, right? So I'm kind of one of these, if you're in for a dime in for a dollar kind of people, right? And just like pilots, you got your aviator wings and you fly whatever you fly, F/A-18. But when you get to a certain point, when you're the commander of the squadron or the wing or whatever it is, you're not doing a whole lot of flying, right? Because you're actually leading the organization. And it was very hard for me to come to the personal realization that, wow, I'm not going to be doing like the cool guy stuff anymore.

But that being said, I've eventually come to a place where I realized, but I am leading a lot of different people, like all of the surgeons and most of the Medicine doctors and a lot of other specialists in ways that I think is not only good for us, i.e., the system, but it's definitely good for the patients and, honestly, it's good for them, because I really try to mentor and shepherd people that are struggling and having difficulties, and that unfortunately takes a person out of the operating room to be able to do that. So, it is what it is.

Host 2: I think about David Brooks. He wrote from Strength to Strength. And one of my CRA colleagues retired and started to work for Habitat for Humanity. And with the workforce shortage, I asked him if he'd come back and help in the operating room, and he said, "Hmm. No, I'm happy where I am." But he said, "Mitch, I wish I'd read this book 15 years earlier." And so, he gave me a copy and I read it.

And the short premise is that, when we're young, can go through that residency. You are willing to put in the time and investment and the resources and the energy to do what you need to get done. But as we transition through our careers, if we want to pass something along, it's this idea of becoming Yoda. How do you share your wisdom so that the people behind you don't necessarily make the same mistakes that you do, or if they're stuck in a rut, you guide them out of it, but mostly that they're going to make different mistakes, but how do they have the agility to sort of respond to those situations? So, kudos to you.

Dr. James Cole: Yeah. I mean, to be honest with you, do I miss the OR? Yes. But you know what? I do miss those Military operations in the austere environment even more. However, I also recognize I could never do that anymore. That's another sort of grip with reality. Like, I can't do that anymore. I mean, I'm not going to be physically able to do the things that the young guys running and gunning did that I participated in, but it's just life, right? But I'm happy for the experiences that I did have.

Host 2: You talk about austere environments or just change, and the pandemic's in the rear view mirror, I'm assuming you were in a leadership position during that time. My thinking is that we've sort of just forgotten about it, and I hope we never do. But what did we learn? And then, what do we need to hold onto in case the next pandemic comes or the next climate change disaster, supply chain comes down the road? What do we need to hold onto?  

Dr. James Cole: First of all, it is really hard from a post-pandemic perspective to, you know, identify real successes. But I will say there were a lot of real successes during the pandemic. I basically sat in the Incident Command Center directing traffic for almost a year, like, you know, really participating in this. Because as you know, we had to completely reorganize everything, the OR, how we had got people to the OR, how you prioritized getting people out of the OR and where they recovered and everything else, ICU and everything else.

But I will say that the people that did actively participate in the care of all those patients, basically, our worst public health nightmare of our lifetime fighting an invisible enemy on an unconventional battlefield, they need to congratulate themselves for a job well done. But now that it's mostly behind us, these post-pandemic times are challenging, right? Because we're still suffering from the effects of the pandemic, right? Some of the misinformation that still lingers. Access problems during the times of the pandemic, immediately post-pandemic has resulted in sicker patients with less insurance coverage. Some, more Medicaid; more, no insurance at all. So, we have fewer funds to take care of sicker patients, less resources. It's really tough, right? So, that's made things tough.

There are also fewer doctors, nurses, and technicians out there that even want to work at all. And there are, like I said, more patients to care for. So, we have to do all of this with fewer collective resources. It's also hard to keep people motivated to work a little harder under these constraints that we're all forced to, i.e., less money, more time, more patients, all this other stuff. And this whole work-life balance thing is something that I'm hearing more and more and more that we just have to grapple with. Like, how do we satisfy staff of every type, keep them working here. You know, everybody wants more money, but it's not like anybody's giving us more money to pay these people that want the money. And even when we do pay them more, it does not buy them happiness, right?

So, what do we need to do? Like, if we just want totalk about how do we prepare for another disaster? Well, first of all, be prepared. Run drills, run scenarios, educate ourselves, and anticipate things that may likely never happen. You know, trauma surgeons, Military members, and disaster specialists, they understand this. All too often civilian hospitals, they don't rehearse things like pandemics, earthquakes, and other natural calamities. But we need to, because if you give enough time, history always repeats itself. And I remember when I first went through Military training, they trained me on nuclear, biological, and chemical warfare response and treatment. And I was always one of those guys that about every year or two would reread those little books to be sure that if something happened, I would know how to take care of them, you know? Because I just believe it's important to be prepared. So, I was personally being prepared.

I think that we collectively, as healthcare in America, leaders in healthcare, we need to do a better job at it, because we will forget the lessons learned. If we forget the lessons learned, just like always happens in every war, we're going to be forced to reinvent the wheel, right? It happened after World War I, World War II, Korea, Vietnam, somebody's always reinventing the wheel. If somebody loses the knowledge of what we learned worked best during COVID, we will repeat that mistake in the future.

Host 2: I think about the tsunami in Indonesia, right? Where the elders knew that if the ocean disappears, it's time to start running for the hills.

Dr. James Cole: Yep.

Host 1: Well, Jim, this has been incredible. We could sit here and pick your brain for hours more and your hospital system would not be happy with us if we did so. Thank you so much for coming on. Before we go, any wisdom, any knowledge you want toshare? We have a crowd of perioperative people, right? So, it's people from your environment. Any last minute wisdom you want to share with that group?

Dr. James Cole: All I want to share is that we are privileged to do what we do. Working in an operating room in any capacity, it's amazing when you really think about it. Like, a hundred years ago, 1925, there was no IV, right? There was no endotracheal tube. There was no anesthesia machine. There was no ventilator. There was no thoracic surgery. The heart was considered for the most part off-limits. And in the hundred years since, surgery, operating room procedures and operating room teams, it's a super cool club that those of us who are in those teams, we take it for granted. But I think if we step back and reflect at this amazing privilege that we've been given to be a team member is something worth celebrating. By the way, there's going to be a lot of people that need us in the future. So just, you know, keep doing what you're doing because it's a gift.

Host 1: Jim, thank you so much for coming on, man. This has been incredible. I'll probably continue to pepper your email inbox with dumb questions. And I've enjoyed the heck out of this. Thanks for coming on, and thanks for your service.  

Dr. James Cole: Hey, Matt, thank you so much. Mitch, thanks so much. Honestly, this has been great. This is like questions and topics that I've actually enjoyed speaking about more than anything I've spoken on a very long time. So, thanks so much for thinking about me and inviting me. Appreciate it.

Host 1: Thank you so much. Guys, this has been another episode of The Fresh Flow Podcast. Thanks for tuning in, and we will catch you on the next one.