Sula (00:00.184): Hello, I'm Dr. Sula Windgassen, health psychologist and psychotherapist and host of the How We Really Feel podcast. This season deep dives the biopsychosocial nature of pelvic, bladder, and continence conditions. In this episode, I explore the question how do we accept our health realities without shrinking our lives to fit broken systems? I was joined by two incredible guests, highly qualified, to explore this question and more. Matt Castelluccio. President of Community Support at United Spinal Association, where he uses his lived experience as a paraplegic and over two decades of expertise to help people navigating spinal cord issues, including changes to bladder and bowel function. A passionate patient advocate, Matt helps others advocate for themselves and get involved in collective efforts to shift systems to provide better care for all. Joining him was Jane Wierbicky, the nurse information specialist at the United Spinal Association. Leveraging over 35 years of nursing experience focused on spinal cord injuries and related disabilities. With her deep expertise in addressing the complexities of bladder, pelvic and continence issues, Jane provides essential guidance and support to individuals navigating these challenges, supporting them to advocate for themselves and working with professionals to ensure they receive the compassionate and informed care that they deserve. What I loved about this conversation was the recognition that change starts small. The power of collectivizing in whatever way is accessible to you in this moment, and that our capacity and scope for changing big structures evolves as we arm ourselves with knowledge, curiosity, and connection. I hope you enjoy this. speaker-0 (01:43.074) This podcast wouldn't be coming to you if it wasn't for our wonderful partners, Convitec Continence Care. I worked with Convitech to develop a free to access, first of its kind, holistic wellbeing program tailored for the several million people who intermittently self catheterize. This online interactive program covers everything from bladder and catheter related concerns, impact on socialising, sex life, and well being, to reconnecting with yourself so that you can live a life with confidence. Whether you use catheter or support those who do, you can access this completely free by checking out the show notes. speaker-0 (02:21.582) Thank you both so much for agreeing to come on the podcast and share your wisdom. I'm really excited to have you both and to to talk about this topic, which is often one that really stumps people. You know, we're not really taught to to think about acceptance and, you know, where's the line between accepting things and, you know, stepping into empowerment. So I'm really, really excited to get into it. But before we start, perhaps would you be so kind as to introduce yourselves, perhaps starting with you, Jane. speaker-1 (02:51.048) Yes, thank you. my name is Jane Werbiggy. I'm a nurse information specialist with United Spinal Association. I work in the resource center here, fielding many of the calls that come in from our members who are people with many wide range of conditions, spinal cord injury, spinal cord disorders, and other neurological conditions as well. So I address many of those is issues as they come in. I formerly worked with a spinal code injury model system center here in the United States for more than twenty years, as a rehab nurse and then later in some research. speaker-0 (03:28.264) And perhaps also just to give a backdrop of the the organisation, Jane, for people who aren't aware of United Spinal. speaker-1 (03:34.626) So United Spinal Association is a membership organization for people with spinal quid injuries, but also wheelchair users where there is alignment with our mission and values and resources that we offer. we have multiple services, but like I said, I work with the resource center and so we address questions that come in on all manner of things from new injury or new diagnosis to living with the condition for many, many years. We offer a great deal of peer support. We have a magazine, New Mobility Magazine for wheelchair users that discusses all manner of living with spinal cord injury and other, you know, active lifestyle issues. So it's a great magazine. We have advocacy and you know pol public policy division that focuses on you know making sure that the needs of our members are met. And so that's just a very brief overview. speaker-0 (04:35.404) Yeah, sounds fantastic. Yeah. I I can't wait to dive into some of what you do and the specifics in those different areas. Matthew, I'd love to hear a bit about you and what you do. speaker-2 (04:45.432) Good morning. I'm Matthew Castellccio. I am currently the interim CEO for United Spinal Association. I'm also been associated with the organization f since the onset of my injury 23 years ago. I've been a chapter leader for the last sixteen years for the Hudson Valley Chapter in New York State. and prior to United Spinal. I worked in rehab for 15 years in multiple roles from peer mentor coordinator to professional trainer to administration. after that transitioning out into the community in roles with the Centers for Independent Living and ultimately we united the Spino. As I stated earlier, I've been chair user for twenty-three years. I am a parablegic with brachial plexus injury that impacts my upper extremities as well. so thank you for having us here today. speaker-0 (05:54.146) Yeah, it's fantastic to have you both. And it what's so lovely about this podcast and the people that I've gotten to speak to and you guys too is the level of insight, you know, from you know, lived experience as well as very on the ground broad range of professional experience, you know, working directly with users. Often a lot of the guests like yourself, Matthew, have experienced, you know, some of the issues that we're talking about. And then all the way up to the more kind of policy, structural, and systemic issues and and kind of how we influence those. So I'd love to start exploring all of this with you. And and I guess one of the things that commonly comes up when I'm working with clients who've gone through health changes, often stark, you know, in in nature. So going from one reality to another is to what degree is it possible to change what's happening and to what degree Do I have to accept? And I remember going to see, I don't know if you've heard of Russ Harris, who talks a lot on acceptance commitment therapy. And, you know, he's written some fantastic books about this topic of acceptance, but he talks about acceptance commitment therapy have having a branding problem because we so often equate the words acceptance with resignation, and it feels like a powerless act. So Yeah, I'd love to hear f both of your perspectives just to start off with, you know, what does acceptance mean in the context that you work in and how do people you work with relate to that word? speaker-1 (07:28.014) You know, I would say that acceptance, you know, for for many of the people that we work with or who engage with our organization looks different for everybody across time and everyone adjusts to that new injury and new reality in different ways and in different time frames. And that's okay. I think you know, acceptance can look like resignation in some ways, but I think of acceptance as being a more active role where people might understand that there are some changes that they have to adapt to, but there are things they can do to maximize their health and wellness and sociability and all all manner of things over time. Sometimes it takes a bit to get people there, of course. That's how I experience it. speaker-2 (08:22.55) Yes, I I completely agree with what Jane said, you know, I think initially it's resignation, like this what I have to do to manage my bladder. and then I think over time through exposure to peers and other situations we see our members be more empowered to make decisions regarding their bladder management. from you know, exploration into systems of management and great give greater independence. for myself, you know, I do know there was some resignation at first for about a year until I realized, you know, all right, I need to actually learn more about what I can do to create a system. So, you know, i it takes time and it's a different stages. And as time goes on, there's different needs for acceptance and empowerment. You know, especially as we get older, things change in different stages. What you we used to five years ago may be different today. And it's our job in our resource center to try to help instill that empowerment, help our members to take a leadership role in their lives and Their systems. speaker-0 (09:51.372) Yeah, I I think that's really important to recognise, right? That initially, you know, resignation is almost path of the course because, you know, understandably you can be so overwhelmed with what's happened, the new reality, all of the things that you suddenly need to get acquainted with. and it is naturally overwhelming. And I talk about how that can be a protective thing that our body kind of does for us of like switching off. But that knowledge, or at least hope, that resignation at the outset doesn't mean resignation all the way through and that things are gonna stay, you know, as they are to begin with. What have you guys seen in terms of the steps of that shift change? You know, when things start to go from feeling resigned to perhaps dipping one's toe into there are things that I can do. speaker-1 (10:32.386) Ooh. speaker-2 (10:47.458) You know, I think that occurs when people start to get exposed to others in the community and learn what others are doing and understand that they can have some control over this and that it doesn't have to be this major impact on their day to day lives that they can control and manage it and still live a full life. I mean, for myself it came from peer exposure. And understanding what others are doing. And I think that's what we see a lot of is when people attend support groups, people attend our virtual groups, there's this le in our peer mentoring program, there's a level of understanding. and that's where I see the shift occur. speaker-0 (11:31.722) So powerful to see what others are doing and that can create like a template or at least a an awareness of what what other options there are. speaker-2 (11:39.948) Yes. speaker-1 (11:40.48) Absolutely. And one thing I just would add to that is today for the members that we serve, there can be a certain degree of isolation after a new injury. And certainly bladder issues can add to that, fear of you know having an accident when they're out and about or inability to find an accessible restroom, things like that. So today, you know, I think we're very fortunate because there's a lot of easier means to connect with others with similar conditions through virtual support groups and other men and other issues like that. So kind of battling that isolation and trying to make those connections as more possible. speaker-2 (12:20.3) And a lot more resources are available digitally now. So and websites that people can visit and connect with others of similar injury levels so they can learn more and educate themselves more. and not like Jane said, not feel so isolated. speaker-0 (12:39.124) Yeah, it's a really good point as well there, Jane, that you were making about the initial isolation that can happen. And I suppose what you're reflecting on is that virtual world now can can be a really good stepping stone to start to help people engage perhaps in in more of a live interactive way, you know, out out in the world. speaker-1 (13:02.878) Right. Absolutely. Gives somebody a chance to try it out and see if how they like it. You know, some oftentimes we hear from folks who are very resistant to peer support initially because for lack of better word, I guess it's becoming part of a group you did not ask to join. Yeah. And so there is a lot of resistance sometimes. But as people move on and usually when you get home and maybe start to realize maybe there's an easier way to go about this or you know, so some people come to it gradually over time, some people want to connect right away and you know, it's different purpose. speaker-2 (13:36.404) And in the US at least, there's a short and length of stay. So individuals are overloaded with information at the time of the initial rehab. And bladder menagene is one component of many things. And then they transition home and there's this feeling of disconnect from that support system. And as Jane said, the isolation occurs, a loss. So with this capability of going online and learning and getting access to fact sheets and a a better understanding and reading blogs. You know, I know for myself I wasn't initially ready to engage others, but having, you know, as more information became available digitally, it helped me to start to overcome those barriers and have a little bit of level of understanding. And also to understand what questions to ask others once I did. feel comfortable with the engagement and learn. And it's been a very big tool for a lot of our members. And then having access to our resource center has also been a great support system for them to be able to call in and gain that contact with our staff. speaker-0 (14:56.588) And I'd love to, you know, actually explore that with you a bit about when you do start to engage, like learning how how to engage essentially, what questions are important to you f to ask and you know what what connection looks like now. And maybe being surprised that it doesn't actually look that different in a lot of respects. But b before we go there, I I'm really keen to explore the bit about resistance because yeah, that can be such a hard thing to work with. And I know for clinicians as well. There is an ambiguity in when is it the right time to push or encourage engagement? And when does that actually become an unhelpful thing for somebody because they're not quite at the right stage? And I wonder if you could share some insights from what you've seen of like, are there indicators of when somebody's resistance is perhaps malleable enough to be worked with, or when They might benefit from just being allowed to be in that resistance stage? I know it's not necessarily an easy question. speaker-1 (16:01.516) You would say from a healthcare professional standpoint, you know, some people will very much let you know that they're not ready. And I think it's just important to just periodically check in and remind people what's available out there, not necessarily force it upon them, but to reconnect, re engage, let them know what's available. And, you know, oftentimes people will come when when there's sometimes maybe a precipitating event like they needed help with something and you know they've come to realize that there's a maybe a better way to go about things. So sometimes it's a precipitating event, sometimes it's just over time, you know, oftentimes it used to be, you know, hospital length of stay used to be longer. And so once people got home and it they're no longer in a particularly accessible environment or, you know, the the same amount of help isn't there, that's when there's a realization like, I need I need to connect with my community. speaker-2 (16:59.714) What I find today more than when I was in rehab is, you know, health professionals are utilizing peer mentors to come in and help support their efforts in helping, you know, engage that patient and help to educate and empower. And, you know, it is really hard. You know, I used to always tell my coworkers in the rehab world is you gotta meet a patient where they're at. Yeah, you you explain to them the that this is a tool for empowerment and then leave that and then revisit it, but you can't force it because it'll become an adverse engagement. But I think a lot of times now I'm seeing in the rehab centers, especially with our hospital partners, a lot of them have access to our chapters or our peers, and they bring the peers in to help to facilitate that engagement. So it's been a great help having that partnership. speaker-1 (18:02.636) But there's been some research too that has shown engaging people with lived experience, peer mentors in the actual rehabilitation center, in their rehabilitation activities as part of a member of the team can really be helpful. And so there's been some programs that have built upon that. speaker-0 (18:21.46) It makes a lot of sense to me as well because, you know, one of the things that I often hear people talking about in in my community is it feels like people don't understand how hard it is or what it is like. So, you know, having a healthcare professional suggests something can almost reinforce that inadvertently. But if you're hearing something from somebody who who knows or has had a similar experience, that counts for for so much more and it it makes a lot of sense that that would enhance engagement and and outcomes. I wanted to ask as well, Matt, in particular, you were saying about what did you say, meeting a patient where they are. So like it means that that's an evolving thing, right? It's not static. And I think that can be a hard thing as well in the context of systems where you might only meet a patient once or twice. You know, there's o certainly in the UK there's a lack of continuity of care. And so the Patient then only gets a couple of touch points with their particular professionals, but also the professionals only get particular touch points with the patients. And that can really solidify a sense of like that's the trajectory for that person, or this is the trajectory for me, coming whichever way you're looking at that interaction. Do you have thoughts about how we might help healthcare professionals or improve systems so that People don't get so kind of s stuck in the point at which they're seen by a particular healthcare professional and and there is a bit more of an awareness of that evolution that things can change. speaker-2 (19:55.53) I think there has been some evolution in this area, right? So when I first came out, you know, my urologist gave me one product, one system, that's it. I wasn't exposed to others. Now I feel like healthcare professionals are more aware of different products, different styles, different techniques, different methodology. I think having the conversation of how's it working, w you know what's working for you, what's not working for you. making that a key part of that few times that you engage that patient, having systems with telehealth systems, having ways of communicating with your doctor. And also for doctors to understand and healthcare professional understand the value of, you know, the engagement with other peers and understand what others are doing and bringing that information back to us. to help us drive our decision making process. One of the struggles I had, and I think many of our members feel like that they're told what to do instead of having a dialogue on you know, back and forth. You know, this is working, this isn't working with me. and it goes back to that empowerment. Our goal is, you know, our mission as an organization is to Teach our members to be empowered to ask those questions, say, look, this isn't working. And what can we do? What can I do? And advocate for themselves with their doctors. I think for healthcare professionals, they also need to take the sample of how can we empower you? What do you need? And instead of talking to your patient, having that back and forth dialogue is key and crucial. And also having access to a variety of systems of support and knowledge about systems of support. for that their patience, you know, is key. speaker-0 (21:51.778) So from the the healthcare practitioner point of view, just the power of asking questions and being curious about what is going on for for their patient and what that means to them, how that fits with them, and being open then with some flexibility of of of trying new things out when they get back that information. But if you don't ask the question, you can't find out the the answer. speaker-2 (22:16.376) Some of what happens is is I think I think instead of talking to your patient, you need to ask questions, draw the answers out from your patients. Get the feedback from your patient more than than anything else, because that's gonna drive your decision of how you're gonna assist this patient. So part of the way I operated in the rehab world was coming from, you know, a point of where are you at? Like I said, meeting a patient, where are you at? What is some of the challenges? Because I knew from my first hand experience that I didn't have that. I was using a product that wasn't working for me and no one was giving me options or asking me what is not working, what can we do. And it wasn't until I was taught to empower to to ask for a different method and a different system that I became independent with my bladder management and it didn't become such a hindrance in my day to day. I didn't want to leave my house because I feared You know, the system wasn't gonna work for me. And it was one doctor that actually taught me the about dialogue. Like that doctor asked me the question, what's not working? What can we do? Let's try this out. Let's do this. Give me your feedback. And worked with me. And it in some patients aren't gonna be forthcoming. So you need to armed with those questions to ask to draw out those answers. speaker-0 (23:41.752) Know, even just you asking that question of like what's not working for you, th there's something very hopeful about that. You know, it automatically opens up a sense of, okay, this doesn't have to be the way it is. It's it's implied but and it's a hopeful implication. so it can be so powerful just as you say, to to switch the directive statements and instructions to curious questions that you can then tailor. Jane, I'd love to hear your thoughts. speaker-1 (24:11.88) I I entirely agree with that. curiosity from the healthcare professional, it can't be overrated, you know, the willingness to dig and and find out like the details of that picture when somebody says, I had incontinence. Well, what did that mean for you? What did that look like in your life? How did that impact you? So really getting the full picture painted on how that's impacting somebody's lifestyle and and being willing to go deeper and also a willingness to collaborate with others. So sometimes not every clinician has every answer. And you know, I firm believer in teamwork. So, you know, do you need to incorporate some other specialists and to help find a solution? Do you need an occupational therapist who might look at this problem differently? Do you need a physiatrist who's going to look at the overall quality of life and how a particular issue is impacting somebody? So really thinking outside of the box and engaging other clinicians to help address the problem. speaker-2 (25:17.08) Collaboration, Jane, you hit an Led. 'Cause that was one of the things I see all time and time again. People are referred to a doctor and there's this like disconnected communication from your physiatrist to this urologist to the OT. But having a collaborative conversation and plan in place because when it comes to bladder management, it is OT with clothing management. It is, you know, the urologist with all the systems there and the physiotrist was gonna quarterback all that. And it is a key essential to helping your patient understand. And some of the times your questions, like you might ask a question, How are you doing with your catheterization? And patient might say fine. But then you need to so are you going out? What it what is your lifestyle like? And then you'll discover more of, well why aren't you going out? And realize that that fine answer was just you know, wasn't was just on the surface. There's more depth to the problem. speaker-0 (26:23.092) It yeah, it's it's interesting to explore how how closed a consultation can be without the addition of those questions, but also to unpick some of the reasons why physicians might not ask those questions or go deeper, like you two are saying are so important and I completely agree, is often what I've reflected or heard back from clinicians is because Well, I'm not psychologist or I'm not a you know, whatever the question, field of question is. And that's where the collaboration comes in, right? But do you think there are particular reasons why clinicians might find it hard to collaborate or to look into signposting? Because that would alleviate a lot of the burden on them to ask about some of these questions, to be like, I don't have the answer, I don't know exactly what to do. But I think this will be really helpful to you and you can go explore that. So from your perspective, have you seen either what helps clinicians collaborate or what gets in the way of that? speaker-1 (27:24.032) What we hear a lot of are, you know, from our members is that they've gone to a clinician who maybe isn't particularly expert in managing somebody with a disability with their particular condition. And I think a lack of training many times in working with people with disabilities, we see it all the time. So I think there's a fear of digging too deep. And so that's something we always are hoping to address is you know, providing more education for healthcare professionals so that they are more confident in providing care. I think a lot of times it's a lack of confidence and and training, but knowing when to say, Okay, this is maybe outside of my scope and I need to help this person find somebody who is particularly a specialist in this area. speaker-0 (28:16.28) Fantastic. Just even recognizing the fear can be a factor for clinicians. It's important for clinicians to reflect themselves. Like is is that some of the blocker of why I don't want to ask? Because that that's potentially an easy ish fix, you know, to take the pressure off you. You don't need to know everything as long as you've got some resources that you can signpost to. Just on, you know, thinking from the patient side of things, as you mentioned before, Matt, some patients are more forthcoming than others in a consultation. So some will have no problem saying, This is not working for me and what are the other options? Or I'm thinking about doing this. But a lot of the time it's not that way for people, especially when, you know, perhaps they're demoralized, their sense of self identity is being shaken from what's been going on health wise, and there's a lot of unknowns. And as we know from the research, and perhaps just your own personal experience of going to the doctors, there is a a power imbalance because there's an assumed person that has expertise and knowledge, and you're going in without that. So automatically we can feel as the patient, I need to defer to what this person's telling me. And whatever they say or whatever they elicit is like the tone of this conversation. it's not for me to direct it. How do you help patients advocate for themselves? What sorts of things do you you do to to help that advocacy? speaker-2 (29:51.288) So a couple of things that I teach people to do is first of all, prior to a doctor's appointment, write down some of the concerns, questions, issues you're having. Because what happens a lot of times is also people get into the appointment and they forget what they need to ask or they're embarrassed to ask it or or everything else. But if you ever written down, you can share it and say, look, here's some of the things. What I tell also individuals is that these healthcare professionals are they're a partner with you to help you achieve the ultimate independence and goals that you have. So if you would like to achieve something and don't think it's possible, you'll not know it's possible unless you ask that question. So arming yourself with the proper questions, asking the questions. And not being fearful of the response you might get. And also understanding that, you know, talking to others and asking others prior to that appointment, like what are you doing and how do you do it? And putting yourself out there with a peer and understanding what some others are doing can arm you with the knowledge of what to ask when you go into that appointment. I also, you know Like you said, sometimes when you go into an appointment, you know, you feel like, Well, this is the expert. They know better than me and I you know, and I said you can't view a relationship that way. That relationship's gotta be this is one of the tools. This person's here to help you to meet your needs. And if your needs are not being met and your lifestyle is being impacted, this person's gonna help you to Overcome those barriers and challenges that you're facing, whether it's an incontinence issue, it's a system issue of of utilization of a product, unless you ask, if you know, unless you talk, unless you or have someone advocate for you, go with someone, a family member. If you're uncomfortable, empower the family member to help open that conversation and be your support system when you're in that room. But speaker-2 (32:09.932) That dialogue needs to start with you and that's the only way it's gonna happen. speaker-0 (32:16.822) Yeah, there's some really important elements there, you know, pre planning the the questions and and checking in with your right to ask questions and to check things out and that being an important part of the consult and acknowledging that it can be difficult to to do that. So if there is a way of bringing somebody that might help advocate or nudge. That could also be like a stabiliser, right? You know, initially you go in and you get used to asking these questions with somebody else that can help you and then you you gain confidence and can do it by yourself. Jane, is there anything that you would add in in helping people advocate for themselves or get comfortable advocating? speaker-1 (32:57.996) I agree entirely with what Matt had to say. Writing down your questions going to the appointment very organized with what you wanna accomplish, like what do you want to accomplish out of this meeting and what your goals are for that. Also, I think for some people it's helpful to almost interview their doctor before they settle on a doctor. You know, is this person somebody who is gonna go maybe a bit above and beyond for me? because I have a lot of complex needs. So really kind of learning about the doctor in their style and will they do they have the you know, the curiosity to dig deeper in some of your issues. speaker-2 (33:37.178) And not be afraid to change your doctor, right? If the doctor's not addressing your needs. You know, that's a big challenge with we see with our communities. Some people stay with a doctor far longer than they should and their needs are not being met. And teaching someone that you're not tied to this, you're not contracted to this one doctor. There's many other doctors. Find out, talk to your community who they see in their area. Use your peers to guide you in finding someone that will meet your needs. speaker-0 (34:11.21) It's interesting because obviously the the US healthcare system is different from the UK. So there is potentially more scope for doing that in the US, although I should stress in the UK we can also s request different doctors. So we might not be able to pick them, but we can say I don't want to see that doctor anymore. We can make complaints and we can then be put with a different clinician. I'm recognizing that that is possible even in our our national health service. But I'm really curious in the US system where you can pick different doctors and that's kind of part of your your system possibilities more so than here. What do you think it is then that makes people stay with a doctor that's not quite working for them? speaker-1 (34:51.135) I think that can be where resignation comes into play versus acceptance. And again, sometimes it's a precipitating event that, you know, they're kind of cruising along without any particular issues, but then maybe there's new change, you know, bladder changes after years of dealing with neurogenic bladder. And so maybe there's new change that has now requires a higher degree of support. And so speaker-2 (35:17.998) Some of it is geographic, right? How close is the doctor to me? some of it is an insurance base here in the US. It's you know, what insurance plans is this doctor accepting? And then wait for an appointment, right? Sometimes there's a long wait for certain doctors that you know in their area, so they just concede to staying with their current doctor because they know they get an appointment right away and get their other needs met. speaker-1 (35:47.48) Quickly. speaker-0 (35:48.214) Yeah, sorry. It was really interesting as well to to hear about what you were reflecting on there, Jane, in terms of there can be precipitating events. So like there's a resignation part where perhaps that's just the assumed normal then. So you're resigned to it because you don't know what a doctor should be like and because you haven't had any other experience until that point, it's just assumed, well, this is what they're all gonna be like. And I think just even us talking about this and saying, you know, check out what you assume to be normal when you're you're having your healthcare consultations because perhaps it's it's really off and it's not normal whatsoever. And also the other the precipitating piece, so that things can work till a certain point and then you have additional needs. And you were saying that too Matt, that then maybe that's not the right doctor for those needs. And that can be quite a confusing thing, I think, when your doctor's been helping you in a really useful way for one particular thing or for a whole range of things, but now you're experiencing something slightly different. The care's not quite what you require. I think our brains can find that tricky to reconcile, to be like, no, but I thought this doctor was good. And we go into this dichotomous of good versus bad, but it's just great for that, but not so skilled in in this. speaker-2 (37:05.26) Yeah. And I think, you know, you gotta understand, like when we transition on we're given suggestions of doctors to engage with out in the community by our case manager. And then we have so many other aspects of our lives that we're addressing and trying to rebuild and restructure and and do this that the idea of modifying the selections of doctors becomes an overwhelming concept. We don't know where to begin. We don't have that necessarily that support system to guide us that we had when we were inpatient. So it's like, where do I start? Where do I go with this? So you just end up kind of, as Jane said, just accepting. Like it's meeting my basic needs right now. I'm just gonna stay here because it's just overwhelming concept of going to my insurance and figuring that out. And many of our contacts and our calls in our resource center are those individuals that have hit that barrier and just don't know where to turn. speaker-1 (38:13.354) And I would just add that it it doesn't always require a an entire change. If somebody is meeting the majority of your needs, but there's an aspect, you know, that's new, change in your urological situation, then maybe you just need to see a sp more of a specialist there, a neurologist, for example. So, you know, it doesn't always necessitate an entire change, but maybe just a second look or a specialist to consult with a specialist. speaker-0 (38:41.814) Yeah, not throwing out the baby with the bathwater. This conversation connects closely with the work I'm doing with Confitec Continence Care and their Mi Plus program, which supports people using intermittent catheters with both practical guidance and emotional well-being resources. If this is of interest to you and you'd like to find out more, visit Confitech dot com and access the Continence Care Mi Plus resources. Links can be found in the episode description. So I think this is a really nice introduction then to exploring the impact of some of these systemic challenges, right? So g Matt, you mentioned going from perhaps inpatient care to then this complete shift to being an outpatient and then having to find who your doctors are, what that care looks like, and just being presented with your initial normal, whatever that looks like, and and working it out as it goes. So there's the potential then for there to be real difficulties and issues at that point of transition f for people. Maybe I'd like to to start by asking a bit about what are the more systemic challenges and barriers that impact people at that point? speaker-2 (39:57.55) So, I mean at the point of transition out, I mean it's you know, here in the US we we have some challenges with insurances and gaining access to options and understanding what our options are and understanding even just the insurance model and how to navigate your insurance. You know, I know for many of our members when they leave they there's that. Disconnect of support systems. That's why organizations like United Spinal exist to help individuals support them through that. We recently have challenges with, you know, changes within the insurance model of competitive bidding right now for catheters. Now the options of access to vendors and distributors that can provide us and awareness that there are other products out there that can help us and understanding their other systems and you know, being taught with those other systems. So, I mean, there have been great challenges in that realm, but there's also been some advancements in there. You know, our community has been able to, you know, be more involved in some of the the development and the research of products and utilization of products. And, you know, that has helped to bring awareness of different products and and systems that exist for us to help be more independent with our management of bladder. There's been more resources and information available to us, greater products and modifications of products to give us independence. So that involvement, our our membership involvement in some of those discussions and decisions has been a huge growth. also in the advocacy realm there's been a lot more outreach to our community, get involved in some of the advocacy to help support systemic change and to bring our voice to the table to be heard and understood of why these things are barriers or what barriers exist and how to change it. And that has led to a lot of growth in that area. But you know, part of like for the newly injured speaker-2 (42:24.098) The challenge is is where do I begin? Where do I get started and how do I connect? And I think organizations like I said, like United Spinal provide that bridge to getting involved and to give that support system for someone to understand that peer connection to understand, you know, where to begin, what s steps to take to start to empower yourself to overcome some of those barriers that you're facing. speaker-0 (42:50.668) Yeah, there was so much in in what you said there about I guess starting to recognize that as overwhelming as it can all seem and be at the outset, you know, with all of the potential obstacles that there are and systemic things that we don't always have control over directly, it doesn't mean that A, that remains to be the case, and B that your efforts as an individual are futile because I guess what was really standing out to me is that power of collective action and voice and taking some kind of action or inroads to feel part of a collective. So it's not just this you against this huge whatever it's a conglomerate or, you know, insurance company or faceless healthcare system, but that you are part of a group that are affected and and can affect change over time. speaker-2 (43:41.854) A hundred percent. I mean, you know, what I like to see now is like I said, product development is key. A lot of times our community was adapting to what products were available to us, but now our voice is being heard at the development of the product so that the manufacturers are creating a product that meet the needs of our community and are modifying cre their development to accommodate a greater number of individuals. And also, you know, we we've been able to impact. I mean, I'll give you an example personally, like at the time for me when I first got hurt, because of my diagnosis, they said you are eligible through insurance for this one type of catheter, a straight cat. But I because of my complex disability, I kept getting UTIs one after another. And I was trying to express that. I need something else because this is just not working for me. And one of the suggestions of a peer was a closed system. My insurance was denying me of it. And I actually had to demonstrate over a period of six months all these UTIs before they would even consider it. Nowadays, twenty two years later, getting a closed system, you don't necessarily require to have to go through that and part of that came from our community having an opportunity to express the value and professionals working together to express the value to insurances of approving coverage for these products to reduce some of those medical complications that I was experiencing. Many of my members were experiencing many years ago. speaker-0 (45:27.436) It's really inspirational to hear that because when you're faced with it and you're like, What, this is my reality. I have to just keep getting these infections and proving that I'm getting them, you know, going back to that word resignation, you can see how that would make one feel resigned and there's no guarantee that even if I prove this, they're gonna change anything. So you can see how it becomes demoralizing. And I think hearing stories like yours of I went through that, I identified that as a problem, not just for me, but For others that are likely to be impacted by this. And then that collective action and and working with others to then influence change, you know, I think just recognising the process can be grueling, but change is possible. And you can guarantee, because I guess going back to your the word that you mentioned, Jane, at the beginning about that sense of isolation when you're going through something so difficult, especially when it is around these. bladder and pelvic issues that no one really wants to talk about or share, you can feel like it's really just you that's dealing with this. But when we do recognize actually there's lots of us going through these things. And if it if it is a problem for me, it's a problem for somebody else, no doubt. How can we work together to change that? That can be really galvanizing. And it can also, I suppose, what I've observed for people that I work with, it can create a bit more of that sense of empowerment more so than if you were just thinking of I have to fight for just me. so there's something really special about hearing that process. Thank you for for sharing that. Jane, do you would you say that there's any particular systemic issues or barriers that patients often come up against that feeds into that sense of resignation? speaker-1 (47:09.9) Well, I would say here in the US sometimes, particularly for folks who are in a rural area, really kind of finding the clinicians that can best help. But again, there's improvements there in terms of greater availability here in the US for telehealth services and and the ability to connect with folks that way. And of course, like I mentioned earlier. The lack of training oftentimes among general clinicians who don't specialize in spinal cord injury or neurological conditions or disability in general. The lack of training and understanding of their responsibilities under the ADA and the architectural barriers. So there are there are a number of barriers that sometimes can create that that sensation. speaker-2 (48:02.324) I mean one of the nationwide challenges is accessible offices, you know, you might have a urologist in the area, but you can't easily get onto their table or of system. So there's been a huge rise in a campaign for equitable health care and educating professionals about why making their offices having elevated tables, high low tables is so crucial. for the well being of our community. And, you know, Jane touched on, you know, sometimes in the town there's only one urologist. I know one of the challenges in my area that I get a lot of calls about in is you know a urologist that specializes in spinal cord. And the one that did retired. And so now people are sent to a general urologist who's learning as our population and j overgeneralizing their practice to us, and doesn't have a fully accessible office and people can see to that, you know, all right, well, I have to work with this 'cause this is the only one. But and that's a big problem in some areas, especially rural areas, is exactly what Jane said, is that, you know, people are limited. I mean, telehealth has opened it up to a greater coverage area and access, but There's still a big challenge that needs to be addressed. speaker-0 (49:34.636) And I think that's a really good example of how yeah, how one can really feel like there's not much choice here that I've got. You know, access to healthcare practitioners being a big one, well, this is the only person in my area or this is the only person in my area with an accessible office for me to get to. So this is what I've got to to work with. And certainly in my clinic There are issues with accessible practitioners and and and people that are trained in particular in relation to particular illnesses that people are experiencing, bladder wise and other. And so one of the conversations that is common then is so what can we do? You know, if that is the reality and if the the this is the limited choice right now, how do we keep hope and how do we work with what you've got? I'd love to hear your insights from, you know, dealing with very real barriers and challenges. How do you support people or how do you see people kind of deal with those real barriers and challenges in your community? speaker-1 (50:41.59) Well, certainly it is a challenge, as we've stated, but you know, there are things that can help. For example, and I just think staying connect again, staying connected with your community is important. For example, some of the spinal quid injury model system centers in the United States will consult with other clinicians. They don't give medical advice or opinion, but they may consult with other healthcare professionals that don't specialize in final coat injury or whatever the kid condition may be, but are willing to give advice. So that can be a helpful place to start. So certainly, you know, it is a challenge, but there are, you know, maybe workarounds sometimes. So connecting with your community, your peers, organizations that serve your condition to kind of find out what those resources or maybe general workarounds may be. Again, Having a a physician that is willing to collaborate and make those connections when they do not specialize in the particular issue you're experiencing is important. So I think finding yourself a general practitioner and urologist that are are willing to collaborate is important. speaker-0 (51:59.714) I guess one thing standing out to me there is about this staying connected with your community because you don't know what you don't know and you know, when you are faced with a particular barrier, then that understandably can feel like it's just it. And if you don't have that community that you're engaging with, that can remain your reality. Whereas if you have other people that you're in contact with navigating different elements and and similar elements to what you're going through. then opportunities can arise, you know, and and maybe sometimes they're unlikely things that you would never be able to search out yourself, but it's just through conversation or happenstance that you then get that opportunity to explore a little bit more. So I think that's a real big theme out of this conversation so far is the importance of engaging with community. speaker-1 (52:51.576) We do hear from people a lot who have, you know, been cruising along pretty well for a number of years and then, you know, some changes happen. Or they just have been cruising along doing fine and are still doing fine, but think, well, you know, it's been a long time since I've checked in to see what's new. I mean, is there anything new and how this is managed? And so I think that's an important step for anyone with any condition. Just keep yourself informed, keep connected. learn about what's new. It may not be relevant for you right now, but maybe it's something to tuck away in your mind for future use. speaker-0 (53:23.726) Absolutely. I was talking actually the other day with somebody about how even just knowing that there might be more, even if you're not engaging with it right now, can be a really protective, hopeful thing. And so maybe you're not actively engaging in particular forums or meeting up with the particular communities, but getting a newsletter so you can see things in your periphery, that at least plants the seed of there are things going on and at some point maybe you find that's the point that you want to engage. Yeah. Just homing in a little bit on the the bladder element of things and the continence element. This is so often something that can leave people feeling so helpless because as one person put it to me, it feels like the most basic of bodily function and and that everybody can just assume happens and now I I can't. And that feels so upsetting and violating. And and you used that word resistance before as well, Jane, and that's definitely what I have have witnessed in a lot of people that are dealing with these sorts of issues. So what simple concrete shifts might someone going through that make to feel a little bit more influence in their kind of bladder or continence care? speaker-1 (54:41.624) So for sm small steps is making that call, making that appointment to the physician to say, this is no longer or it never was working well for me. And what are the next steps that I can do? Again, painting that picture of how how it's not working for you, how what are the specific ways it's impacting your life? I think those things can really grab the attention of your physician more than anything else. The the very Specific details of how this has impacting your day. So reaching out, making that call, starting a plan, working with again, like Matt has said, connecting with some peers. What have you done when you've had things like this? Now, of course, ladder management is different for everyone. What's right for one is not necessarily the right approach for somebody else. But when you collect these ideas and bring them to your doctor and say, you know, this is something I'm curious about. Would this be applicable for me? Will this help me address it? So I think you know, those two steps can get people a long way in terms of advocating for their own speaker-0 (55:47.958) Yeah. Well thank you, Jane. Would you add anything there, Matt? speaker-2 (55:51.532) No, I think you know, I agree like collecting methods and information you mentioned to educate yourself. Education is empowerment. Might not be applicable to your life right now, but to gather that education, bring it to your doctors, share it, see if it works, if it's an option, learning, it's essential. I mean it's what carries most of our members to evolve in their day to day routines and and even if something is working right now, trying to see if there's other options down the road. Like what can I do? Like this is working right now, but are there any other ways and and things that I should be considering or know about? And you know, a lot of doctors will provide you with resources to go home or to look into and explore. And, you know, when it comes to bladder and bowel, it's a big load for us to carry. You know, I always say to people like when I got paralyzed, I was like, all right, I accept that I can't walk. And then I learned what else was impact. I said, whoa. And the bladder and bowels were a big thing for me. And my peer connection was really, you know, what gave me the knowledge to and the tools to go to the doctor and say, All right, I wanna learn more. I need to take control of this because it's not working for me and it's keeping me from, you know, lifestyles of I see others living. And, you know, it's it's essential, I I guess. speaker-0 (57:39.146) Yeah, it relates to what you were saying, Jane, about really spelling out and I think w I can't remember which conversation it was we had on the podcast, but somebody else had said similarly. S if you go beyond, you know, what the symptom is to what the impact is and really spell that out and how that gets in the way of you living your life, that can really open up how clinicians are are thinking about you as a person and also they're thinking about what might be important and going back to what you both were saying earlier about what other services might be helpful or what other collaborations might be useful here. So I think that that's a really helpful thing to be aware of. Sometimes you need to spell it out because for you it's your reality and you know it day to day, but it might not be so clear to the physician. And the other thing that I'm hearing is the willingness to gather information whilst not putting too much pressure on yourself that you need to to enact everything as you're gathering the information. I think that's perhaps one of the things that becomes a barrier for individuals because they're like, if I know the information, then I have to action it and I have to find the right plan and, you know, I need to work it out all all as it's happening live. But what's been really lovely as a strand in this conversation as well is recognizing that not everything needs to happen at the outset. You know, we can we can gather, we can evolve that in understanding, we can come back round to it, but at least it creates some sense of scope of choices and options. Can I ask you a little bit, Matt, about specifically kind of system shifting? Because one thing that I talk about with people and comes a lot in the the community work that I do, and I commented on it or or kind of explored it in in my book, which is called It's All in Your Body, about how There's this fine balance between stepping into your empowerment, recognizing what influence you have, and then having the messaging that it's all on you, you know, to make any difference. You basically need to to do more and empower yourself more. And there's such a fine balance between empowering yourself and acknowledging where other things need to change. And I think that's the point where speaker-0 (01:00:00.118) a lot of the people that I work with can end up feeling quite hopeless because it feels like we were talking about before, it can feel like these organizations are big faceless things and there's so much red tape and there's so much, you know, it's all beyond my control. So actually you were talking about some examples before, but perhaps we could revisit that where you have seen systems shift and perhaps whether that's on a like a a policy or infrastructure level or a practice level and what you've what you identify as like being influential over those shifts. speaker-2 (01:00:31.054) So I think two part answer, right? So first with the individual, right, and feeling like it's overwhelming. I think for individuals you had asked earlier, the first step for me and for any individual is to understand w what it is to be an advocate. Advocate doesn't mean you need to make these grandiose changes. Sometimes it's just, you know, understanding what systems need to be changed, what people are dealing with and getting involved with like an advocacy group or virtual advocacy group and understanding that you're not alone with these system barriers and these changes and how you can get involved. You know, everybody's definition of advocacy is different. Some people want to go and storm the the doors of government office and demand change and some quietly will put their name on a letter, but everything makes a change, right? And what I've seen over the years, especially over the 23 years, is that Small and large, our community has taken a greater effort to have their voice heard. And there's a lot more companies seeking our input on the development of products. A lot of more access to research and awareness of research programs that we can get involved in. Our organization or other organizations are posting those opportunities more readily. With the internet, there's more opportunities to learn about it and how to get involved. So, you know, there's been a lot of growth and development within the bladder management industry as a result of this. Right now, as I said, there was a push for competitive bidding in the catheter world. Well, I've been impressed by seeing the involvement of our community to work together and organizations to work together to push back on this policy change and to fight. for our right to have opportunities of multiple vendors and distributors of products. We're not limited to one. And that all came about through, you know, these advocacy groups being out there and newsletters and and different systems in our communities engagement and in and I've seen the evolution of products, you know, from a person with limited hand function like myself. speaker-2 (01:02:55.758) You know, catheter companies heard our voice and created catheters that have extenders that I could push on that extend the catheter so I don't have to touch it. I mean, you know, it I over the twenty-three years there's been a huge shift in a positive direction and there needs to be continued involvement. But what I always say to our community is we can identify barriers, but it's our job to work together to try to make a change there and it starts with us getting involved, educating ourselves in what ways we can get involved, small and large. speaker-0 (01:03:33.122) Thank you. You you've given so many great examples there, you know, which really are hopeful and inspiring to so many people. 'Cause like you say, and I really loved that contrast, you know, for some people it's putting their name down on a petition or or just to get more information and informed. And then for other people it might be bigger acts of, you know, storming offices and what have you. But everything counts and t to have some of those tangible examples, you know, really r really is is wonderful. And I think, you know, that that related to my next question, which was about a lot of time people that I'm working with feel so overburdened already. So they're like, I can't extend myself much more to do this. It feels too big. But as you broke that down, you know, recognizing that that small elements count, and they can also snowball. speaker-2 (01:04:28.344) Hundred percent. You know, I mean me myself in the early stages of my recovery and journey of recovery, I wasn't the one that was gonna be storming the the groups. I recognized challenges I was facing and then someone helped explain to me that advocacy takes different forms and if you're recognizing a challenge And you want to make a change or need a change, you know, figure out what form you're able to do to fit into your lifestyle at this point and and do that so that you could be part of the solution and drive. And when I realized I, you know, it wasn't didn't have to be this major commitment that a small step goes a long way, I realized I can make a difference. And you know, I brought that to others in my community and said, look, small steps, small baby steps, small involvement. Even if you just educate yourself on some of the policies and share it with others, that sharing of need can motivate someone else that has a little more drive or time or capability to get involved, you know, and it it it it does go a long way every little bit and I've seen it firsthand. in my own life and through my work. so, you know, it's it's one of the big things that our advocacy team has tried to express to someone. Even attending a group once a month to ha you know, share your experience can empower someone else to use your story to drive an initiative. speaker-0 (01:06:14.126) Could you share more about that advocacy group? What what does that look like? speaker-2 (01:06:19.374) So our advocacy team has a series of working groups, right? That and the focus is virtually to bring people together from all over the place to share their stories, their experiences, to understand what steps they can take either in their own personal life, like you had mentioned. You know, some people f have a barrier with their doctor's office or don't know what steps to take to advocate in their own personal life with their doctors. These virtual groups are offered, they're available on our our events calendar on our website, United Spinal.org. Someone can log in, it's once a month, and what they do is they have an opportunity to engage with others, hear other stories. They can either actively engage during the group or just participate passively and listen and hear and understand, you know, what others are doing to empower themselves. And it's a great opportunity for people to be educated, understand that they're not alone in some of the challenges, and gather resources to help them to address some of their needs and to understand how they can get involved. speaker-1 (01:07:29.602) Mm-hmm. speaker-0 (01:07:30.226) It's really lovely to hear about that as an advocacy team and group, j because it really reflects, right, that just even engaging and and hearing from others, even if you don't feel like you're particularly advocating or asserting, that is a step towards advocacy and and makes a big difference potentially. speaker-1 (01:07:53.006) And a sense of accomplishment that comes along with it when you've been able to make an impact. It's very satisfying, not only on a personal level, but for community as a whole. speaker-0 (01:08:03.042) Yeah, that's a really good point, Jane, because we can underestimate how contagious it can be to be amongst people that are talking language that that is our own and and having experiences that we've also had. It can be very galvanizing and just even participating, even if you haven't contributed to the discussion, but you've been along with it or you've had agreement, that can build that self-efficacy that then you don't know where that goes to really. But without having that first step, everything feels much harder. So it's yeah, it's really lovely to to draw out just those initial steps of of advocacy. I'd love to thank you so much for your time. You've both been so generous. So I'm gonna finish off with two questions. what I like to do is kind of think about these introduce two questions at the end from an individual's point of view or a patient's point of view and one more thinking about clinicians who might be listening. and we really appreciate clinicians who are listening because it it speaks to that, you know, appetite for holistic care and thinking about the patient as a whole person. So perhaps let's start with a clinician question. I'm really keen we touched on this a little bit at the beginning of the conversation, you know, thinking about that patient centered care and how there needs to be more of a dialogue and curiosity. Perhaps on that line or maybe there's something else, do you think there are particular misconceptions that clinicians could do with unlearning when it comes to providing patient care for people dealing with bladder or pelvic problems or continence problems? speaker-1 (01:09:42.274) Maybe not unlearning per se, but acknowledging that oftentimes the person who is living with spinal quid injury or whatever the condition may be has come to learn their body very well. And so the the importance of listening to what they're telling you about that, instead of having preconceived notions, acknowledging that the person knows their own body best. And so, you know, taking that into account, I think would be something that's important. speaker-0 (01:10:12.78) Yeah, it's it's interesting because that comes up a lot with patients that I work with with bladder issues and continence issues. This sense of what they're reporting doesn't seem to marry up with what the clinician expects and then there is this disconnect. So yeah, just that acknowledgement that the patient is most well acquainted with what what's happening in their body. speaker-1 (01:10:36.696) So I guess, you know, toward that end is, you know, not having something be overstandardized, if you will, but listening to what the unique aspects of that person's challenge are and being creative, perhaps, in addressing it. speaker-2 (01:10:52.588) And I think also considering the patient's lifestyle and what works for them, right? You know, sometimes medical professionals will suggest a solution to a challenge that's not gonna work with the li not considering their lifestyle and also their comfort, right? Like you know, procedures are recommended and it's like, well Like with the procedures are an alternative and you know there then there's a breakdown in communication. So I think for a clinician to consider all aspects of that individual's life when they're trying to solve a problem. speaker-0 (01:11:36.258) Yeah, it's so important. And I mean, obviously none of this is for all clinicians, but I I do think in our medical systems, you know, in the US and and in the UK, a very biomedical model often shaves off the the person and the life around the procedure or the intervention. which quite obviously when we think about it misses out a big part of that that picture and unlearning that very specific biomedical approach does exactly that right, Matt, to remind ourselves that it's a it's a person in front of us with l habits and thoughts and processes that are gonna interact with whatever's been suggested medically. speaker-1 (01:12:15.714) Looking at it holistically. speaker-0 (01:12:17.952) Yeah. Last question then. What one small thing might somebody listening now do to try and increase their own sense of personal empowerment for change? speaker-2 (01:12:18.862) A hundred percent. speaker-2 (01:12:32.994) I think Jane touched on it numerous times throughout this podcast is engaging with your community and your peers, learning who's around you that, you know, and who you could talk with to understand what they're doing, engaging with organizations, seeking with, you know, organizations your that cater to your challenges, your disability that you can engage with is the first step. in empowering yourself to to educate yourself. You know, that's been probably one of the greatest assets to our membership is that opportunity. I mean, Jane, would anything else you would add? speaker-1 (01:13:15.658) No, again what you said, but also l learn what's new if you've been living with a condition for a long time and just learn what's new. Maybe listen to there are ladder buzz podcasts, this podcast. So listen to what's out there and and keep yourself informed. speaker-2 (01:13:37.186) And also I I don't know if I I think in in Europe they have these, but in US we have abilities expos, which are opportunities in different states to be exposed to different products that are being offered to the disability community. So I think, you know, making yourself available to attend those periodically so you can learn what new products are out there or what new systems are out there. You know, and as we said earlier, might not be appropriate at this time for you or you might not need it at this time. But creating that library of resources and knowledge to bring back to your medical professionals to have that dialogue and that conversation with them, you know, helps empower you. speaker-0 (01:14:23.692) Yeah, thank you. I I think one thing that's really exciting to me is as you both have been speaking, the common difficulty that comes up when I'm working with people is when they do feel so isolated and when there have been so many very real barriers, that resignation steps in or that fear, you know, of the unknown now because it it it feels like for so long the external world has been hostile or misunderstanding. And so even that first part of Where do I go to find that community can feel difficult. and and you mentioned as well, Jane, at the beginning, it feels it for some people it can feel like, well, they're not my people because I didn't choose this and maybe I, you know, I won't feel connected in that sphere either. But as you've both been talking with these really tangible steps, it's been making me think about how we can look for this in in areas that might not automatically come to mind. You know, organizations that are working in this and saying, you know, I'm somebody that's impacted by this. I'd like to offer my insight if there are opportunities or, you know, if there are charities doing particular work around things or, you know, organizations like United Spinal Association, you know, just seeing what yeah, what is already going on in that sphere and curiously getting involved and and seeing what community might be there if you dip your toe in and a and permission again not to have to throw yourself in and be the the hundred percent full time advocate, but just speaker-1 (01:15:56.108) Right. One small step one email, one one call today, just one small step is where it all starts. speaker-2 (01:16:03.87) Yeah. And you don't have to even do that at first. First you might just troll a website and learn what United's Final or other organizations are doing. See where resources are available. A lot of these websites and y you know, you can find resources, information, knowledge, and it starts with wherever your comfort is, but you have to keep that momentum going, right? You can't just stop. speaker-0 (01:16:04.056) Yeah. speaker-2 (01:16:30.722) Especially with in the area of bladder management. There's so much coming out, so many new products, so many new stuff that you need to learn and educate and you gotta start to explore. Exploration is key for evolution in the process of how we do things. speaker-0 (01:16:50.262) Yeah. I love that as a kind of ending note to to this episode actually. You know, just that exploration as a first step, you know, i is fundamental to everything else. Absolutely. Thank you so much for your time. You've been incredibly generous and I feel like this has been a very rich conversation that will inspire so many people. So I really appreciate it. speaker-1 (01:17:10.062) Thank you. It was a pleasure to be here. speaker-2 (01:17:12.194) Yes, thank you for having us. speaker-0 (01:17:18.176) Learned something today? Your brain hasn't finished with it yet. Research shows revisiting new information is all it takes for your brain to start connecting to the dots on its own. So subscribe, listen again, and let it do its thing. Thanks again to our partners at ConvoTech Continents Care. Don't forget to check out the resources and references linked in the show notes. If you found this episode helpful, please consider rating and reviewing the podcast. It really helps to connect the podcast with those who will benefit most from it. This podcast was produced by Maya Silence and Music.