Mental health stigma continues to be a major issue in healthcare, exacerbated by the overwhelming stress and burnout that healthcare workers face daily. Increasing burnout highlights the urgent need for change. It is crucial to advocate for transparency in medical licensing and to make mental health resources more accessible to healthcare professionals. By normalizing conversations about mental health and encouraging the sharing of firsthand experiences of vulnerability, we can break the stigma around seeking help, fostering a healthier and more sustainable workforce in healthcare.
On today’s episode of In Network's Designing for Health podcast, Nordic Chief Medical Officer Craig Joseph, MD, talks with Stefanie Simmons, MD, Chief Medical Officer at Dr. Lorna Breen Heroes' Foundation. They discuss Stefanie’s background, the impact of mental health stigma involving healthcare professionals, and the WELL-OPS approach which provides strategy for improving healthcare worker’s well-being. They also talk about the foundation’s work to reduce burnout and foster collaboration among healthcare organizations to improve workforce wellness. To learn more about the foundation and become more involved, visit the website at drlornabreen.org
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READ THE TRANSCRIPT
Show Notes:
[00:00] Intros
[01:01] Stefanie’s background
[04:56] Dr. Lorna Breen’s story
[07:58] The impact of mental health stigma
[10:50] Improving transparency and communication with mental health-related questions
[15:26] Burnout vs. mental health
[21:56] The importance of including the frontline healthcare workforce
[23:07] The WELL-OPS process and resources for healthcare leaders
[33:31] Stefanie’s favorite designed thing
[34:15] Outros
Transcript:
Dr. Craig Joseph: Dr. Stefanie Simmons, welcome to the pod. How are you today?
Dr. Stefanie Simmons: I'm doing great today. Thanks for having me.
Dr. Craig Joseph: Where do we find you today? Where are you recording this podcast from?
Dr. Stefanie Simmons: Today, you find me in the not-so-snowy climes of Southeast Michigan. So, I live in Ann Arbor, Michigan.
Dr. Craig Joseph: Awesome. So, is it warm? That's what I think all our listeners want to know.
Dr. Stefanie Simmons: That is, relatively speaking, for December in Michigan. It is warm. It is in the high 30s. So, everything is melted, and it is gray and mushy, which is sort of normal for our winters.
Dr. Craig Joseph: That's definitely better than the Arctic. So, we'll just go with that. We'll go with the global warming of mushy. So, so you are the chief medical officer for the Lorna Breen Heroes' Foundation. Why don't you give us a little rundown as to how you got there? I'd like to always start with nursery school or preschool and just take us year by year from there to today.
Dr. Stefanie Simmons: Well, I am an emergency medicine physician by training, and I got there in a bit of a roundabout way. I was a history buff and thought I was going to be a history professor. When I was in college, I loved learning about why things happen in society and why, you know, big themes and changes occur. And I still love that.
I decided late in my undergrad career to go into medicine and late in my medical training career to go into emergency medicine. In fact, I imagined anesthesiology and then switched to one of the few physicians to switch out of anesthesiology.
Dr. Craig Joseph: Yeah, that's kind of unheard of.
Dr. Stefanie Simmons: I loved the sort of wild environment of the emergency department. It had a lot in common, actually, with what I liked about anesthesiology, but also really interesting patients to interact with in their most vulnerable moments. I started a fellowship and the Robert Wood Johnson, Health Policy Fellowship, and it was around that time that I experienced a wellbeing crisis.
I had postpartum depression from my second child, and I had been in school for, at that point, a very long time. And I had this crisis of when am I going to start doing all the things I've been training to do? I came to the decision to stop my fellowship and, to work for the community, partner in my residency program as an emergency medicine physician and just try everything. And that was my explicit goal when I took the job, which was that I was going to work, two thirds of the time clinically, and I was going to try everything and find my hobby at work. And so, at the end of that year, I was the hospital lead for the Keystone Quality Initiative for the hospital and very interested in the culture of safety between teams and how we get safe environments, that great patient care can happen. And what are the human factors in that? How do people work together to make that happen? And my boss at the time offered me the job of the chief quality officer for the group. And I said, you know, I think you can find someone else to do that, but you don't have anyone looking after the patients or patient experience.
I started as the medical director of patient and clinician experience with that group. It was about 900 doctors in 30 hospitals in emergency medicine. And as that group grew, merged, acquired, merged, merged, as has happened so often in healthcare, around the environment, my role grew. And so, in the spring of 2020, I found myself as the vice president for patient and clinician experience in a group, you know, with 20,000 physicians, staffing, 100 hospitals, in emergency medicine, anesthesiology, radiology, women's, children's and general surgery. Really, at the on the eve of the pandemic, caring for the professional well-being for a large number of critical care and critical access health care workers in emergency medicine, ICU and hospital floors in the northeastern panhandle, in Texas, in the Midwest who needed a lot of attention for their professional well-being in the next few years.
As I was doing that, the foundation was born, and I reached out to the co-founder Corey Feist and let him know the work I was doing in my organization and asked to be of service. He put me on his board, and I did some work with the foundation over several years. And then last year, became their chief medical officer.
Dr. Craig Joseph: So, tell us about Doctor Lorna Breen and the foundation. How, what's it all about? Why did you want to become involved? And what do you do?
Dr. Stefanie Simmons: Learn everything. I was an emergency medicine physician. She worked and was the department head, in one of the busiest hospitals in New York City, New York Presbyterian hospital to faculty at Columbia, and by all accounts, was a wonderful friend. Was a wonderful aunt and sister and daughter and really cared a lot about emergency medicine, about caring for patients and about her colleagues. She was called back from a family vacation with her sister, brother-in-law and their kids, the Faith family, to care for patients in the first few days and weeks of the pandemic. And I think we all have memories of what the images look like coming out of New York City during that time.
Like many health care workers during that time, she was working 20 hours days caring for patients, also caring for her colleagues, making sure that the operations in the department were running effectively, that people had PPE and were staying safe. She got sick with Covid and like many health care workers, she came back. She came back as soon as she was technically able to come back and was a federal for 24 hours. But as we know now, just because your 24 hours in February doesn't mean you're fully recovered. And, she became profoundly fatigued, had a hard time keeping up.
And there was this overlay, in addition to the fatigue of just real concern that she was failing her colleagues and that they would be, that they would see that she couldn't keep up and that there would be judgment there. She ended up being evacuated by her friends and family to her childhood, Charlottesville, Virginia, to receive care after essentially becoming catatonic. And she received her first ever mental health care there. And, you know, she expressed to her family that she was terrified that because she had received mental health care, she was going to lose her license to practice. She was going to lose her credentialing at the hospital. And she would no longer be able to be a leader in her field. And she died by suicide. Less than 12 hours after her death, The New York Times published an article about her death, including the cause against their family's wishes. And, as you might imagine, that was from the attic for them. But there was an unexpected side effect of that, which is the outpouring of support and of personal messages from health care workers across the country saying, Lauren is not alone.
I'm afraid of this, too. This is a real issue. We are all struggling. This has been going on forever, not just during the pandemic. Health care burnout has been a real issue. And we don't have a voice. And so, her family, her sister and brother-in-law Jennifer and J. Corey Feist chose to start the foundation. The Dr. Lorna Breen Heroes Foundation for all health care workers, with a vision of creating a world where seeking mental health care is viewed as a sign of strength and of helping to advance solutions that can provide an environment where health care workers can find joy in the practice of their mission and of their profession. I don't think I need to say why. I would love to get involved in that, right? Doesn't that sound like you?
Dr. Craig Joseph: Well, when you put it that way, that does sound like something that we would all want to be involved with. And so, I withdraw that part of the question. No, it's a, it's a kind of a touching, obviously sad story. And as a physician, I totally see how it happened. I remember as a resident pediatrician being told by a more senior pediatrician that, if I wasn't sick enough to be admitted to the hospital, I was okay to come to work. And that wasn't written down anywhere, but that was certainly the idea that, hey, when you're not here, everyone else is doing a lot more work. Forget about the effect on the patients. It's there's an effect on your colleagues, and. And you don't want to let them down. Certainly, don't want to let your colleagues down. And it's nice to think about, but it's not reality.
Dr. Stefanie Simmons: There's this in the service of, in really instilling this professionalism of caring for patients, of being there even when you're tired, even, you know, when you'd rather be doing something else. There's this insidious passage that sneaks in, which is, you are expected to sacrifice every part of yourself to this profession. And in fact, if you take care of yourself, if you maintain your identity, if you care for yourself, if you have a medical or mental health condition, that is in fact unprofessional. You know, health care workers are human beings, and the system has been designed to get the result that we're seeing, which is devastatingly high levels of burnout, mental health conditions and the suicide of healthcare workers. So, if the system's designed to get the results that you're getting, you don't like the results, you need to change.
Dr. Craig Joseph: Okay. So, one aspect of that was and you just so eloquently talked about it was Dr. Breen's concern that since she had received mental health care as a patient, that she was now, almost officially not a doctor anymore, that she would lose her license. Is that being that true? What is the reality there?
Dr. Stefanie Simmons: Yeah, the reality is, it depends. And it's complicated. And it's not universally consistent. All of which combined to exacerbate, you know, Laura's uncertainty. The rules are unclear and unknown to most people. So, one of the things, the first thing that the foundation tried to do is, is to make the rules transparent. And so, we looked at the state medical board licensing applications and said, hey, are there questions on this application that ask about any diagnosis or history of mental health condition? And we made a map and said, here are the states where they don't ask. And here's this, you know, here's the states where they do. And the irony is New York State Medical Board doesn't ask about the history of mental health conditions. But at that point, there were, you know, 39 states that did. And you can imagine the confusion where there's no place you can go to look that up.
There's this pervasive culture around whether it's okay, and there's other places where these questions are asked outside of medical boards. There's hospital credentialed professional ability applications pay your applications. And so, one of our initiatives has been to systematically educate, the folks who are asking these questions about the impact that is having on health care workers, and then to provide a way forward, a toolkit on how to audit, change, and most importantly, communicate those changes to the health care workforce so that they feel safer to receive care and then to as a foundation to communicate those changes globally and help to inspire, changes in this state. Licensing boards of all health care, licensed health care workers, and the credentialing applications of all hospitals.
Dr. Craig Joseph: Yeah, kind of amazing that once you've seen one, let's even just focus on state license. Once you've seen one state license application, you've seen one. Yeah. They're all different. Much like we need a driver's license. And whenever we move to a different state, we need a different driver's license. That same for physicians in terms of the ability to practice medicine. And as you mentioned, it's not just the states. Every hospital has their own application, and every insurance company has an application. And they can all be asked these questions. And for most of us, there's no way we're going to remember which asked. And, and certainly we're probably signing a statement saying that if we ever receive these services that we agreed to notify them. Transparency is a gift if you can achieve it sounds like.
Dr. Stefanie Simmons: There have been organizations who have been advocating for these changes for some time, like the Federation of State Medical Boards, Federation of State Health Programs, the AMA, and there has been some progress. So, when we started this work in 2022, there were 19 states that had state licensing applications consistent with that. Now there are 29. So, in two years there's been a lot of change. And we know that there are many more in process that we will be awarding, the All in credentialing and licensing application badge too so we created this badge because we wanted that communication component to really be front and center.
Since health care workers will assume that worse than the absence of information, because that’s the economically safe thing to do. Right, we created this badge, we've been able to award it to 29 states. We've got many more, in the process. And we've also been able to award over 400 hospitals the badge for their credentialing application team. So, we are seeing increasing numbers of states and of organizations taking up this challenge and saying, yeah, you know, these questions don't really protect patients. And we also know that they inhibit health care workers from receiving care. It doesn't prevent health care workers having mental health conditions. It just prevents them from receiving care.
Dr. Craig Joseph: Yeah. If only it did the former that would be pretty cool. So obviously one big aspect of the work of the foundation is that transparency and kind of pushing entities like states and health care systems in the right direction. Another thing that the foundation works on is, is physician burnout or clinician burnout more generally, what do you see as the kind of connection between clinical clinician burnout mental health? And are there, how do we find out what are the solutions that can take us in the right direction?
Dr. Stefanie Simmons: It's a great question. And part of the issue of work and professional well-being has been a confusion of terms are you have well-being, professional well-being, wellness, mental health, burnout. And they are all related, but they need slightly different solutions. And so, the way I like to think about this is, is in grouping it by the solutions and the actions that are needed. So, you know, you can imagine mental health conditions. You know, over here they require removing the barriers to access for mental health conditions, licensed and credentialed health care workers, screening for suicidality, and making sure that health care resources are available.
And by the way, mental health resources that are culturally competent for health care workers because it's a unique environment and it can be very hard to start with a counselor or a therapist who has no background in that environment, and the type and degree of stressors that are experienced. I hear from healthcare workers all the time that they're reluctant to talk about the types of traumas they've experienced because they don't want to traumatize their counselor. And so having a counselor or a therapist who has that background can be really helpful. On the other hand, you have burnout. And burnout is an occupational phenomenon. It is a mismatch between work resources and work demands.
And there when you add inpatient here to that, there's an additional component where you witness human being suffering because of that mismatch. And that also causes moral distress in the healthcare worker. So, you know, I'm in the doc, you can take the girl out of the ER, but you can't take the ER out of the girl. So, when I think about burnout, I think of a wounded patient in front of me. That's our healthcare workforce. We know over 44% of them are experiencing burnout, and severe distress. So, what's the first thing you do when you've got a wounded patient in front of you? You hold pressure, okay? You got it. You got to slow the bleeding. That's individual support. And so, we need systems, and we need processes in place to provide individual support for healthcare workers, whether that's peer support, coaching, you know, support during litigation, resilience training. All of those are individuals who support intervention.
If that is all you do, the patient will still die eventually because you have not addressed the source of the bleeding. You have only slowed it down. And so, you need to go to the source of the bleeding and address those operational and environmental issues that are causing the work demand mismatch, that are causing patient harm and putting healthcare workers as the last remaining barrier between their patient and the system.
Okay, so looking at removing administrative burdens, streamlining processes, making sure that the EHR works or health care work, health care workers and patients, and not just for billing and insurance. Right. And so, all of these processes of really fixing that environment are ultimately the operational changes that need to occur.
Dr. Craig Joseph: Yeah. That's a great way of thinking about it. Because I thought all we needed was maybe some pizza and some resilience classes. But the idea of that, hey, if you're bleeding, we need to do two things. One, to apply pressure and to stop the bleeding. And, doing one without doing both is not going to ultimately solve the problem.
And it will just crop up again and again and again.
So, let's focus then on some of the systemic things that you had mentioned. That are, that kind of contribute to, to burnout. How do you think about design? How do you design programs? Interventions, operations that help move us in the right direction, kind of fixing the problem of bleeding? Or are there some programs that you can kind of point to and say, well, this seems to work.
Dr. Stefanie Simmons: It's a great question. And the first thing I would say is I would never design a system, but what I would be happy to opine on is how organizations harnessed the wisdom of their healthcare workforce to design the system. And so that ends up being a key component of this. There is incalculable wisdom and experience in the healthcare workforce, and they know where the sticking points are in the processes because they are pebbles in their shoes. Right. They can identify those. They often have great ideas and how they can be fixed, and their voices need to be included in every step of the way.
There's this idea of the triple aim health care quality, right? Patient, good patient experience, great outcomes with efficiency financial efficiency. And the quadruple aim includes the impact of that work on the workforce and harnesses the knowledge of the workforce. You can harness that apparatus and just take a ten-degree and look at the outcomes on the workforce to instantly have dozens of healthcare workers well-being project. It's more of a philosophical shift than it is in a completely new process or a completely new apparatus. And, what we've done at the foundation is we've developed, something called a “WELL-OP”, which is a process, that you can use as a hospital or health system quality improvement process that makes sure that that voice of the health care workforce is being incorporated in each step of the planning of the op rationalization and of the sharing of results in quality improvement. Another operational project.
Dr. Craig Joseph: So, tell me more about WELL-OPs. What is that?
Dr. Stefanie Simmons: So, W stands for who's on the team. And it really is who you are including in your planning team. And that needs to include your frontline health care workforce. It also needs to include, you know, quality improvement folks, the clinical and operational leadership of the organization.
E stands for evaluating your current state. And that means both quantitative and qualitative evaluation. So really listening from the frontline workforce about what are those pebbles in their shoes. What does need changes? What is the current impact of the process or the operative procedure? And then also looking at the data that's available, whether that, you know, EHR generated data.
L, the first L, is to learn what's possible through case studies, through best practices, through experts. And the second L is to really lean into measurement and think about how you're going to measure the results in a way that is meaningful to the healthcare workforce.
Then you've got the dash in WELL-OPS, which is take a pause, make sure the problem is still the right problem. Make sure everybody on the team still agrees.
OP is going to be operative. Planning and producing results. And then once you have those results, you know what's worked and what hasn't worked. We're going to share those results. And you're going to share what works not just within your organization, but among your hospital colleagues within your state, or across the country, because we need to reproduce what works. There are enough problems and enough people facing the same problems that we need to start sharing where we have success.
Dr. Craig Joseph: Yeah. I think it's like an arrow from, you know, learning what's possible. Learning what's possible only happens if others are sharing what they've done. And also, being open many times when I have the CMO hat on, I've had physicians and other clinicians, everyone comes and tells me what they, you know. Hey, I need a new order set. Hey, I need some new documentation. Well, sheet row or often they don't know what's possible, so they're not actually asking for the right thing. And what we really need to do is go back a couple steps and say, hey, what's your problem? And then let me somebody pose some solutions to you. And to me, it's a very similar thing. Right? I think to your point, if you don't know all the different choices that are out there, then you could possibly, be likely to make the right choices.
Dr. Stefanie Simmons: That's right. And so, this isn't putting the burden of the operative change on the frontline workforce but making sure that their voices are heard, and that the communication loop is closed. But there's not the close communication of, hey, we've put this process in place because we heard that this was difficult. And we heard that this was one of those pebbles in your shoe. How does it work? How does it help? Right. And then that that serves two purposes. One, you might find out the answer is no, in which case you need an iteration on the process. Or the answer might be yes. And at that point you've communicated it to a frontline health care worker that their feedback mattered, and you made a change based on it. And, you know, and it's made their life better. And that becomes a virtuous.
Dr. Craig Joseph: Yeah, absolutely. Well, you know, one of the things that you've talked about is, is normalizing conversations around mental health, specifically in the health care industry. How does one go about doing that, whether there are regulatory or legal requirements or not? There's still that stick. What can we all do? It kind of works towards getting rid of those.
Dr. Stefanie Simmons: So, I think of stigma three ways in health care. The first way is internal. What does it mean about me if I need help? And healthcare workers are achievement oriented, often compulsive. You know.
Dr. Craig Joseph: The guilt.
Dr. Stefanie Simmons: They don't want to get anything less than an A plus and everything. And so, part of this is an inside learning, right? And an examination of what it means to be human and vulnerable and what's okay. And it's sort of an inside job. You have to do that work first.
The second part of stigma is external, and it's what we fear others will think of us if we are human and need help. And part of what we can do there is, if we have an experience that we can share from a position of strength, share it appropriately in the appropriate setting with the appropriate people, so that these stories of humanity become more common.
In fact, that was the thing that helped me when I was struggling, was one of my colleagues who was senior to me, who, I really admired and looked up to, shared with me, that he also, struggled with anxiety. And I thought, oh, well, this guy who's like a totally crushing it here in the ER, who, who I like and respect, has dealt with this. Maybe it's okay for me to share and get help with what I'm feeling. We also need to think about how we talk about mental health when it's a patient, because our colleagues hear that and we still have societal stigma around mental health conditions, substance use disorder that show up in the language we use in medicine.
So, understanding, educating we and each other around that practicing language is the third area of stigma is institutional stigma. So, what are the policies and procedures that we have around health care workers with a health condition, with a substance use disorder? Are we equating those with a moral failing, or are we treating them like we would treat a health care worker who developed a physical health condition? And I would argue that there's no parity in how we treat those conditions. Right now. The foundation is launching a Stop the Stigma campaign, in March of 2025, and we're looking at how we can ensure mental health access for health care workers.
Dr. Craig Joseph: So, what is the answer? Is it being I always put be.
Dr. Stefanie Simmons: I will see the girl myself.
Dr. Craig Joseph: Are you okay? Well, I mean I think that's very helpful for everyone to hear that. You know, I've been semi-successful, you've been very successful, and we've had different answers to our standard question how? But seriously, how does the foundation work with health care institutions? To kind of redesign systems to promote well-being, to reduce burnout, to get rid of stigma.
Dr. Stefanie Simmons: So, we have two signature programs, and the first is the All in Champions Challenge badge for licensing and credentialing. And we've gone into that. But we do provide a lot of technical assistance to organizations, the state boards, to insurers and anyone who has questions on their credentialing or licensing applications. We will provide technical assistance.
We also work with states and other organizations to help them advance in their professional well-being journey. There's two ways that we've done that. One is through the impact Well-Being guide, which is a leadership guide for hospitals and health systems that we co-produced with the CDC. And I actually, it really has the first six steps that hospitals and health systems should take. And it's a self-guide. If you wake up on any given Wednesday morning and you want to address professional well-being, it can feel like you must fix the US health system, which is all your business. So, this is like there's your elephant. Here's the first six bites okay. And here are some people you should invite along with you. What we found is that if you can put organizations together in a learning community to do that work, it is very helpful. So, we have led statewide initiatives, forming learning communities at a state level and bringing the hospitals and health systems in the state.
Together with the professional organizations, the hospital association, nursing association, medical association, the health informatics, and the pharmacists as well, and really look at how as a state, we can address the issues of institutional stigma, making sure that there is a common vocabulary around the drivers of burnout, what can be done to address them, and then putting these organizations together and learning communities as they go through the WELL-OP, so that they have people to bounce their ideas off. We get national experts in to speak with them about different components of the steps and to provide that as they go through the process. And then this also with the sharing of what works, where it works. Because in these learning communities, when there is a barrier that's identified or a best practice that's identified, they can share together. And everyone learns. So, we talk about statewide cooperative action. And when it comes to the well-being of the workforce, that's definitely an area where cooperation is mutually beneficial and the rising tide results.
Dr. Craig Joseph: I like competitions. That's a good one. So, you know, we have listeners who are health care leaders and clinicians. How do they learn from the foundation how to become more involved if they're interested?
Dr. Stefanie Simmons: We have a number of ways to learn and become involved. So, first, I'd encourage every health care leader to go through the auditing and communication process on our website. Under Remove Barriers. We have a toolkit. I think the link will be in the show notes. Of how to do that audit, change, communicate, process, and go through your credentialing applications. Make sure that they adhere those best practice standards.
If your organization is at a level of maturity where you want to continue that professional well-being journey and really build readiness and a more mature approach to professional well-being, the caring for caregivers' program is available for organizations, and we can help provide that technical assistance. And the impact Well-Being guide is also available online.
You know, you paid for with your tax dollars to the US federal government. And so, free, and freely available. You can there's also for individuals who are interested in getting involved. We have an ambassador program. So, we have about 200 health care workers and family members of health care workers, sometimes surviving family members of health workers who have died by suicide, who come together and help to bring this message forward to promote the work of the foundation and bring, the message of the foundation to new audiences. And so, we always are happy to entertain applications for new ambassadors as well.
Dr. Craig Joseph: Well, that's great. We'll definitely include those links, as many links as necessary. All the information is in the show notes. We've learned a lot, which I've learned a lot. Thank you so much for your time. As we get to the end of our time together, one of the questions we always like to ask is about design. And, if there's 1 or 2 things in your life that are so well designed, they bring you joy when you interact with them. And so there something that's so, so well designed that, when you use it, when you interact with it, you're happy.
Dr. Stefanie Simmons: And then, the thing that comes to mind and really has brought me really the most joy in my life, came about because right after residency, I was sitting, doing a grant prep session, probably my 90th or 100th hour working on a grant. And I had this moment of thinking to myself, is this really it like, is this all this, all we're going to do? Oh, just sit here and work on things like this. And at the time, I had a four-year-old and a one-year-old and I thought, you know, I'm going to design a system where I'm very mindfully spending time with my children and that not only on a day to day basis, but also taking a trip with them in moments in their life.
And so, when my kids turned five, I took them to Chicago, which part A for our train ride and the American Girl Doll store and the aquarium and a dinner out. Just mom and them when they're nine, it's Washington, DC for museum monuments and the zoo, when they're 13, they get to choose where they go. And, I've had one child, so far to Alaska, and the other one to Disney World.
So, you know, you get a little sense of who they are at 13. And then when they're a senior in high school, they choose where they go in the world. And, you know, at this point in my life, I've got a 19 year old, a 16 year old and a ten year old, and so I've gone through a number of these trips and, every time I think about that moment in my life where I decided to design a way to build in these vacations with my kids, I'm so thankful that I did, because the memories that we built together, we still talk about, and I look forward to the trips that are yet.
Dr. Craig Joseph: Well, I can't wait to read about it in the book that I'm going to ask you to write. I'll give you a little time, so that all of your kids can go through all of their trips, but, yeah, that's, what an amazing gift that you're giving both them and to yourself that's a great use of design. And it's intentional. Right. This didn't accidentally happen. You kind of came up with a plan and then executed it on that plan. Well, thank you so much. This has been really enjoyable. I think we've all learned a lot. And most of us have follow ups. Now you've assigned, you didn't know it, but you've assigned homework to us.
Dr. Stefanie Simmons: I ended up more on the history professor's side of things. After all.
Dr. Craig Joseph: And you really are a professor, and I'm just scared about the test. I'm not sure when it's coming and if it will be multiple choice or essay. Clearly, I'm going to vote for multiple choice. And I will, if I don't know, the answer would be no.
Dr. Stefanie Simmons: No, because I'm the one.
Dr. Craig Joseph: Oh, you're writing the test. Okay. See, you are correct.
Dr. Stefanie Simmons: Thanks for having me on. I appreciate the conversation.