Jakson Do We Have the Courage? Pregnancy, Policy, and the Price Surgeons Pay täydellinen litterointi

00:04:32.879 Those are excellent points. 00:04:32.959 --> 00:04:35.600 And I'd like to focus on the preterm delivery rates. 00:04:35.759 --> 00:04:46.160 And I just want to take a moment and remind our audience that all gynecologic oncologists that trained in this country practice obstetrics at one point in our lives, what may seem like a long time ago. 00:04:46.319 --> 00:04:50.399 So even if it was just during residency, these are really shocking numbers. 00:04:50.560 --> 00:04:56.000 And we, from our days of practicing obstetrics, know what the implications of a preterm birth can be. 00:04:56.240 --> 00:04:56.480 Dr. 00:04:56.720 --> 00:05:04.639 Goon, in your study, you found that 25% preterm delivery rate, which is really actually more than double the general US population rate. 00:05:04.879 --> 00:05:07.600 What were your first thoughts when you saw that number? 00:05:08.000 --> 00:05:08.959 I couldn't believe it. 00:05:09.120 --> 00:05:14.079 I honestly rerun the numbers several times because I was convinced it was just a mistake. 00:05:14.480 --> 00:05:14.879 Dr. 00:05:14.959 --> 00:05:18.079 Walsh, when you first read that, what was your immediate reaction? 00:05:18.480 --> 00:05:21.920 Yeah, my immediate reaction was also one of shock. 00:05:22.480 --> 00:05:30.720 So not only was there a 25% preterm delivery rate, but over half of the live bursts actually involved in major complication. 00:05:31.040 --> 00:05:31.360 Dr. 00:05:31.439 --> 00:05:33.920 Mills, which complications surprised you the most? 00:05:34.000 --> 00:05:36.319 And which did you sort of expect going in? 00:05:36.800 --> 00:05:39.360 You know, I wasn't totally surprised as I alluded to. 00:05:39.439 --> 00:05:48.720 I'd had a lot of these sort of secondhand conversations and was expecting that people were going to report some things, but it was crazy to see a lot of it actually come out on paper. 00:05:48.879 --> 00:05:56.240 And I personally had expected that we would see more of the hypertensive sort of placental dysfunction spectrum disorders. 00:05:56.480 --> 00:06:04.560 I'd always seen like my colleagues telling my, you know, pregnant colleagues, like, sit down, put your feet up, like you don't want to get pre-eclampsia and have your placenta fail. 00:06:04.800 --> 00:06:12.480 But it is true we did see that quite prevalent in the study, about 20% nearly, whereas the baseline population is more like 10 to 15%. 00:06:13.199 --> 00:06:17.279 But really that preterm delivery rate was just a complete shock. 00:06:17.920 --> 00:06:19.199 Yeah, absolutely. 00:06:19.360 --> 00:06:20.399 And I do want to get Dr. 00:06:20.560 --> 00:06:21.680 Sanders' thoughts on this. 00:06:21.759 --> 00:06:22.800 But before then, Dr. 00:06:22.959 --> 00:06:28.639 Goon, can you tell our audience how your findings compare to what a similar study found in general surgeons? 00:06:28.720 --> 00:06:33.040 And what do you think are some of the similarities or differences between the two populations? 00:06:33.439 --> 00:06:42.639 In a similar survey study based on American surgeons published in JAMA Surgery in 2021, the preterm delivery rate was 15%. 00:06:43.279 --> 00:06:52.800 Their population was really similar to ours in terms of age, distribution of practice settings, and geography, and about 6% identified as oncologic surgeons. 00:06:53.040 --> 00:06:58.800 They had nearly identical rates of overnight call, hours worked, and hours operating in the third trimester. 00:06:59.120 --> 00:07:07.519 While 6% of our population reported decreasing work hours for pregnancy, nearly 17% of surgeons reported adapting their hours. 00:07:07.759 --> 00:07:13.279 While much is similar, I think the difference in preterm delivery rate that we've already touched on is really stark. 00:07:13.519 --> 00:07:19.199 Either our numbers are wrong, or there's something different about our population that we haven't yet figured out how to capture. 00:07:19.439 --> 00:07:37.439 As we kind of alluded to already, I want to hammer home a little bit that I also think about the MFM counseling that I heard as a resident really emphasizing that the highest risk for preterm delivery is a history of preterm delivery, which means that this is likely to be a compounding issue for anyone thinking about subsequent pregnancies. 00:07:37.680 --> 00:07:38.000 Dr. 00:07:38.079 --> 00:07:40.079 Sanders, in the editorial or Dr. 00:07:40.160 --> 00:07:45.360 Walsh, and I'm really honing in on this preterm delivery rate because that it really is such a stark issue. 00:07:45.519 --> 00:07:52.720 But in the editorial, you raise the question is this really about older maternal age or is it the work environment? 00:07:52.879 --> 00:08:04.319 And you cite, you know, a similar Canadian cohort study that showed preterm rates of about five and a half to seven, eight percent, even in an older population, which is a little bit different than the JAMA surgery article, of course. 00:08:04.480 --> 00:08:08.319 But this is a fourfold gap from the findings in this study. 00:08:08.480 --> 00:08:09.920 What do you think about that? 00:08:10.720 --> 00:08:22.399 So if we round up and consider the preterm birth rate for a singleton pregnancy to be approximately 8 to 10% in the US, again, this rate of 25% is substantially higher than what we would expect. 00:08:22.639 --> 00:08:37.279 While most of the preterm deliveries in this study were late preterm, so between 34 and 37 weeks, we know that even late preterm births can have meaningful consequences for both mother and baby, including longer hospital stays and additional healthcare visits after discharge. 00:08:37.519 --> 00:08:47.679 The median maternal age at the end of pregnancy in this study was 35 years, and 90% of respondents delivered either during fellowship training or within the first seven years of their careers. 00:08:47.840 --> 00:08:59.919 Given the magnitude of the difference in preterm birth rates compared with population

level estimates and the relatively young age of this cohort, I think that these findings suggest that maternal age alone may not explain the increased risk. 00:09:00.159 --> 00:09:06.960 There must be other factors related to either work environment, training, career stage, or other occupational demands that are contributing. 00:09:07.120 --> 00:09:09.919 And I think that this is an area we really need to continue to study. 00:09:10.559 --> 00:09:10.799 Dr. 00:09:10.879 --> 00:09:12.399 Walsh, do you have any other thoughts? 00:09:13.279 --> 00:09:21.600 Yeah, if you look across the literature, the preterm delivery rate is about 4% to 16% globally and about 10% in the United States. 00:09:21.759 --> 00:09:22.320 And Dr. 00:09:22.399 --> 00:09:29.120 Sanders and I referenced this study from Canada because it's a large study that broke down preterm delivery rates by maternal age. 00:09:29.279 --> 00:09:43.679 And as we think about why the preterm labor rate is so much higher in gynecologic oncologists, I think it's important to ascribe that we can't just say that this is maternal age and we need to think critically about how our work environments might be contributing. 00:09:44.240 --> 00:09:50.799 So kind of touching on work environments, I just want to pull the group and ask how many hours you operate in a typical week. 00:09:51.039 --> 00:09:55.440 For me, currently, it's about eight to 10 hours, but right now I have a lot more administrative time. 00:09:55.600 --> 00:10:00.000 When I was a junior faculty member, it was probably closer to 20 to 25 hours a week. 00:10:00.240 --> 00:10:00.559 Dr. 00:10:00.720 --> 00:10:01.200 Goon? 00:10:01.759 --> 00:10:05.759 Yeah, well, I'm a fellow, so it's about 30 to 40 hours a week right now. 00:10:06.320 --> 00:10:06.639 Dr. 00:10:06.799 --> 00:10:07.360 Mills? 00:10:07.840 --> 00:10:08.799 It varies highly. 00:10:08.960 --> 00:10:16.000 You know, sometimes it's more like five to 10 because I do have some protected time as a fellowship PD now, but sometimes it's triple. 00:10:16.240 --> 00:10:23.039 And during my pregnancies, particularly my first, I was definitely closer to the like triple number than to that five to ten. 00:10:23.600 --> 00:10:23.919 Dr. 00:10:24.000 --> 00:10:24.639 Walsh? 00:10:25.200 --> 00:10:31.519 For me, it's 10 hours per week, but then it can increase from there when I add on cases outside of my block time. 00:10:31.840 --> 00:10:32.159 Dr. 00:10:32.240 --> 00:10:32.799 Sanders? 00:10:33.200 --> 00:10:35.440 Usually about 20 to 25 hours a week. 00:10:35.919 --> 00:10:39.120 That is a lot of time cumulatively in the OR. 00:10:39.279 --> 00:10:40.080 That's amazing. 00:10:40.320 --> 00:10:47.360 So the finding that operative time of more than 12 hours per week in the third trimester raised complication risk significantly. 00:10:47.519 --> 00:10:49.679 The odds ratio was almost 1.6. 00:10:50.000 --> 00:10:56.879 It's a bit sobering in that a third of the respondents felt that their

work node negatively impacted their pregnancy. 00:10:57.039 --> 00:10:59.519 I really want to open that up to the to the group here. 00:10:59.600 --> 00:11:00.080 Um, Dr. 00:11:00.159 --> 00:11:01.440 Goon, you're still in fellowship. 00:11:01.519 --> 00:11:02.559 I'm gonna start with you. 00:11:02.879 --> 00:11:03.120 Yeah. 00:11:03.360 --> 00:11:11.600 So I'll acknowledge that the perception of the impact of workload on pregnancy is probably where the findings of our study get much more subjective. 00:11:11.919 --> 00:11:23.519 That said, I think long-hour standing, fasting, strenuous lifting activities, these are all things that have modest, if somewhat inconsistent, correlations with preterm birth in other populations. 00:11:23.840 --> 00:11:32.159 I do wonder how much of the operating component is related to these features, things like, again, prolonged standing or fasting that come with much longer cases. 00:11:32.480 --> 00:11:49.679 A piece of our data that I've really puzzled over is the finding that pregnant trainees who did work more weeks that were greater than 60 hours and also took less leaves than attendings were not any more likely to report that the workload negatively impacted their pregnancy. 00:11:49.919 --> 00:11:53.840 Does this suggest that the nuance is more environment-specific? 00:11:54.080 --> 00:11:58.720 Is it a product of being a couple of years younger during training, your expectations being different during training? 00:11:58.879 --> 00:12:02.159 I don't really think we have the data to dig into that, but it's certainly interesting. 00:12:02.399 --> 00:12:10.960 And then overall, I interpret our findings as emphasizing the need for policies that at least open the possibility of workload modification. 00:12:11.200 --> 00:12:30.879 When we step back and think about the fact that these pregnancies are mostly happening early in a gynack career, I think the way that an institution navigates a pregnancy with a young physician has the potential to either lay the groundwork for a successful long-term relationship or burn bridges at a time when people are already making lots of life changes. 00:12:31.200 --> 00:12:32.159 Excellent points. 00:12:32.399 --> 00:12:32.639 Dr. 00:12:32.720 --> 00:12:33.840 Mills, your thoughts? 00:12:34.159 --> 00:12:37.440 Yeah, I mean, it's multifactorial probably, much to what Dr. 00:12:37.600 --> 00:12:38.480 Goon is saying. 00:12:38.720 --> 00:12:42.879 Maybe levels of stress and like sort of cortisol you have swirling around. 00:12:43.039 --> 00:12:48.320 I I mean, I think about when I was a resident, you know, I was at a program, we didn't take 24-hour calls. 00:12:48.399 --> 00:12:52.240 And even as a fellow, I felt like I was like hustling and really owning things. 00:12:52.320 --> 00:12:55.600 But I do think that sort of like it all ends with me part. 00:12:55.679 --> 00:13:05.919 Um, maybe if you're not the one who's necessarily like moving the patient, you know, from the surgery to

the PACU, but you're sitting there and dealing with the stress of it. 00:13:06.159 --> 00:13:18.639 And another thing that I think, you know, really resounds with me is that, you know, the vast majority of programs anymore are doing some sort of outreach, you know, especially for the younger folks who are hired in, you know, you're gonna be here, you're gonna be there. 00:13:18.960 --> 00:13:28.320 And when you're at an outreach site, I think the built-in support is often far less available and structured as it would be when you're at like your hub. 00:13:28.480 --> 00:13:38.559 So when when we're on campus here and I'm operating, if I need to call a partner, there's probably at least a handful of people who are somewhere in an OR nearby or in their office. 00:13:38.720 --> 00:13:40.879 We've got residents, fellows, you name it. 00:13:40.960 --> 00:13:42.879 If I had a problem, someone would come. 00:13:43.039 --> 00:13:54.559 But when I was out at my off site, you know, an hour and a half away from the main hospital and operating all day long from 7:30 until five, it was just me and a PA, kind of come what may. 00:13:54.879 --> 00:13:56.240 And who was I gonna call? 00:13:56.480 --> 00:13:59.840 Maybe a general surgeon, if I if I had something to ask them to help me with. 00:13:59.919 --> 00:14:02.480 But otherwise, I was really doing the meat and the potatoes of it. 00:14:02.559 --> 00:14:05.759 And I think that potentially is an area much to what Dr. 00:14:05.840 --> 00:14:17.600 Goon is saying, like looking at what you can do to make certain modifications at a time that's like critical to continue to build these really nice relationships in the workplace with the employers. 00:14:17.840 --> 00:14:28.480 I think this is a moment to say, okay, well, if there's one thing we could modify, maybe it's being in isolation where some of that stress factor could perhaps be magnified. 00:14:29.120 --> 00:14:39.200 Very excellent points as we are really working to care for our patients and go to where our patients need us to decrease the financial toxicities and other barriers that impact care. 00:14:39.440 --> 00:14:40.159 No question. 00:14:40.320 --> 00:14:42.159 More and more of us are doing outreach. 00:14:42.399 --> 00:14:42.720 Dr. 00:14:42.799 --> 00:14:43.759 Walsh, anything? 00:14:43.919 --> 00:14:45.440 Any other things to add? 00:14:46.399 --> 00:14:55.440 Yeah, I agree that this is probably multifactorial and our jobs are just very demanding, both physically as well as emotionally. 00:14:55.600 --> 00:15:00.720 And I think we have a culture in our profession of being tough because of the nature of what we do. 00:15:00.960 --> 00:15:06.639 And this tough it-out culture can make it uncomfortable when we need to advocate for our needs. 00:15:07.039 --> 00:15:21.200 So a few minutes ago, we kind of averaged out how many hours we all work in a week, knowing that it can change from when you're a fellow to a junior faculty to more senior, but clearly the five of us averaged way more than 12 hours a week in the operating room. 00:15:21.360 --> 00:15:27.679 And in this study, 60% of the respondents were operating more than 12 hours a week during the third trimester. 00:15:27.919 --> 00:15:31.279 And very few actually reported any work reductions. 00:15:31.519 --> 00:15:35.919 Why do you think formal accommodations are so rare, even in academic settings? 00:15:36.159 --> 00:15:36.480 Dr. 00:15:36.639 --> 00:15:37.039 Goon? 00:15:37.600 --> 00:15:44.720 So only 5% of our respondents reported having access to an institutional policy for work hour restriction. 00:15:44.960 --> 00:15:58.320 I do imagine that a large piece of this is also cultural in terms of wanting to maximize maybe time away after a delivery and therefore not wanting to impose on colleagues or invoke leave time a minute earlier than necessary. 00:15:58.480 --> 00:16:14.720 You know, of the three pregnancy-related leaves that I coordinated as a resident and in thinking of the experience of myself and my co-fellow recently, I'm pretty comfortable saying that all of us almost universally focused on maximizing time with our newborn at the expense of trying to push harder towards the end of pregnancy. 00:16:14.960 --> 00:16:27.440 And then from a trainee perspective, you know, you add in thoughts about your case numbers and your competencies, and you're like trying to weigh what it might mean for your time in training if you start to miss portions of cases before you even start racking up your days of leave. 00:16:27.519 --> 00:16:29.360 It's, you know, a lot going on in the head. 00:16:29.600 --> 00:16:37.919 The magic of policy, I think, is that it can take the onus off of a pregnant individual from having to ask for something that's actually pretty crucial to their well-being. 00:16:38.080 --> 00:16:46.799 The example that really comes to mind for me, again, from my residency experience, was putting a firm gestational age and postpartum time limitation around taking overnight call. 00:16:46.879 --> 00:16:49.200 And I was somewhere that took a 24-hour call. 00:16:49.440 --> 00:16:55.679 Once this policy existed in writing, the puzzle of rearranging call was actually like easier to solve than we expected. 00:16:55.840 --> 00:17:10.160 And because the policy existed, trainees weren't having to negotiate with their peers or their near peers, and we received less grumbling from an administrative side from people who were not engaging in in their own pregnancies and training because it was just accepted as a this is how we do things now. 00:17:10.480 --> 00:17:11.039 So, Dr. 00:17:11.119 --> 00:17:12.720 Walsh, I'm going to put you on the spot. 00:17:12.799 --> 00:17:16.880 And as a leader at your institution, what are your thoughts about this? 00:17:17.359 --> 00:17:20.480 Well, this paper feels like a real wake-up call. 00:17:20.720 --> 00:17:32.960 I think over the last decade, our society has started to address the problem of

provider burnout and addressing the need of gynecologic oncologies during pregnancy feels like a natural extension of that work. 00:17:33.200 --> 00:17:34.160 I agree with Dr. 00:17:34.319 --> 00:17:41.839 Goon about the magic of putting a policy in place, a policies in writing, it's transparent, it puts everybody on the same page. 00:17:42.000 --> 00:17:45.519 And uh, we actually did some of this work at the University of Colorado when Dr. 00:17:45.599 --> 00:17:47.039 Sanders was a fellow with us. 00:17:47.200 --> 00:17:51.519 And so I looked back at that document, and that is from 2023. 00:17:51.680 --> 00:18:00.880 And at that point, we indicated that work accommodations would begin for fellows at 36 weeks gestation, unless earlier accommodations were recommended. 00:18:01.039 --> 00:18:07.359 And in light of this current paper, I think we have to go back and take a look at that and possibly make revisions to that policy. 00:18:07.599 --> 00:18:19.599 And I appreciate that this paper that we're talking about today provides us with some concrete recommendations from the American College of Surgeons that we can all consider implementing at our own institutions. 00:18:20.240 --> 00:18:26.400 I will unabashedly admit that before reading this paper, I was not aware of the ACS guidelines. 00:18:26.640 --> 00:18:37.359 We've already transitioned away from making people make up for or front load call for the most part, but I think that this still happens for many of us, as been stated earlier, this feeling of obligation. 00:18:37.599 --> 00:18:45.279 We do have longer parental leave allowances, primarily for faculty, but you can definitely argue that it's not long enough for our trainees for all the reasons that Dr. 00:18:45.359 --> 00:18:46.720 Goon just mentioned. 00:18:46.960 --> 00:18:54.319 At my institution, we have not routinely modified OR schedules and cases, but we've honored requests when surgeons have asked for them. 00:18:54.559 --> 00:18:59.599 And to the group, are there any best practices at your institution that you'd like to share? 00:18:59.759 --> 00:19:00.799 I'm going to start with you, Dr. 00:19:00.880 --> 00:19:01.279 Goon. 00:19:01.680 --> 00:19:01.920 Yeah. 00:19:02.079 --> 00:19:06.079 So as a trainee, you know, my perspective is a little bit different than the others on this call. 00:19:06.240 --> 00:19:16.880 I'm fortunate that at my dual-site training program, my clinical co-fellow and I are actually, we run two completely separate and independent services, and in that we're not interdependent on each other for calls. 00:19:16.960 --> 00:19:19.759 So when one of us goes out, it really doesn't impact the other one. 00:19:19.839 --> 00:19:22.000 It doesn't all automatically fall on their plate. 00:19:22.319 --> 00:19:22.559 Dr. 00:19:22.799 --> 00:19:23.359 Mills? 00:19:23.599 --> 00:19:35.839 Yeah, I mean, I think there are some incredible leave policies here at U Chicago, particularly for the faculty, having fully paid 12

weeks, both for, you know, if you're the caring partner versus if your partner delivered. 00:19:35.920 --> 00:19:47.920 I've had colleagues who were able to then stack basically kind of two three-month maternity leaves to base paternity maternity leaves to allow like their baby to basically not have to be in daycare right away. 00:19:48.000 --> 00:19:50.559 And there's been some really nice flexibility with that. 00:19:50.960 --> 00:20:01.279 You know, departments are allowed to approach some of this with some individuality, but our department hasn't routinely asked for anybody to make up calls or payback time when they're pregnant. 00:20:01.759 --> 00:20:07.759 I was basically told sort of like the policy was I provided call during the nine months of the year that I was present. 00:20:08.319 --> 00:20:10.480 We also have a really nice, and I'll point this out. 00:20:10.559 --> 00:20:13.359 I know we didn't really, we couldn't really touch on lactation in the survey. 00:20:13.759 --> 00:20:21.119 You know, at some point you have to stop asking questions, but we have a very unique lactation provision here at U of C that I think is really great. 00:20:21.440 --> 00:20:28.640 And it basically adjusts your work RVU targets to be reduced by about 5% during the nine months when you come back from your leave. 00:20:28.720 --> 00:20:30.880 And it includes a block in your clinic. 00:20:31.039 --> 00:20:32.880 And it's just it's really nice. 00:20:33.200 --> 00:20:37.039 You know, to what everyone's been talking about, you have this policy in place and you're empowered to use it. 00:20:37.440 --> 00:20:42.480 You go sit down in your office and you pump and you don't feel like you're really, really far behind. 00:20:42.640 --> 00:20:50.240 And I do think it helped me, you know, this second time around, feel like really empowered to keep going pumping all the way to that full one year mark. 00:20:50.880 --> 00:20:56.480 But yeah, I I think like many places, we don't have like a super formal in writing. 00:20:56.559 --> 00:21:04.400 I just found that like my partners were saying, just call me, like, let's do these cases together, like, you know, don't do this call, I'll take this weekend. 00:21:04.559 --> 00:21:06.079 But again, more informal. 00:21:06.799 --> 00:21:18.880 Yeah, we have a similar lactation policy with time and an RVU modification for a year and even up to 24 months because of the recommendations from the American Academy of Pediatrics regarding lactation and breastfeeding. 00:21:19.119 --> 00:21:19.359 Dr. 00:21:19.440 --> 00:21:20.559 Walsh, any additions? 00:21:21.119 --> 00:21:28.960 Yeah, we've had faculty and fellows out on parental leaves in the last couple of years, and our division has been generally supportive. 00:21:29.200 --> 00:21:34.960 Most have taken two months off after delivery, and that's both maternity and paternity leaves. 00:21:35.039 --> 00:21:38.480 And some of our faculty have chosen to take even longer leaves of three

months. 00:21:38.720 --> 00:21:41.119 And the leaves don't have to be consecutively taken. 00:21:41.200 --> 00:21:47.200 So sometimes the provider will take a month off, come back to work, and then take another month off when their partner goes back to work. 00:21:47.519 --> 00:21:55.920 So I feel fortunate that our group has been able to accommodate these leaves and time offer appointments, and we've been able to absorb the extra work. 00:21:56.319 --> 00:21:57.039 That's awesome. 00:21:57.440 --> 00:21:57.680 Dr. 00:21:57.759 --> 00:21:59.759 Sanders, yeah, I agree with what's been said. 00:22:00.160 --> 00:22:08.559 Said, and in terms of trainees, I also try to encourage trainees to work with their colleagues to limit their call after they also return to work. 00:22:08.799 --> 00:22:12.799 So I know that call obviously adds sleepless nights, but so does having a new infant. 00:22:13.119 --> 00:22:19.599 And it sort of seems like anecdotally, when a lot of folks are going back to work, is sort of when we quote unquote say the infant wakes up. 00:22:19.759 --> 00:22:26.799 So not only are you then getting back into the call pool, but then you're also having to care for this infant that uh seemingly doesn't want to sleep. 00:22:26.960 --> 00:22:34.400 So I do um again encourage trainees and also faculty to give themselves a little bit of time to readjust before taking on a full clinical workload. 00:22:34.799 --> 00:22:36.079 Thank you all for sharing. 00:22:36.240 --> 00:22:38.799 I want to get back to the topic of making up call. 00:22:38.960 --> 00:22:39.359 Uh, Dr. 00:22:39.440 --> 00:22:40.079 Goon and Dr. 00:22:40.160 --> 00:22:50.880 Mills, you were very candid that accommodating one person's pregnancy may or may not affect the whole team's call burden, especially for other trainees, junior faculty, or residents for that matter. 00:22:51.039 --> 00:22:58.720 How should programs think about that trade-off and instead of just avoiding it or maybe making folks make up the call, even if policies say otherwise? 00:22:58.799 --> 00:23:01.839 Again, we all feel very irresponsible for our teams and our partners. 00:23:02.079 --> 00:23:02.319 Dr. 00:23:02.480 --> 00:23:03.839 Goon, I'd like to start with you. 00:23:03.920 --> 00:23:13.200 As the only trainee in our podcast today, your survey reported that 72% of trainees took less than eight weeks off versus 27% of the attendings. 00:23:13.359 --> 00:23:17.920 Is this a training culture problem, a policy problem, or both? 00:23:18.319 --> 00:23:23.039 You know, it's probably both, as with most things we've been talking about today that are multifactorial. 00:23:23.279 --> 00:23:25.759 I suspect a good piece of it is policy related. 00:23:25.920 --> 00:23:37.599 I will also say that, you know, ABOG more recently updated their leave policy for trainees and that a number of the pregnancies that were captured in our survey occurred before that that change went into place. 00:23:37.759 --> 00:23:46.240

But I think some of it's probably cultural too, more from an aspect, I think, of trainees feeling averse to extending their training as a result of taking longer leave. 00:23:46.400 --> 00:23:48.400 But the time has to come from somewhere, right? 00:23:48.480 --> 00:23:51.920 And we have to graduate as competent gynecologic oncologists. 00:23:52.079 --> 00:23:58.079 So I think perhaps normalizing delayed graduation just to take the stigma away from it may be a reasonable first step. 00:23:58.400 --> 00:24:02.640 And I think it's definitely one that's worth considering, I think, on an individual basis. 00:24:02.880 --> 00:24:04.240 As you mentioned, Dr. 00:24:04.400 --> 00:24:07.920 Goon, A Bog updated their leave policy in 2020. 00:24:08.079 --> 00:24:15.359 But given that most of the pregnancies by the survey participants predated that change, do you have any sense of whether things have actually improved since then? 00:24:15.519 --> 00:24:15.759 Dr. 00:24:15.839 --> 00:24:16.880 Mills, what do you think? 00:24:17.200 --> 00:24:18.960 I mean, obviously it's hard to say. 00:24:19.119 --> 00:24:22.799 We aren't like walking around being like, you were a fellow who then had a baby. 00:24:22.960 --> 00:24:26.400 Like that would be you'd probably be able to figure out who those people are pretty fast. 00:24:26.559 --> 00:24:28.960 But I think it's just the normalization of it. 00:24:29.039 --> 00:24:41.599 You know, I have heard more and more people saying, like, you know, I'm actually graduating from fellowship on this date, which I know as a fellowship PD is not exactly in line with when you might expect based on a traditional calendar. 00:24:41.839 --> 00:24:46.880 And so I think perhaps maybe it's both like trainees are feeling empowered to do it. 00:24:47.119 --> 00:24:56.640 But I think also you're seeing folks who are in that fellowship PD hat saying, like, I'm going to just tell my fellow it's fine. 00:24:56.960 --> 00:24:58.240 Take the time you need. 00:24:58.480 --> 00:25:01.599 I'm gonna tell you in 10 years, you won't even remember this. 00:25:01.759 --> 00:25:08.799 It will be the tiniest little blip and wherever you're headed next won't know or care for that matter. 00:25:09.119 --> 00:25:18.480 If you graduated on this date or six weeks later, I think it's just important that we recognize that that time can sometimes need to be longer. 00:25:18.720 --> 00:25:19.680 And that's okay. 00:25:19.839 --> 00:25:36.240 But we want people to come out both competent but also well and healthy and complete so that when they start their job as an attending or faculty or wherever they end up, they're in a good state of mind and they're not just like scrambling trying to make this happen. 00:25:36.559 --> 00:25:38.400 Yeah, I mean, I really couldn't agree more. 00:25:38.559 --> 00:25:50.000 A month, six weeks can seem like such an eternity when you're in the moment, but in the grand scheme of the marathon that is our careers, and that these are such

important, monumentous moments for all of us. 00:25:50.160 --> 00:25:53.680 It really is, like you said, just a blip on the radar screen. 00:25:53.920 --> 00:26:02.480 While there have been many sobering comments and findings from this paper tonight, I do want to touch upon an experience that respondents had after a pregnancy loss. 00:26:02.720 --> 00:26:10.720 84% of the respondents took no time away after a pregnancy loss, and only 40% indicated that their colleagues supported their time away. 00:26:10.960 --> 00:26:14.319 33% said that their leadership supported their time. 00:26:14.559 --> 00:26:21.759 What would meaningful support after a loss actually look like as we think about even privacy and disclosure of that pregnancy at that time? 00:26:21.920 --> 00:26:25.279 From these responses, it really seems like colleagues were aware. 00:26:25.440 --> 00:26:25.680 Dr. 00:26:25.839 --> 00:26:26.559 Goon, Dr. 00:26:26.640 --> 00:26:27.920 Mills, what thoughts do you have? 00:26:28.240 --> 00:26:30.400 So I think loss is really complicated. 00:26:30.559 --> 00:26:37.200 And I think there's probably a great deal of losses that we didn't necessarily capture, and we've talked about that a little bit already. 00:26:37.440 --> 00:26:40.720 But in our study, about a quarter didn't want to disclose. 00:26:40.880 --> 00:26:42.400 And that's really meaningful. 00:26:42.640 --> 00:26:56.160 And that also might mean that there are probably many people who, when the survey went out, skimmed it really quick, didn't really think we wanted to capture those or whatever else, or didn't really feel comfortable for fear of identification or, you know, I don't know. 00:26:56.400 --> 00:27:08.640 But I just wonder how often when people are having a loss and they're not talking about it for whatever the reason, you know, shame, anger, grief, et cetera, that they'd rather not have to disclose it to anybody that they work with. 00:27:09.039 --> 00:27:22.000 And I also think, you know, sometimes we could project our own beliefs onto others and say, like, you know, there could be some signaling that a loss doesn't like require leave or sick time, maybe unintentionally, right? 00:27:22.319 --> 00:27:28.880 These are are rough periods when you go through a loss for whatever the reason and the emotions can be widely variable from person to person. 00:27:29.359 --> 00:27:36.640 I think just there can be the option, probably for many people to feel empowered to even just use a little bit of their sick time. 00:27:36.960 --> 00:27:43.200 You know, I I'll come right out and say, as my own experience, I I did suffer on a miscarriage with my first pregnancy. 00:27:43.279 --> 00:27:45.759 I was devastated and I told nobody. 00:27:46.000 --> 00:27:48.960 I just didn't want to even have to cross that bridge. 00:27:49.279 --> 00:27:52.559 And I don't now looking back at it, I don't know why. 00:27:52.720 --> 00:27:57.599 I don't know why I didn't feel like I could go to somebody and just be like, I had this miscarriage, I'm totally devastated. 00:27:57.839 --> 00:28:01.599 I just need more than like this weekend and come back. 00:28:01.759 --> 00:28:02.880 Like I just need a little time. 00:28:03.119 --> 00:28:05.920 But I I didn't feel like I could for whatever the reason. 00:28:06.000 --> 00:28:16.559 And I I hope that maybe just by people talking about normalizing you, you know, using leave as needed, even if it's not for a live birth, like people will feel empowered to do so. 00:28:16.880 --> 00:28:17.200 Dr. 00:28:17.359 --> 00:28:19.440 Mills, thank you so much for sharing that. 00:28:19.599 --> 00:28:21.759 I think that's really a very important message. 00:28:21.839 --> 00:28:30.079 And it's important for us as attendings to share those kinds of things so other people feel more comfortable and safe in a space to talk about it. 00:28:30.319 --> 00:28:30.559 Dr. 00:28:30.799 --> 00:28:32.559 Goon, do you have anything to add? 00:28:32.880 --> 00:28:35.039 Yeah, just a couple short things. 00:28:35.200 --> 00:28:42.960 I think my first takeaway is that I wouldn't want to put everyone into a universal bucket for how to process the grief that comes with the loss. 00:28:43.200 --> 00:28:49.039 I think some people would prefer business as you as usual or somewhat close to usual, and I think others need time. 00:28:49.359 --> 00:28:58.559 My ideal world would probably manage leave after loss, honestly, similar to any other type of bodily injury, which admittedly should also be afforded a lot of privacy. 00:28:58.880 --> 00:28:59.440 100%. 00:29:00.000 --> 00:29:01.279 I completely agree. 00:29:01.519 --> 00:29:08.640 We do have to create space for individuals and privacy to navigate these difficult situations as they feel like they need to. 00:29:08.960 --> 00:29:14.319 While this is so important, I do want to pivot a little bit because our time is limited to talk about solutions. 00:29:14.559 --> 00:29:21.039 But before we do that, 62% of respondents delayed childbearing for training and three-quarters regretted it. 00:29:21.200 --> 00:29:24.799 I know that we waited to start our family until after I finished my fellowship. 00:29:25.039 --> 00:29:28.720 What do program directors most need to hear from that statistic? 00:29:28.799 --> 00:29:29.680 And I'm going to ask Dr. 00:29:29.759 --> 00:29:30.480 Walsh and Dr. 00:29:30.559 --> 00:29:35.039 Sanders to address this in their roles as division director and associate program directors. 00:29:35.200 --> 00:29:35.440 Dr. 00:29:35.519 --> 00:29:36.799 Walsh, let's start with you. 00:29:37.599 --> 00:29:42.160 So, like you, I also waited to start my family until after I finished my fellowship. 00:29:42.240 --> 00:29:44.960 And I think that was really common in our era. 00:29:45.200 --> 00:29:49.200 It seems like this might be shifting where more trainees are now pursuing parenthood. 00:29:49.440 --> 00:29:54.000 And we mentioned in the editorial, the road to becoming a

gynecologic oncologist is a long one. 00:29:54.079 --> 00:29:58.480 And it's difficult to be at about 33 years old at the end of training. 00:29:58.640 --> 00:30:04.000 And so there really is no perfect time to start a family when you are on this on this track. 00:30:04.240 --> 00:30:13.279 And it's inevitable that a division director or a fellowship program director is going to have a junior faculty member or a fellow come to them with news of a pregnancy. 00:30:13.440 --> 00:30:20.400 And I think this article points out really the importance of having a policy in place in order to provide the needed support. 00:30:20.720 --> 00:30:21.039 Dr. 00:30:21.119 --> 00:30:21.759 Sanders? 00:30:22.319 --> 00:30:23.279 Yeah, I agree with Dr. 00:30:23.359 --> 00:30:23.920 Walsh. 00:30:24.000 --> 00:30:27.920 And, you know, we're seeing that our trainees and colleagues are coming to us with news of a pregnancy. 00:30:28.000 --> 00:30:35.440 And you can see that they're actually almost nervous to oftentimes tell their program directors and faculty or partners when they're pregnant. 00:30:35.599 --> 00:30:39.359 So I think it's really important that we let our trainees know that we really can work together. 00:30:39.599 --> 00:30:42.640 We can optimize both their training and their pregnancy outcomes. 00:30:42.799 --> 00:30:47.680 And while, you know, words are important, I think that really showing what we mean speaks volumes. 00:30:47.759 --> 00:30:50.559 And I feel that in my own experience, and I'm not just saying this because Dr. 00:30:50.640 --> 00:30:57.359 Walsh is also with us, but I really was supported, you know, before, during, and after the birth of my own child in fellowship. 00:30:57.519 --> 00:31:00.880 And so I hope that my experience becomes more of the rule than the exception. 00:31:01.039 --> 00:31:11.519 I also hope that if we repeated this study in another 10 years, we would hopefully see that there are going to be fewer folks who felt that they needed to delay their childbearing and even fewer that regretted that. 00:31:11.839 --> 00:31:12.079 Dr. 00:31:12.240 --> 00:31:14.079 Mills, in your paper, you and Dr. 00:31:14.160 --> 00:31:19.039 Goon lay out four specific recommendations modeled on the American College of Surgeons guidelines. 00:31:19.200 --> 00:31:22.640 Which one do you think is most feasible to implement in the next year? 00:31:22.720 --> 00:31:24.880 And which one might be the heaviest lift? 00:31:25.200 --> 00:31:32.480 Well, I think one of the most feasible realistically is that Gyneunks shouldn't be penalized from promotion trajectories, progression. 00:31:32.720 --> 00:31:40.960 And I think that's one that current leadership could really like take to heart and latch onto because it doesn't really cost them anything, right? 00:31:41.200 --> 00:31:48.720 You aren't looking to hire a locums person to cover for three months or, you know, find a way to keep their salary support going or something. 00:31:48.960 --> 00:31:56.720 This is just recognizing that their contributions that they've made and will make when they come back are not somehow less by taking a parental leave. 00:31:57.039 --> 00:31:57.279 Dr. 00:31:57.440 --> 00:31:57.920 Goon? 00:31:58.400 --> 00:32:06.640 Yeah, on the flip side of that, I think in terms of biggest lifts, things like compensation and eliminating call makeup are gonna take the most effort. 00:32:06.880 --> 00:32:12.480 To some degree, it's you know, it's a resource management game and you can't just draft more time and money out of the ether. 00:32:12.960 --> 00:32:15.440 As a chair, I completely understand that. 00:32:15.759 --> 00:32:20.319 But talking about our society, what role should SGO itself play here? 00:32:20.480 --> 00:32:23.359 You know, is this a job for society level guidelines? 00:32:23.599 --> 00:32:26.160 Do we leave it to our individual institutions? 00:32:26.559 --> 00:32:30.799 Both we've talked about the importance of having policies in place for this. 00:32:31.039 --> 00:32:31.359 Dr. 00:32:31.440 --> 00:32:34.400 Walsh, I'm gonna put you on the spot here and start with you. 00:32:34.799 --> 00:32:40.799 Yeah, so you know, the question of whether SGO should play a role is a really great one. 00:32:41.039 --> 00:32:47.359 I think that different programs and different practices are probably going to approach this differently. 00:32:47.440 --> 00:32:54.559 There will be nuances to how this is implemented, but I think guidance from SGO could be really valuable. 00:32:55.039 --> 00:32:55.759 I agree. 00:32:56.079 --> 00:32:56.400 Dr. 00:32:56.480 --> 00:32:59.279 Sanders, I'm gonna ask you to put your associate PD hat on. 00:32:59.359 --> 00:33:02.319 And I think a lot of fellowships are maybe a little bit different than Dr. 00:33:02.480 --> 00:33:07.759 Goon's experience, where if you have a small fellowship, the two fellows are interrelated. 00:33:08.000 --> 00:33:12.480 How does a program manage when one of two clinical fellows takes time off? 00:33:12.640 --> 00:33:18.400 Small fellowships or even small practices don't have the redundancy or slack that larger departments do. 00:33:18.640 --> 00:33:23.119 What would you say are answer or suggestions for a two-fellow program? 00:33:23.920 --> 00:33:34.640 I think if a program has such little redundancy that one fellow being away makes it impossible to maintain adequate patient care, I think it's also an opportunity to reconsider how the system is functioning. 00:33:34.880 --> 00:33:41.279 So in a two-fellow program, this requires a little bit more planning and creativity, but life happens during fellowship as we know. 00:33:41.359 --> 00:33:48.960 So whether that's the birth of a child or a cancer diagnosis of a co-fellow or a death in the family or another unexpected major life event. 00:33:49.119 --> 00:33:51.279 So this isn't just isolated to a birth. 00:33:51.519 --> 00:33:56.160 The answer can't just be that the fellow who remains simply absorbs the

additional workload indefinitely. 00:33:56.319 --> 00:34:07.359 I think that programs need to be creative and adaptable, and whether that means leveraging faculty or redistributing clinical responsibilities, adjusting rotations, or temporarily modifying schedules. 00:34:07.519 --> 00:34:14.239 I think that we can continue to provide excellent patient care and meaningful education while also supporting our trainees through major personal events. 00:34:14.559 --> 00:34:15.360 That's great. 00:34:15.599 --> 00:34:17.039 That's the ideal world. 00:34:17.280 --> 00:34:19.039 Any other thoughts from the panel? 00:34:19.679 --> 00:34:20.239 I think Dr. 00:34:20.320 --> 00:34:21.679 Sanders summed it up pretty well. 00:34:22.000 --> 00:34:22.880 I would agree. 00:34:23.119 --> 00:34:23.599 All right. 00:34:23.760 --> 00:34:29.039 So the editorial points out financial disincentives, which we haven't discussed yet. 00:34:29.199 --> 00:34:35.840 And while this doesn't apply to the training necessarily, it can most certainly impact the faculty or those in private practice. 00:34:36.079 --> 00:34:39.760 Most places do have an RVU-based compensation model. 00:34:39.920 --> 00:34:41.199 So how do we account for this? 00:34:41.360 --> 00:34:50.239 The American College of Surgeons specifically highlights that adaptations to third trimester work hours and leave after delivery should not be penalizing the surgeon. 00:34:50.480 --> 00:34:52.239 What happens at your home institutions? 00:34:52.400 --> 00:34:52.719 Dr. 00:34:52.800 --> 00:34:53.519 Walsh? 00:34:54.239 --> 00:35:03.519 So we do prorate work RVU targets to account for time off from work, whether it's for parental leave or being out sick for some other reason. 00:35:03.840 --> 00:35:08.480 And so our individual providers that take leave are not individually penalized. 00:35:08.719 --> 00:35:16.000 But as a group, if we have a lot of providers out in one fiscal year, it can have an impact on the finances of the entire division. 00:35:16.159 --> 00:35:19.039 And it could impact end-of-year incentives. 00:35:19.360 --> 00:35:25.119 Yeah, these are the unfortunate realities of medicine nowadays, for sure. 00:35:25.360 --> 00:35:28.000 The editorial, and this is an important issue. 00:35:28.159 --> 00:35:33.360 I don't mean to cut finances and productivity off, but there's a lot of other things I want us to talk about today. 00:35:33.599 --> 00:35:41.760 So the editorial ends by asking gynecologic oncologists directly, do we have the courage to champion this call to action? 00:35:42.000 --> 00:35:46.960 I would like to ask the panel, what would it look like to actually show up and take this on? 00:35:47.199 --> 00:35:55.840 If a division chief, a fellowship director, a department, a practice leader who is listening today could only do one thing, what would you want it to be? 00:35:56.079 --> 00:35:56.400 Dr. 00:35:56.559 --> 00:35:57.039 Goon? 00:35:57.840 --> 00:36:02.960 I think in the absence of protective

policy, I would ask for help with problem solving. 00:36:03.119 --> 00:36:17.679 You know, is it the flexibility to move an OR or even one or two clinic appointments around that could honestly be the difference between a program that supports you and a program that says you need to fit everything about your life into the rigidity of this job as it stands right now. 00:36:17.920 --> 00:36:21.360 As a trainee, you honestly don't always have this type of autonomy. 00:36:21.440 --> 00:36:25.360 So even being given even a small dose of it can go a really long way. 00:36:25.760 --> 00:36:26.079 Dr. 00:36:26.239 --> 00:36:26.960 Mills. 00:36:27.599 --> 00:36:31.440 I would probably vote for leadership flexibility. 00:36:31.679 --> 00:36:42.719 So recognizing that, of course, written policy is the best, but also understanding that those policies can maybe not always be like one size fits all. 00:36:42.960 --> 00:36:46.719 So, you know, looking at the person in front of you and saying, like, what do they really need? 00:36:46.800 --> 00:36:47.920 Where can I meet them? 00:36:48.079 --> 00:36:50.800 Where, you know, where we're at right now. 00:36:50.960 --> 00:36:59.599 You know, I think sometimes even just saying, like, you know, the junior, the junior faculty is in your office saying, hey, I'm pregnant. 00:36:59.760 --> 00:37:01.840 Maybe I've already had a preterm delivery. 00:37:01.920 --> 00:37:04.320 Like, can you help me figure out how we're gonna do this? 00:37:04.559 --> 00:37:09.440 And feeling like, yeah, actually, I've looked through all the OR cases and, you know, I'm gonna scrub them with you. 00:37:09.599 --> 00:37:12.239 Or we're splitting them up between me and these other partners. 00:37:12.320 --> 00:37:17.920 And I think those small little things outside of like written formal policy go a long way. 00:37:18.480 --> 00:37:21.039 So actions speak louder than words. 00:37:21.360 --> 00:37:21.679 Dr. 00:37:21.760 --> 00:37:23.360 Sanders, any other thoughts? 00:37:23.760 --> 00:37:24.639 I totally agree with Dr. 00:37:24.719 --> 00:37:25.119 Mills. 00:37:25.199 --> 00:37:27.519 I was just gonna say, show your support, don't just say it. 00:37:27.679 --> 00:37:43.519 So, you know, I would call your trainee and wish them a health, healthy delivery, check in with them before their first big case back from leave just to see how they're feeling about returning to the OR, or you know, close the abdomen for them, even as a faculty after a long case so that the fellow could go step away and express milk. 00:37:43.760 --> 00:37:51.840 So I think sometimes again, showing your support is just as simple as anticipating what your trainee may need and making it easier for them so they don't have to ask. 00:37:52.239 --> 00:37:52.559 Dr. 00:37:52.719 --> 00:37:54.559 Walsh, any other thoughts? 00:37:54.960 --> 00:37:57.840 Yeah, I agree with all of those comments. 00:37:58.000 --> 00:38:01.920 I agree that it's probably not a one-size-fits-all solution.

00:38:02.159 --> 00:38:04.159 Everyone's going to have different needs. 00:38:04.320 --> 00:38:15.920 I would support having a menu of options available for the guy nonkise's pregnant, and then they can decide what feels right to them and at what point they would like to institute work accommodations during the third trimester. 00:38:16.079 --> 00:38:22.400 And the article does a really nice job of providing some examples of how some of our colleagues were supported. 00:38:22.559 --> 00:38:36.719 And so that could include work hour reductions, decreased surgical volume or intensity of cases, transitioning to an exclusively ambulatory clinic role, pausing on the acceptance of new patients, or reducing the number of hours work per week. 00:38:36.880 --> 00:38:43.199 But most importantly, I think it's important that the leadership and the members of the practice of the program show their support. 00:38:43.920 --> 00:38:46.320 Before we wrap up, I'd like to ask Dr. 00:38:46.400 --> 00:38:50.239 Goon and Mills, what's the next study you'd want to do here? 00:38:50.480 --> 00:38:56.960 Should we survey reintegration to work after leave, lactation support, RVU models, or other impacts? 00:38:57.119 --> 00:38:57.440 Dr. 00:38:57.519 --> 00:38:58.159 Goon? 00:38:58.559 --> 00:39:00.880 You know, we've thrown around all of those topics. 00:39:01.039 --> 00:39:06.159 I personally would love to dig deeper into the reintegration piece, in part because I think as Dr. 00:39:06.239 --> 00:39:13.760 Sanders mentioned earlier, it extends beyond pregnancy to other ways that our life might impact our careers as gynecologic oncologists. 00:39:13.920 --> 00:39:19.679 And in part because I think there's also probably a number of hidden best practices that have yet to be told. 00:39:20.079 --> 00:39:20.559 So true. 00:39:20.800 --> 00:39:21.039 Dr. 00:39:21.119 --> 00:39:21.679 Mills? 00:39:21.920 --> 00:39:23.280 Yeah, I completely agree. 00:39:23.440 --> 00:39:23.679 Dr. 00:39:23.840 --> 00:39:28.719 Goon and I have obviously like talked about this in detail about like how we would follow this up. 00:39:28.880 --> 00:39:32.559 And both of us having done the reintegration, it's really tough. 00:39:32.719 --> 00:39:33.840 It's really fragile. 00:39:34.000 --> 00:39:42.159 I think it's one of those times that you are coming back to work and you're trying to reintegrate into your job, but you're also a different person than you were when you left it. 00:39:42.239 --> 00:39:47.360 And the things that maybe you thought were so important even six months ago are now 180 different. 00:39:47.519 --> 00:40:01.599 So I think it would also be interesting to look into, you know, what roles or or how the impact of different leadership styles on a reintegrating, you know, return from leave provider, what's best practices, right? 00:40:01.679 --> 00:40:05.199 Because I think it's sort of left to the individual to know. 00:40:05.280 --> 00:40:09.920 And perhaps we're not helping the reintegrating process as much as we could be. 00:40:10.239 --> 00:40:14.639 Yeah, I like that idea of reintegration being the first place to think about next. 00:40:14.719 --> 00:40:16.719 It's so important because you're so right. 00:40:16.800 --> 00:40:18.960 You are not the same person when you come back. 00:40:19.360 --> 00:40:23.280 I really want to thank all of you for joining me for this really important discussion. 00:40:23.360 --> 00:40:31.519 And I want to finish a line from the editorial, and I kind of alluded to this earlier, and I'm just going to quote it because it's so well written. 00:40:31.679 --> 00:40:42.239 As gynecologic oncologists, do we really have the courage to champion this call to action and to give our colleagues the time and support needed for pregnancy, postpartum, and other health needs? 00:40:42.480 --> 00:40:50.719 I would say that to those of us who are further along in our careers, that really we need to lead this effort and give voice to our younger colleagues. 00:40:50.960 --> 00:40:55.119 Just because this might not have been our experience doesn't mean that it should be theirs. 00:40:55.360 --> 00:40:56.800 So thank you all so much. 00:40:56.960 --> 00:40:59.360 I was honored to moderate this with you today. 00:40:59.440 --> 00:41:04.559 And please, let's not allow this to be the end of this conversation, but the beginning of our action. 00:41:06.880 --> 00:41:10.719 My thanks to our podcasters and all of our guests for joining us today. 00:41:10.960 --> 00:41:17.199 The article and editorial we've discussed are available at gynecologic oncology online.net. 00:41:17.440 --> 00:41:23.440 And you can access our podcast at the journal's homepage, Apple iTunes, Google Play, and Spotify. 00:41:23.679 --> 00:41:25.679 Thank you for listening and be well.