The Neurologist Is In, Ep. 3: Fostering Wellness in Neurology

In episode 3, Rachel Marie E. Salas, MD, interviews Jennifer Rose V. Molano, MD, and Jennifer Bickel, MD, about their career journeys with wellness in their respective fields of sleep medicine and headache medicine; tips for gauging your patients' well-being; and tips for promoting your own wellness. A full transcript is provided below.

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About the Speakers:

Rachel Salas, MD

Rachel Salas, MD, MEd, is an associate professor of Neurology and Nursing; director of Interprofessional Education and Interprofessional Collaborative Practice; director of the Neurology Clerkship; and 2019-2021 Josiah Macy Jr. Faculty Scholar at Johns Hopkins University in Baltimore, Maryland.

Jennifer V. Rose Molano, MD

Jennifer Rose V. Molano, MD, is an associate professor in the Department of Neurology and Rehabilitation Medicine at the University of Cincinnati Academic Medical Center in Cincinnati, Ohio.

Jennifer Bickel, MD

Jennifer Bickel, MD, FAAN, FAHS, is a Professor of Pediatrics at Children’s Mercy in Kansas City, Missouri where she serves at the Headache Section Chief in the Division of Neurology and as the Medical Director for the Center for Professional Well-being in Medical Administration. 

Transcript:

Dr Rachel Salas: Welcome back, everyone. This is Dr Rachel Salas. I'm a sleep neurologist at Johns Hopkins. I have two fabulous Jennifers with me today. I have Dr Jennifer Molano, who is an associate professor at the University of Cincinnati.

She is the chair of the University of Cincinnati Faculty Wellness Advisory Council and the UC Medical Center GME Wellness and Well-Being Committee. Also, she is a sleep and behavioral neurologist, so she does both of those specialties.

And we have Dr Jennifer Bickel, who is a professor of pediatrics. She is a headache specialist, and she is the medical director for the Center of Professional Well-Being at Children's Mercy. Thank you both for being here. It's always great to reconnect and hear about what you both are doing.

Why don't we get started by talking to the audience a little bit about what brought you into wellness? Both of you are practicing in specialties of neurology. How did you transition to wellness? We'll start with Dr Molano.

Dr Jennifer Molano: I fell into wellness after I was asked to be a part of the AAN Presidential Task Force under the guidance of Dr Terry Casino to be a part of the—then called—Burnout Task Force.

I was a part of the group that helped to study burnout in neurologists after there was shown that neurologists have one of the highest rates of burnout and one of the lowest rates of work-life balance. I've been working in that space for probably the past 5 to 6 years and didn't realize that it was a new career path in my own personal journey. That has been fruitful.

Some of the things that we've done on the AAN side of course is including the Live Well experiential learning areas within the annual meeting, the Live Well, Lead Well Leadership Program in addition to providing resources as well for that. We've been doing a lot of work in that space.

Around that same time locally, I was asked to join and be a part of a training for a mind-body skills group here at the University of Cincinnati, which was run by our Center for Integrative Health and Wellness.

The Mind-Body Skills Group is a 9-week program, where a small group of people or a small cohort of 10 people, co-facilitated by 2 additional leaders, learn for that 9-week period of time for 2 weeks at that time a way to learn various mind-body skills, be it mindfulness, meditation, biofeedback, and things like that.

That was my foray into wellness at the local level. Given my roles with the American Academy of Neurology or the AAN, I've shifted into some of these roles in terms of looking at and helping with faculty wellness and resident wellness as well.

I will say as a sleep physician as well as a behavioral neurology-trained physician as well, we know that sleep is very important in terms of brain health. In terms of my own career path, that has been a nice complement, working on wellness.

We do know that lifestyle behaviors are critical in terms of optimizing brain health including exercise, proper nutrition but also sleep. It's been a very nice marriage of all of the different things that I'm interested in and again has been a very nice career path for me to date.

Dr Salas: That's great! Thank you for sharing that. I have several colleagues that have gone into wellness. It's interesting to hear how people land there because it's not like a specialty training discipline as of yet. Who knows? I'd like to hear Dr Bickel's story. How did you get into wellness?

Dr Jennifer Bickel: It's an interesting question because it's not like one of those things like back in our neurology residency that I'm like, "This is where my career path is going to go. Fifteen years later, I'm going to be in administration dealing with wellness." That would have been not a chance, is probably what I would've put on that career path.

What's interesting is probably how we all have similar stories. What it is, is probably a natural tendency towards dealing with complicated situations that don't have clear answers and that have this complex interaction. Dr Molano, listening to you talk about the sleep, that's a combination of a lot—neurological, behavioral, very complex.

It requires communication, and it also requires advocacy for people to understand that it's important. That's where my background as a headache specialist—that headaches are incredibly underserved. They're very misunderstood, and they are a huge problem with very little resources.

For years, I worked side by side with social workers, pain psychologists and learned a lot about the same sort of thing like the mindfulness, the importance of relaxation, the importance of those things but also realizing that in headache medicine, that so much of it was that the system was not built to be able to help those people with headaches.

There was only so much those individuals could do without the system being built the way that they needed it be built, the way that they needed to be seen, the way that they needed access to care.

As the well-being stuff started showing up more and as I started learning it, I got involved in it through various different ways. Basically, a job opened up at my organization called medical director of Center for Professional Well-Being.

At the time, the job had focused predominantly on helping people in crisis. I knew that I didn't want to do that. It's incredibly important work, but I knew that there was so much more to be done proactively at the front. Not necessarily just about helping people that have been broken but keeping the system from breaking people and how could we do that?

Over the last 2 years, I have to tell you that when I first stepped into this job, I gave up teaching the neuroscience course curriculum as the course director, and I thought that that would be an equal swap. Two years later, this job is 0.7, 0.8 of my career. It's been amazing to watch the need for it in this area that we didn't even think of 15 years ago.

Dr Salas: That's amazing. I'm curious to know—because I have you still on the line here, Dr Bickel, I'm curious to know, what are your thoughts? Do you think that eventually, there's going to be a specialization in wellness? Trainees like residents and fellows, should they be thinking about a career in wellness and getting some type of formal training? Do you think that's coming?

Dr Bickel: That's a great question. I wondered when, for example, the chief wellness officer roles first began, if this was just a fad that was going away. There's not any sign of this dying down. As a matter of fact, every tragedy might have some benefits, and then with COVID, I'm getting so many more phone calls, and so much more advice, and so many more people saying, "What can we do? What can we do?"

One of the things that I always talk about is the fact that this was a problem before COVID began, but maybe this is shining more light, shining more resources on it.

The other thing too is that is this something—when we think about the different fellows and everybody who is out there, I think that it's twofold. First of all, that yes, there will be just like how we have people that are specialized in faculty development, we will absolutely start to normalize people who focus on well-being with an organization.

The other thing too is that we are already seeing the younger workforce be more knowledgeable about the gaps and more knowledgeable about what is needed. We're seeing people make better decisions about choosing places that support their well-being and not just their success by external metrics. It is—it is this movement that is happening.

This is me treat—talking to the dreams, right? At some point, I see every resident who's going out to find a job, not to just ask about salary, doesn't ask just about productivity but asks about, "What are… these 5 things that you're going to do to support my well-being?"

Dr Salas: That's a good point. I saw Dr Molano shaking her head in agreement with a lot of the thing you were saying. Let's transition a little bit more because our audience is several general neurologists out there, a lot of people in private practice.

I'd definitely want to share some of the things that you're doing in your own practices with your own patients. Hopefully, at the end, we can circle back and see what you all are doing for your own well-being and wellness and what you would recommend for our peers out there who are out in practice and seeing patients—also, dealing with everything that everyone's dealing with, the pandemic, the political landscape, the issues with racism going on.

Dr Molano, why don't we start with you? How are you integrating wellness and well-being with your patients? How are you even bringing that up? Is that something that’s a standard practice? Let's open it up. What are you doing?

Dr Molano: As a sleep specialist, this comes very naturally. One of the first questions I ask is, "How are you sleeping?" A lot of times, that opens up the conversation of, if people are sleeping poorly or having disrupted sleep at night, a lot of it is due to stressors.

I've heard everything from concerns about the pandemic, concerns about not being able to see a loved one who's in assisted living or in a nursing home, people who were very stressed out over the election, and some of the racial issues that have arisen and come to the forefront and become more highlighted in this sense.

It's a natural extension of the questions that I already asked because we do know that in terms of burnout, it's a result of chronic stressors and people having an inability to regulate that. That doesn't just apply to physicians and neurologists but certainly applies to our patients as well. We have a conversation about that.

We delve into, what are the various stressors that may be contributing? Is it having to try and manage a full-time job and at the same time, trying to homeschool children virtually which is a challenge? Trying to figure out all of those stressors.

As Dr Bickel said, the COVID situation and pandemic has highlighted the fact that stressors were there before COVID. COVID has just put all of that in the forefront and made it important and a priority.

One of the things that I've been trying to think about in my own practice, in my own life, and also when I'm talking with my colleagues is, how do we manage these stressors? I know that Dr Bickel, in some of the talks that she's given in the past, has talked about this idea of one's circle of influence or locus of control.

I found this decision tree, so to speak, in a book that I'm reading for a course here at UC called "The Engaged Caregiver." It's very practical. You have people, first of all, identify their stressor, and then the question that they ask them is, "Well, can I eliminate the stressor?" If they can eliminate the stressor, then eliminate it.

If they can't eliminate the stressor, then the next question to ask is, "Can I lessen that stressor?" If you can lessen that stressor, find ways to do it or ask other people how they can do that. If you can't eliminate the stressor, then what can you do to cope with it?

I've piloted this just out of curiosity in my own life as well as talking to some of my patients about it. That whole decision tree has resonated with them. It brings it back to that idea of there are some things that we can control, there's some things that we can't control.

What are the things that we can control, and how can we either eliminate those stressors or lessen them so that they're more manageable? That's what I've been doing in terms of the people that I've worked with in the sleep clinic as well as some of the other work that I've done at my institution.

Dr Salas: I think some people are probably going to listen to this and say, "Yeah, that's great, but I'd have to squeeze in some time to really get into their sleep issues," or, some of these other things when I'm dealing with my patients' Parkinson's.

As a sleep neurologist, I always want to advocate for asking about sleep. I'll start with you first, Dr Molano. Do either of you have any comments that you could say to show you care and that you're opening the door if there was something serious, something that they wanted to talk to you that you're there?

Are there any key things that we could say to let our patients know that we're here and we're interested in listening? "Please, if there's something going on, to let us know." I don't think a lot of times patients talk about this stuff, especially if they're feeling lonely and their well-being's impacted.

We know the suicide rate is up. People are lonelier than ever. Depression's up. Studies are showing people are taking more sleeping pills, more antidepressants, more antianxiety medications. Are there any suggestions on what we can do in our practice to let patients know that we're here, and we're listening, and we care?

Dr Molano: From my perspective, just asking, "Is there anything that's really concerning you?" Again, as a sleep doctor, it's very easy to segue into that. The way that I can frame it, "Is there anything that's interfering with your sleep?"

Maybe you can even say, "Is there anything that's interfering with your quality of life or how you're dealing with things?" Opening up that question and just asking, "Do you have any concerns, or what is really mattering to you, and what's concerning you, and what do you feel is really impacting your health and your ability to take care of yourself?"

Dr Salas: Perfect. Dr Bickel, I know that you've gotten recently into counseling. You're also using a strengths-based approach that I have embraced, and I'm now using in my practice. I'm curious to see what your perspective is on that same question.

How are you reaching out to your patients because you're not necessarily in the field of sleep? How are you making that connection, and are you using that strengths-based approach to do just that?

Dr Bickel: That's a great question. I wonder—you had said counseling. Did you mean coaching?

Dr Salas: I did. Yes, coaching.

Dr Bickel: Perfect. I wanted to clarify on that. It's several different things that I think about it. One of the things is that as a headache doctor, especially of adolescents, it's always been incredibly important that I be present and I show that I care.

They are in a place of fear. They don't know what's going on, and I'm never going to have a test to show them why they have pain. There has to be that relationship and that mutual commitment that, "We will do this together."

One of the things that I have found is that it's incredibly important to sit, and listen, and be present, because eventually, if I listen long enough, I find out what they need. It's not always about necessarily where I want to take them, but what is it that they want help with?

The other thing that I think about right now is how for some people, when we're seeing them in person, because right now, I'm doing predominantly procedures such as my nerve blocks or acupuncture, and things like that. It gives me a lot of time in the room of talking with them and being able to acknowledge that these are rough times.

I think that sometimes, when we are overly optimistic cheerleaders, that it can be a form of gaslighting. To be like, "Oh, everything's great. This is what we need to do." Instead, just acknowledging for people that it's hard times, and even starting off that way. Like, "These are hard times. How's it going for you? How do you feel like this is working together?"

Because if we present, “this is all wonderful,” then they have to overcome that to share with us how they're feeling. Whereas if we give them that space, we let them guide us to where they want to talk about, it's incredibly important.

I want to say that we routinely do suicide screening on all of our patients. Adolescent headache is high risk, and we do it for all adolescents in the hospital. We also assess mood. We look at quality-of-life indicators, but there is still something about that.

There was one study that showed that, if you do a quiet pause when someone gives you a complicated problem, if you don't give the answer right away but if you take a pause and show that you're thinking about it, that's incredibly meaningful to patients.

Dr Salas: That's fascinating.

Dr Molano: That's great! In terms of following up on that as well, sometimes in addition to being present, part of that, too, is not just listening but also trying to be attuned to the nonverbals that you see. Recognizing if someone is agitated, or if their speech is pressured, or even monitoring your own.

For me, I found that monitoring my own internal responses helps me to identify if there's stress going on. If I feel like my heart rate is starting to rise because I'm hearing my patient's speech start to be a little bit more rushed and things like that, then that indicates to me that there's potentially something there that we need to delve into a little bit more.

Sometimes, what we do with my patients is try to—recognizing that there could be some anxiety there and taking a pause at that point with the patient and saying, "It seems like there's a lot of stress that's going on that you're dealing with right now. Let's just take 3 deep breaths together and see what we can do to try and reset so that we can really figure out what's going on."

The idea of being present, which Dr Bickel so beautifully mentioned, is listening as well as also observing and making sure that you are attuned to those. It's a little bit more challenging in the telehealth world.

You can also listen as well. Using all of your senses to make sure that you're trying to be present for the patient is a great recommendation and suggestion that Dr Bickel provided.

Dr Bickel: That always goes back to that if you're going to support other people's well-being, you're going to have to support your own well-being first. If you go in that room and you're a crazy mess, you're going to over-respond, but once you pay attention to yourself, you can pay attention better to that other person.

You had asked about that strength-based assessment, and how does that look? Over the last couple of months, I've gotten different training in different styles of coaching in order to support colleagues, in order to be able to help develop those in health care.

Even just for my own personal self, it's interesting how if I take the time of when I am "blah" and when I am maybe emotionally ruminating about things a little bit too much and if I take the time and I realize, am I thinking more about my weaknesses and anger at my weaknesses, or am I spending time trying to use my strengths to solve this problem?

That goes back to and what you'd said earlier about that decision tree, which I love. I love how that can walk people through it. I think about that decision tree, mine also automatically goes to, "If I am going to change it, how do I use what comes natural to me? How do I use my talents to being able to help make that change happen in a way that's not exhausting?"

That's part of how I get my energy every day, is really trying to do what I love, trying to have fun, and remembering what it is that I like about things.

Dr Salas: These are all great strategies! These are things that our listeners could start doing today, just taking that pause, asking those questions, breathing, taking that time out with our patient. I think those are great strategies.

What are some of the things that you're recommending? Let's say the patient says, "I lost my job. My kids with virtual learning—it's just too much to handle." At that point, what are some strategies that we could do to get them on the right track? We'll start with Dr Molano.

Dr Molano: It goes back to, what is the one thing that you can do next that will help you regain control back in terms of what you're doing. I will credit my brother-in-law, who's a retired Marine, with this.

I have incorporated this into my own life. He said when he's been feeling overwhelmed with things, what he always asks himself is, "Well, what's the next step?" I've incorporated that in my own life.

When I've got lots of crazy deadlines, and lots of sleep studies to read, and lots of patient things to do, and my brain is going all over the place, and I don't know where to start, it's a grounding practice for me in a way, just like the breathing exercise. Another grounding practice for me verbally is to say, "OK, what is my next step?"

That next step just might be, "Write a to-do list." I can try and prioritize that. Or, the next step is, "There's just too much going on right now, and I actually just need to take a break.” Because I've been working for 2 hours straight without a break, maybe I just need to stand up, get a drink of water, and come back and reset.

Those sorts of things have been helpful. Again, going back to, if things are crazy, trying to distill it back to that next step that someone can do. For me, personally, that has been very helpful. I've asked a couple of patients about that as well, in terms of, "What is one thing that you can do?" They come up with their own solution.

The other piece about wellness and well-being is that a lot of times, it's a journey of self-discovery and trying to figure out what works best for you. One of the things that I like to say is that not one size fits all.

In terms of maintaining one's energy, for some people, it's various forms of exercise. For other people, it's more quiet in terms of meditation, journaling, things like that. Part of the goal is trying to figure out what works best for each person.

Trying to help people and ask the questions so that they can discover for themselves what will work and what their next step will be is what I tend to do. Again, I credit my retired Marine brother-in-law for providing that very transformative question.

Dr Salas: That's great! I love that—what's next? Both of you have been sharing these little quick tips on things you can do, different strategies. Dr Bickel, do you have any other tips to recommend, or maybe you want to talk a little bit about acupuncture? Do you recommend that for wellness, if you feel like people, your patients, could benefit?

Dr Bickel: Yeah. It's funny. Board-certified in neurology, board-certified in headache medicine, and board-certified in acupuncture—another part of my career that I never thought I saw coming. I never thought I would be on a podcast being the one talking about acupuncture as an academic neurologist.

Here's the interesting part about what I've seen about acupuncture. I'll tell it in a story form. I once had a patient that when I first started doing this about 6 years ago, she kept coming back telling me her headaches were the same. We had 6 visits over several months and she said her headaches were the same.

I'm like, "OK, it's time to stop. Let's try to figure out a different treatment." She and her mother were like, "What? We can't stop it." I was like, "It's not helping you," and they were like, "No, no, no, she feels better every day. She just feels better."

One of the things that I found—this is where I'm going to sound a little cuckoo, but I promise that it's based on real expert observation—is that what people often describe is the fact that they were able to deal with their pain more, they were able to show up more throughout the day.

You know that essence, that feeling some days where you just don't feel good? You're not sick, you just don't feel good, and then some days, you feel better. It's sort of indescribable. That seems to be a space in which I've been able to absorb that acupuncture seems to help people.

I can also tell you that my colleagues, not infrequently, knock on my door or text me asking for some needles. Maybe a little bit in the ear, maybe a little bit one on the scalp, something along those lines to take the edges off. That is all the way from the most senior administrative leaders in the hospital to our frontline people, and being able to see the benefit of that.

I would never ever recommend acupuncture as a treatment for severe depression, schizophrenia, or anything along those lines. You know that space between dysfunction and disease? That space, that's where it can provide a little bit of that extra boost.

For our colleagues out there, I would say that acupuncture, in the right hands, in the right way, can absolutely help to alleviate stress and get us some more of that boost that we need to keep showing up, because we're tired. Everybody's tired.

Dr Salas: I couldn't agree with you more. I'm not trained in acupuncture, but I would always get asked about it from my patients for sleep. I went and checked it out. I went and had some sessions, and it was amazing! I loved it. I probably need to go back to it once we're out of this pandemic. It was great.

The problem with the research out there—because not everybody comes and gets the same points, because we all are individuals. We all have different things that we want help with, and so the research overwhelmingly has not been able to say, "This is standard of practice. Let's do it."

With that being said, I have remarkable stories, and not only acupuncture, but I'm implementing things like massage, taking—they call them nature baths, where you walk outside for 30 minutes, and things like that.

In the sleep field—and I know Dr Molano can agree—there's so many sleep, I call them ‘luxury menu items.’ There's so many things out there. If you're too hot when you sleep, guess what? There's cooling blankets, there's cooling pillows, there's weighted blankets, there's aromatherapy.

There's so many things out there that can help, not just with sleep but also overall well-being and wellness. I'm curious—Dr Molano, are there any things out there that you're recommending? I could say, for me, weighted blankets have been helpful for some of my patients. Is there anything like that, broadly speaking, some type of product that you recommend or tell patients about?

Dr Molano: Yeah, the weighted blankets are definitely one of the key ones that I mention. A lot of times, people ask me, "Is there a specific pillow that you recommend?" That one's a little bit more challenging, because it depends on if you want it soft, if you want it firm, or what have you.

For me, the weighted blankets by far has been a key one that I have incorporated in my own practice.

Dr Salas: Dr Bickel, anything from you?

Dr Bickel: Oh gosh! So much of what we recommend, all the way from biofeedback, to aromatherapy, to mindfulness, to even breathing—it's interesting. I don't know that there's necessarily a lot of devices, per se, that I do recommend on a regular basis.

Allowing people to identify with the fact that there are ways that they can help to make themselves feel better beyond taking a pill, that there are ways that they can improve upon it through the various techniques.

Frankly, with the acupuncture, sometimes, we'll show people acupressure spots so that they're able to find areas that help to relieve their pain and decrease their anxiety.

Dr Salas: That's great. We're getting close to wrapping up, and I don't want to leave without sharing maybe some of your own—I know some of that has come out already, I know, Dr Molano, with the next step—that you're using your own well-being and wellness.

Maybe you could share, whether that's in terms of your sleep, or taking some time every day that you go and do something in particular, it's always important for our colleagues to hear, "Well, what do you do?” You're in this space. You're teaching this. You're asking your patients about it, but what do you do at the end of the day when it comes to your own wellness and well-being?

Why don't we start with Dr Molano?

Dr Molano: I have a lot of things in my toolkit, but one of the things that I've been trying to practice regularly is making sure that I get exercise, because I know for myself, that exercise has always been a great stress outlet, even before I formally entered into the realm of promoting wellness for patients and other people. Trying to do that is important.

One of the other things that I've been doing is, I've gone back to playing the piano, which I'm very rusty. I'm not going to be playing any concerts any time soon, but in terms of my own joy, that has been something that I have revived. I'm still using the same piano and playing the same piano that I had that I first got when I was 7 years old. That has been a great stress relief.

Thankfully, my husband is telling me that I still sound good, even when I'm just playing scales, so that seems to help. One of the other things that I've incorporated in my own life is what I've heard in one book called "The Emergency Joy Kit." It's a kit that you bring out when you're feeling especially stressed.

One of the things in my joy kit is I have a folder in my inbox that is specified as "At Joyful Moments." When I'm having a bad day, and I had a bad day just a couple of days ago, one of the things I did was immediately go into that inbox and start reading some of the things that I had received for the past many years.

One of those things that brought me out of my own funk a couple of days ago was reading an email from one of my college professors, who had responded to me after I was asked to write a letter in congratulations for his retirement. He talked about details about our first meeting, and working with me on my Honors Thesis, and all the things that he was proud of in working with me.

That helped me get out of a headspace where I was not feeling optimistic about myself and what I was doing. Sometimes, I forget that I have that there, but I remembered that I had it there and pulled it out. It really did help me. First of all, it helped me sleep because I was having insomnia, because I was worried about a specific situation.

Second of all, it helped me to recalibrate my own thoughts as well. Those are some of the things that I've done. I do many other things, but trying to maintain connection has been also important. Sending brownies out to—that I don't make because I don't bake—other people across the country, doing things like that, those bring me joy. Those help me in those moments. Those are some of the things.

Dr Salas: Those are wonderful. Just awesome. It's important for our listeners to hear, our peers out there to hear that we all have really, really bad days, and bad days, and good days, and very, very good days. It's all about bringing you back and reminding you of the things, essentially, that you're grateful for.

Being grateful is something that I've always incorporated in my own wellness and well-being. Dr Bickel, take us home. What are some tips that you do for your own wellness and well-being?

Dr Bickel: I think that one of probably the most important things is probably along the lines of self-compassion. It's realizing that wellness is not something that you reach one day and that you sit at and you're there at, but it's this iterative process that wellness does not mean never feeling sad.

It doesn't mean that you will always make healthy decisions no matter what, and then you pop up bright and early every day. For me, it's about recognizing that it's not about never falling. It's about recognizing that I have the strength to get back up. It's about also recognizing the fact that some days are going to be better than others.

The more that negative that I speak to myself about that, the less likely I am to be able to come out of those darker times and those harder times. How do I allow myself the compassion to do things a little bit better?

A good example of that is that I've never been very good about keeping up an exercise routine, and then I end up being angry at myself and in all this sort of dialogue about the fact that I don't do it.

What I have realized, if I call it movement and I say, "I want to get more movement in throughout the day," that helps me to feel better. Even right before this podcast, I had 15 minutes between this meeting that I was in before and this one. I could've spent that time with my to-do list. Instead, I got outside my office and walked around, and walked, and moved.

What I find is that if I give myself the permission to do little steps and be proud of them instead of judging myself for the things that I'm not succeeding or that I'm not rocking, that I do a lot better.

I also have, through the years, worked with the idea of downtime is not wasted time, that I do not have to be productive every hour. I don't have to be that way. When I take time to just reflect, that is more important than any email that I could respond to.

What I'm trying to say is that I've tried to understand the fact that action without impact is meaningless, and unless you take time to reflect, unless you take time to really know yourself, unless you take time to chill out, you're more likely to be running in circles and not doing anything.

I work a lot less in a lot of different areas because I'm more intentional of how I spend that time in using my strengths and using my family and my support.

Dr Salas: That was wonderful. I admire the 2 of you and I think that both of you stand as exemplars, not just for other neurologists but for everybody. Even taking this time doing this podcast, I've learned so many new strategies or was reminded of things that I haven't been mindful of.

Even today, I'm going to have more movement and think about my next steps. I want to thank you, because a lot of times, we get busy in our practice and everything else that we're doing, and we don't take that time, we don't make that space for ourselves.

If we can't do that, well then are we truly going to be able to be present for our patients? Going back to what the 2 of you said, to listen, and be there, and not be thinking of something else when you're seeing your patient who's sitting right in front of you, who may be going through something terrible, but they can't get it out.

I want to thank you again for taking the time, taking that pause out and sharing your secrets and tips on not only how you care for our patients with neurological disease, but how you gave these recommendations that I think are going to help our peers and our listeners out there. Thank you so much.

Dr Bickel: Thank you!

Dr Molano: Thank you! It was a pleasure.