January | 2025 | College of Science

Pace Yourself: Season 2 Episode 7

January 4, 2025

Listen Here:

Introduction

Kyle Bradford Jones

Kyle Bradford Jones, MD, FAAFP is a board certified Family Physician at the University of Utah Health. He received his bachelor’s degree in liberal arts and sciences from Utah State University and obtained his medical degree from the Medical College of Wisconsin in 2009. Dr. Jones completed his residency training in Family Medicine at the University of Utah. His clinical practice is at the Neurobehavior HOME Program, a patient-centered medical home that cares for individuals with developmental disabilities, where he leads the Primary Care Team. He is the author of three books “Fallible: A Memoir of a Young Physician’s Struggle with Mental Illness,” “HOSPITAL!: A Medical Satire of Unhealthy Proportions” and “When All Hope Seems Lost A Gospel Perspective on Mental Illness in Youth” (for the LDS reader).

Resources:

Books by Kyle Bradford Jones

The Hippocritic Oath (medical humor on Substack)

https://kylebradfordjones.com/

You can read an excerpt from Dr. Jones’ book “Hospital!” on his blog.

Transcript:

This podcast discusses trauma related to illness, including suicide. If you’re having suicidal thoughts, you can dial or text the Suicide and Crisis Lifeline at nine, eight eight. That’s 9-8-8.

David Pace 0:00

Hi, my name is David Pace, and this is Pace Yourself, a podcast from the University of Utah College of Science and Wellness. Today, my guest is Dr. Kyle Bradford Jones, an associate professor in Family and Preventive Medicine at the University of Utah School of Medicine. His clinical practice is at the Neuro Behavior Home Program, a patient-centered medical home that cares for individuals with developmental disabilities. Kyle is the author of three books, including the award-winning “Fallible, a Memoir of a Young Physician’s Struggle with Mental Illness.”

Welcome, Kyle.

Kyle Bradford Jones 2:20

Thanks, glad to be here.

David Pace 2:20

It’s really nice to have you here. First met Kyle not that long ago at a book signing event. It was a lot of fun. And, actually, I wanted to kind of start with this book. One of your books. It’s a memoir. And I wanted you to read not the opening necessarily, but it is an excerpt from it that kind of frames, I think, for the reader or the listener here what the book is about. And what kind of prompted it.

Kyle Bradford Jones 2:53

Sure.

Antagonistic dichotomy

“Doctors live in an antagonistic dichotomy. They need a thick skin, but a soft heart, a sharp mind amidst extreme fatigue. A compassionate soul with a firm demeanor and complete selflessness at the expense of mental and physical health. The messages medical students get are harsh. Don’t be weak. Dedicate yourself to the care of the patient at all costs. Don’t question your attending. Ignore the fact that you don’t get to eat or sleep and remember that leaving the hospital is abandoning your patient. Don’t do too little because you need to rule out all the scary diseases, but don’t do more than necessary because overtesting and overtreating is also harmful to patients. See patients more quickly to maximize billing and revenue. But don’t skimp on your time with them because they need to give us good satisfaction scores. Make sure you get good marks on your quality measures, but don’t ignore all the other aspects of caring for your patient just to focus on those metrics. Follow this treatment protocol to a “t,” but personalize your care. Even the brightest and strongest don’t stand up well to such contradictory expectations.”

David Pace 4:11

So, wow, that’s very revealing if you look at just the order of or what it is a physician or a health professional is expected to do. And I think the word there is contradictory elements. My understanding is that one in three physicians will suffer mental health issues with three times higher overall suicide rates than the general population. Is that correct?

Kyle Bradford Jones 4:39

Yes. Yeah, I know it’s crazy high. And there are even higher rates than that amongst medical students and residents.

David Pace 4:48

What was your experience as a resident? I mean, I think I know the answer to this But I’d like to have you maybe articulate it a little bit for our listening audience.

Kyle Bradford Jones 4:59

Yeah. In short, it was tough. I mean, you know, we would have 30-hour shifts. And so, of course, at the end of that, you can’t think, you are no doubt, hopefully not, doing some harm to patients or not thinking through things fully. There was also it’s been found that if you are driving so when we would drive home after a 30 hour shift of no sleep, it’s the same as driving drunk. You have that constantly, and you have these kind of like in there, just these constant requests and demands of your time. And so, of course, I didn’t see my family a lot. I felt married to the hospital. Like I was there all the time. There is a lot of emotional abuse that goes on in medical training. And I can safely say this is improving, and I think the experiences had now are better than when I went through training. But then also my experiences were better than the previous generation. But it’s still difficult, and it’s still pretty pervasive.

David Pace 6:21

I’m reminded of when I was in high school and a movie called the “Paper Chase” came out and was about going through law school at Harvard, and it kind of reminded me of that movie when I was reading about some of these experiences that medical doctors in training, if you will, have. And it’s built to destroy you. Yeah, exactly. Yeah. At least it was based upon this movie. But yeah, I was reminded of that ,and I was reminded of the fact, of course, we are observing Mental Health Awareness Week here at the University of Utah. So it’s kind of concerning that our doctors are mentally ill or some of them are. And that’s not even talking about the general population where mental illness is a huge issue right now. And so, yeah, I mean, talk about that interface. I mean, are you here to reassure us? Or are you here to scare us?

Doctors out of the woodwork

Kyle Bradford Jones 7:30

Well, hopefully my purpose and my efforts are getting physicians more comfortable with getting help, being willing to admit to ourselves what’s going on. And when I started writing about my experiences with mental illness — I began writing about ten years ago — immediately lots of physicians and colleagues kind of came out of the woodwork. So to speak, and would say, Wow, I didn’t know. I didn’t know someone else was struggling with this. And it was just so many people. And I thought, boy, we really need to be talking about this more. And I feel like in the last maybe five or six years, that’s exactly what’s happened. It has become much more a priority, both for trainees but also for physicians in practice. And there are still some barriers, such as the, like I read the contradictory expectations. Obviously, as a physician, you’re dealing with life and death. And even if it’s not that drastic in your patient, you’re dealing with quality of life and pain and suffering that sometimes you just can’t do anything about despite your best efforts. But then you have licensing boards that ask questions about your mental health history, and if you receive treatment for mental health. You have all of these different things that still aren’t quite in the right spot to help us to be able to move forward. But I will definitely say that there is more conversation about it, and a lot of physicians are much more open to discussing this and hearing about it.

David Pace 9:20

Yeah. I was talking recently with Susan Sample, who works with end-of-life cancer patients at Huntsman Cancer Institute. And she’s the writer-in-residence up there. And she talked about a lot of different things, obviously, but also the fact that doctors have this sense that they’re not just there to keep someone healthy, but to keep them from dying. Yeah. And that that’s kind of contradictory in and of itself when you realize that death is part of living and part of our lives and part of, you know, it’s the trajectory we’re all headed towards that. And yet there’s a certain, I don’t know if you could explain this better than I could, but there’s probably a certain sense of guilt or certainly a sense of loss when you feel as though you’re not keeping to the Hippocratic Oath, which somehow morphs into this notion that you’re supposed to keep everybody alive that’s in your bay, you know, in your unit. Yeah. Has that been your experience?

Kyle Bradford Jones 10:32

Yes. And it it feels like failure if one of your patients dies. And it could be totally natural, like you say, it’s a part of life, obviously. And even if there was nothing that could possibly have been done, you still feel that like, Geez, what? What did I not do that I should have? Or what did I do that may have have worsened the situation? Again, I do feel like that’s improving in terms of our training and how we approach death and dying and end-of-life issues. But it’s still fairly prevalent to have that feeling of, Shoot. my patient died, therefore I failed as a doctor.

David Pace 11:18

So when did you know, at what point what were the early warning signs, if you will, that what you were experiencing was not just a sadness or, you know, a difficult week or a difficult year?

Kyle Bradford Jones 11:36

Right.

David Pace 11:37

When did you realize that maybe this was clinical?

Kyle Bradford Jones 11:40

So it happened during my undergrad years. I was always very high strung. I was trying to get into medical school, so I felt like I had to do all of these extra things and get perfect grades, etc.. And so I was always very anxious and felt that stress. But then one day I had a panic attack, and I feel like a lot of people throw around that term right now. That’s more than just being really anxious. You know, your heart’s racing, you can’t breathe. You feel like you’re going to pass out. You have the sense, kind of the classic term, you have the sense of impending doom. And I thought I had a heart problem.

David Pace 12:21

And so how old were you?

Kyle Bradford Jones 12:23

23, Something like that.

David Pace 12:25

Okay.

Kyle Bradford Jones 12:27

And so based on the panic attack, I thought, man, that must be what’s going on. So I saw the doctor ,and he said, You know, that sounds a little more like anxiety. And, you know, there is still kind of that stigma in society about mental illness. But for whatever reason, that didn’t bother me. It was like, oh, okay, well, what can we do about it? You know, I want to feel better. I don’t want to be having these problems. And then, you know, struggled with that off and on throughout medical school. And then when I was a resident is when I was diagnosed with major depression as well. And it was the, hey, I can’t sleep, I can’t think straight, I can’t concentrate. I’m not taking pleasure in things that I usually enjoy. All of these things that go along with more of a clinical aspect of mental illness.

No shame zone

David Pace 13:26

So is it hard? I mean, it’s hard. I’ll say it right out. I mean, it’s hard to convince a layperson and non-medical personnel that, you know, mental illness is not something to be ashamed of. It must be doubly hard with medical personnel because it’s almost like you’re a candidate for political office and you have to prove that you are a super dude or a super lady or whatever you want to call it. And therefore you cannot be seen as being weak in this clinical way. But we are talking about an illness.

Kyle Bradford Jones 14:08

Yeah.

David Pace 14:08

Maybe the emphasis should be more on illness when we’re talking about mental illness and anxiety.

Kyle Bradford Jones 14:16

Absolutely. Because, yeah, there’s always the joke of the doctor who thinks that they’re God, and in many ways, that’s kind of a protective mechanism of, hey, if I can focus on doing my best, then yeah, my patients will do better. They’ll live longer, you know, or won’t die. Exactly. And so we’ve kind of convinced ourselves like, okay, well, yeah, I have more control over this than what we really do. But then you have physicians who substance abuse is much more common among physicians. I had a lot of experiences, especially as a resident and as a medical student, where my attending physician was inebriated or, you know, I’ve known many physicians who have turned to illicit drugs because that’s an easier way to cope than admitting, well, I have an illness. And, you know, whether it’s medication you need or therapy or a combination or whatever it may be, it’s easier to just turn to those substances to self-medicate and deal with things that way.

David Pace 15:35

Makes me wonder about, you know, I used to work in the airline industry as a flight attendant actually for 25 years, and it’s very performance oriented, as you can imagine. In fact, they used to tell us in training, you know, that when there is an emergency on the airplane, everybody is going to be looking at you. And what your face tells them is how they’re going to feel, because they’re in a very vulnerable place. They rely on you suddenly, exquisitely, to make it okay. And I’m wondering if that’s true also in the hospital setting or in the medical setting, is that you’re on stage ,and you’ve got your costume, literally the stethoscope around your neck and the white lab coat, and you’ve got the audience and you’ve got the the scenery and the toys, as it were, the props. And I’m wondering if it would be interesting to look at medicine through the lens of the theater, you know, I mean, yeah, because everybody knows that actors are really screwed up, and they don’t know they don’t know how to get off stage. And it’s a drug, man, walking down the hall, you know, in your white shoes. And people are looking at you like you are a bit of a demigod.

Kyle Bradford Jones 17:00

Yeah.

David Pace 17:01

I mean, my wife just went through open heart surgery in April. And so we were very embedded in the university medical system for quite a while. And I think I could write a couple books about that.

Kyle Bradford Jones 17:15

I’m sure you could. Yes. No, it’s interesting you describe it that way as kind of performative because it does feel that way. And there’s kind of a joke where the worst thing for a patient is if the doctor is really excited about your diagnosis because that means it’s rare, it means it’s interesting, it’s weird. And so if the doctor’s like, oh, you’ve got this, then they’re like, oh, maybe I should be a little alarmed. So and you know, when it’s terrible news, you want to deliver it as well and as professionally as possible. So you try not to to really show too much of a negative face. But, you know, at the same time, we’re all human. It’s a human interaction. And it should be that way.

David Pace 18:08

Yeah, I don’t want to make too much of the theater metaphor, but I was maybe this is a good time to pivot a little bit to one of your other books, which is your satirical novel called “Hospital! (Exclamation Point), a Medical Satire of Unhealthy Proportions.”

Kyle Bradford Jones 18:28

Yes.

David Pace 18:30

Which came out in 2022. And I just read the excerpt that you had on your website, which we’ll put in the transcripts so that our listeners can read more about your work. But just the opening scene is is pretty telling. And I wanted to just read the first paragraph of that. I think it’s the opening scene when Dr. “Camus” [Kamas] not Camus [Cam-oo].

Kyle Bradford Jones 18:56

Right. So it is “Camus.” But yes. He doesn’t want to be affiliated with it the French. Right.

David Pace 19:01

Yeah, of course. I think you’re from Utah, so I know I understand where Camus meant.

Kyle Bradford Jones 19:07

Right.

David Pace 19:08

But this is the opening and it really sets the tone for this entire what looks like a really hilarious telling book. I mean, “Doctor Camus powered down the hallway of the Peloton Forward Crescendo Care Amicus Health Priority Catalyst Wellness Code Blue Memorial Hospital of her motherly excellence, whose slogan is ‘We Are a Hospital.’ The tale of his rumpled white doctor’s coat trailed behind him like the cape of an angry 19th century magician.”

Yeah, I got the sense that this was a riff on the television show House, played by the actor Hugh Laurie in the TV series that started in, I think, 2004.

Kyle Bradford Jones 20:03

Yeah, about that.

David Pace 20:04

And he’s just insulting to everybody. Even the patients. Especially the patients.

Kyle Bradford Jones 20:13

Well, that’s kind of the trope of, I would say most medical shows or movies. You have the doctor who’s absolutely brilliant, who is a terrible person and hates people and is really rude, But because they’re brilliant, it’s okay. We’re going to tolerate it.

Hippocritic Oath

David Pace 20:30

We’re going to give him a pass.

Kyle Bradford Jones 20:31

Yeah, exactly. So Dr. Camus or “Camus,” he definitely has that persona, except he’s not very smart. And so you, uh, you kind of have the trope is flipped on its head a little bit, and yet the hospital still won’t get rid of him. But I mean, writing satire is so much fun. Like, Oh.

David Pace 20:54

I could tell you’re having a lot of fun.

Kyle Bradford Jones 20:55

Oh, yeah. So I had four kids, and at the time I was writing it and both of my boys were teenagers, and we just had the funnest time just sitting around coming up with gags, coming up with things and putting it in the book. And it was great. And now I have a Substack newsletter that comes out every week called the Hippocritic Oath, which is also Onion-style medical satire. So do you.

David Pace 21:24

Have quite a following of medical personnel?

Kyle Bradford Jones 21:27

You know, it just came out last month, so it’s growing.

David Pace 21:30

But we want to know the analytics on that after a while.

Kyle Bradford Jones 21:34

Well, and the nice thing about working with medical students and residents is you can say you need to subscribe, otherwise I’m going to fail you. So, you know, I have that up my sleeve when I need it

David Pace 21:46

So you are Doctor Kamus, after all I think, yeah.

Kyle Bradford Jones 21:49

Hopefully not too much. But there’s there’s probably an element in there.

David Pace 21:53

Highly questionable. Yes, indeed. Well, I mean, the rest of this description as it’s told — and actually I have to say this, Kyle — what I’ve read thus far, there’s a smoking gun in here and it’s called the narrator, who is a Brit. And I want to know more about him or her. Definitely.

Kyle Bradford Jones 22:17

Yes. You will learn a lot about her. She’s yet playing on another trope of the very highbrow female British narrator with this lovely accent. She is not that.

David Pace 22:35

Oh, okay. She has her own foibles.

Kyle Bradford Jones 22:38

Exactly. She is also kind of a terrible person with an awful accent and is kind of the opposite of what you typically see in movies with that. So there’s a lot of seeing the tropes and turning them on their head. But I think the book is hilarious. My wife does not.

David Pace 22:59

Oh that’s interesting

Kyle Bradford Jones 22:59

That’s okay. So I don’t know if anyone else does, but I enjoy it. So that’s what matters.

David Pace 23:04

To each his own. Well, just one last hilarious part is that he has a censor who follows him around with a ,what do you call those little air horn air horn. Yeah. And he’s so good at bleeping out all the profanity and how convenient for you, because as an author, you didn’t have to put in the F-word.

Kyle Bradford Jones 23:24

Exactly.

David Pace 23:26

Which can get very tiresome after a while, even for somebody who uses the F-word more than he should. So, yeah, I mean, it’s a delightful book, what I’ve read, and it’s gotten some good reviews, I think. And yeah, I would recommend it. And I haven’t even read it yet.

So getting back to the personal story and the memoir that you wrote, you said you mentioned that there were a lot of people who either heard about this book or read it or both, and they came forward, and that must have been a consciousness-raising exercise as much as a literary one, it sounds like. I mean. I’m assuming that, you know, the audience is, of course, people like yourself who are in the industry. Did I just use the word “industry”? But yeah.

Kyle Bradford Jones 24:19

That’s what we’ve made it out to be.

David Pace 24:20

So everything in a capitalist society, everything becomes an industry after a while. So we have to kind of give them that. But can you tell us a little bit more about the story about how you felt that you moved through or transcended or managed the diagnosis of mental illness that you had? And … how’s it going? I mean, you’re the one that wrote the books, right. To call you out on that.

Kyle Bradford Jones 24:45

Oh, totally. Yeah. I’ve been on medication for 20-plus years. I’m still on medication now. I still have a therapist. Things are going quite well right now for me and have been for for quite a while. I do think writing the book was a bit cathartic, which certainly helped in lots of ways. But looking back on some of those times — and my wife and I talk about this a lot because we were married at those times as well — ‘m not quite sure how we made it through. Not quite sure how, uh, how we were still successful in some of these things. You know, all along. I was not hesitant to have medication and therapy and what-not. And I will say not everyone with mental illness needs medication, and that’s okay. But for me, I definitely did and still do. So we were able to get much of the help we needed, but still, obviously you have to live through it. It’s still a really hard thing, but thankfully things are going well right now.

David Pace 25:55

Nice. So being in, you know, being in Mental Illness Awareness Week, I think is the proper term for it. What would you what would you say to your average Joe Blow or Jo Josephine about mental illness as someone just on the street? I mean, you’ve got a very particular take on it because you not only live with it yourself, but you’re in a setting where mental health is part of the wellness protocol, right? Or the agenda of the health industry. Well, what would you say to somebody who is struggling as an undergraduate like you were? Was it Utah State where you did your undergraduate work? What would you say to somebody, a nd what’s your advice? And if you if you had somebody sitting here, a young woman or young man.

Think you might need help with mental illness?

Kyle Bradford Jones 26:57

First of all, uh, it’s okay. And what I mean by that is you’re not less of a person. It doesn’t mean your talents are any less valued or helpful for yourself or others. We all struggle with different things. It is an illness that there is help for. Now, sometimes it’s tough. Sometimes if you do need medication, it may take trial and error to find what works for you. Sometimes if you have a therapist, you may need to meet with a couple of different people to find someone that you gel with.

David Pace 27:36

Or shop around a little bit.

Kyle Bradford Jones 27:37

Yeah, and that’s totally fine. And they fully recognize that and agree with it and that’s fine. But don’t neglect getting help. Help is available, and you are not less of a person for getting it. My mantra over the last four or five years has become just allow yourself some grace. And I really have come to accept that. Things are not going to go perfectly or exactly how I want them to. That’s okay. Things can still work out.

David Pace 28:11

So there’s and maybe because we live here in Utah where religion is a civilising force for a lot of people. There’s this term called “scrupulosity.” Have you heard of that? And it’s really a disorder, from what I understand, that is based upon — maybe you can talk a little bit about it. You know, without I mean, it can happen in any religious faith or perhaps no religious faith. But what is it exactly? And how does it how does it impact young people, for example, in a university setting.

Kyle Bradford Jones 28:53

Yeah. So I am religious. I am a member of the Church of Jesus Christ of Latter-day Saints. And I actually talk about this in the book is a lot of times the being a member of the church helped and a lot of times it really hindered my dealing with my mental illness. Scrupulosity that you reference is kind of that idea of like, boy, I got to be perfect. I’m going to do all this exactly right. I got to follow the rules perfectly. And if I don’t, I’m a terrible person. This is awful. Yes, period. And during those times when being a member of this church was harder on my mental health, a lot of it surrounded that scrupulosity. But it was as much of the culture surrounding many of the members and kind of the assumed, doctrines or beliefs that weren’t necessarily fully based. And when it was helpful was more when I focused on my relationship with God and building that and some of those deeper foundational principles that were important to me. But, it’s very common amongst, like you say, any religious community when a significant amount of people you live around are part of the same faith, you oftentimes do get some issues with mental illness and some of the scrupulosity.

David Pace 30:31

So it’s really an obsessive compulsive.

Kyle Bradford Jones 30:34

Very much like that.

David Pace 30:35

Yeah. Okay. You know, and I think a lot of us are familiar with that term in a variety of settings or in a variety of behaviors. We’re getting close to having to sign off here, but I wanted you to talk a little bit about your work with folks that suffer from disabilities and how does mental illness play into that? Are there special opportunities as well as special challenges in those settings?

Nobody wants to be a bag of diagnoses

Kyle Bradford Jones 31:10

Absolutely. So, all of my patients have a developmental disability. I would say maybe 80 to 90% have an intellectual disability of some sort. The majority have autism. A lot of them are non-verbal, can’t really communicate much with you. And so when they are struggling with some thing. It can be something physical. They’re just not feeling well. It can be something emotional or behavioral. They oftentimes will lash out behaviorally and so then it’s okay, let’s try to figure out what’s going on even though they can’t really communicate a lot with us about what they’re experiencing. And the clinic that I’m at, all of the patients who are seen there do have a mental illness of some sort. And so I think I am better at working with this population because of my experiences with mental illness. And I think it’s also very healing for me. And so it kind of goes both ways, I think.

David Pace 32:25

It’s helpful and healing to you to help and heal others.

Kyle Bradford Jones 32:30

Yeah, exactly. I understand to a certain extent some of what they’re experiencing. Certainly not all of it, of course, but because of that, I’m able to have a lot more empathy, a lot more patience and focus more on the individual as a whole as opposed to a bag of diagnoses, so to speak.

David Pace 32:54

Yeah. Yeah. Nobody wants to be a bag of diagnoses.

Kyle Bradford Jones 32:57

No.

David Pace 32:59

We save that for Facebook and political discourse.

Kyle Bradford Jones 33:02

Yes, that’s right.

David Pace 33:05

Not to bring in the election. That’s coming up soon. But yeah, in the last episode we were talking about, we were talking about these anxiety disorders that come from very unique what appears to be I don’t want to say unprecedented times because I don’t know necessarily that it is unprecedented, but it feels that way. And so, you know, there is a lot of anxiety going on right now around not just politics, but institutions that seem to be compromised or actually disintegrating. Some doctors might even say the health care system is doing that. But all of it, it seems like it’s all happening or it feels like it’s all happening because we’re all reading about it, you know, I get it. I get an alert from the Associated Press every five seconds about breaking, nes right? And it’s impossible not to look at it.

Kyle Bradford Jones 33:59

Right. Exactly.

David Pace 34:00

There’s a New Yorker cartoon where this guy is at a cocktail party and he’s wearing one of these cones of shame, they put on dogs, holding his martini. And he’s telling the woman he’s talking to “Yeah, it’s to keep me from looking at my phone.” So I wonder if you could sign off a little bit with this podcast about the unique times that we’re in and the anxiety around that and and how we might best approach that, other than getting a therapist and maybe going on medication. Yeah, I mean, without saying that that’s not a real option. And that there’s no shame in doing that.

Kyle Bradford Jones 34:37

Yeah. You know, there are obviously a lot of different theories about why mental illness is so much more of an issue now. My personal belief is simply that it comes down to we don’t have as much mental or emotional stillness as we used to.

David Pace 34:58

Stillness, interesting.

Kyle Bradford Jones 34:58

And part of it is, like you say, those constant alerts, we are constantly bombarded with information, and we don’t get rest from that. And so our minds and our bodies can’t really process the information like we’re used to doing, like our bodies and humans are used to doing. And so I really think focusing on stillness is a big thing, and it’s something that I’ve tried to focus on a lot more too, to separate myself from some of the chaos. And that’s really hard to do. That’s why it’s such a big problem is because it’s really hard to escape. But focusing on that even a little bit, I think can really make a big difference in our mental health.

David Pace 35:48

Yeah, I would think that being a father of four kids, you have plenty of chaos in your lives because you’re not only trying to manage your emotional life, but there’s as well.

Kyle Bradford Jones 35:57

It’s true. It’s true.

David Pace 35:59

But I suspect you’re doing a very good job. And anybody can write “Hospital! A Medical Center of Unhealthy Proportions” is probably on the right path.

Kyle Bradford Jones 36:10

I sure think so. But, you know, I’m sure most wouldn’t.

David Pace 36:14

There you go. So Kyle Jones. Kyle Bradford Jones, again, is an associate professor in Family and Preventive medicine at the University of Utah School of Medicine. Thank you very much for being with us.

Kyle Bradford Jones 36:27

My pleasure. Thank you.

David Pace 36:28

I was going to say happy mental health. I guess we can commemorate Mental Health Week. Yeah, let’s celebrate it. Yeah, let’s do it. Exactly. And you’ve helped us do that today. So thank you very much for being here.

Kyle Bradford Jones 36:41

Yes, thank you.

Pace Yourself: Season 2 Episode 6

January 4, 2025

Listen Here:

Introduction

Ben Lewis

Benjamin Lewis, MD, Associate Professor (Clinical), practices inpatient adult psychiatry at the University of Utah Huntsman Mental Health Institute where his clinical interests involve the diagnosis and treatment of major psychiatric disorders. He has additional interests in medical ethics, the philosophy of psychiatry, and the emerging science and clinical applications of psychedelic medicine.

Resources:

University of Utah Psychedelic Science Initiative (U-PSI)

TEDTalkxSalt Lake City with Ben Lewis:

Could psychedelics help patients in therapy?

Transcript:

This podcast discusses trauma related to illness, including suicide. If you’re having suicidal thoughts, you can dial or text the Suicide and Crisis Lifeline at nine, eight eight. That’s 9-8-8.

David Pace 0:00

Hi, my name is David Pace and this is Pace Yourself, a podcast from the University of Utah College of Science on Wellness. Today, my guest is Dr. Ben Lewis, an associate professor of psychiatry in the Department of Psychiatry at the Huntsman Mental Health Institute here at the U. Dr. Lewis’s research focuses on psychedelic-assisted therapies and his clinical work focuses focuses on adult inpatient psychiatry, as well as ketamine-assisted psychotherapy. He’s currently the clinical director of the Huntsman Mental Health Institute Ketamine Assisted Psychotherapy Psychotherapy Clinic in Park City, Utah. Welcome, Ben. It’s so good to have you here. Great.

Ben Lewis 1:51

Great to be here. Yeah, Thanks. Thanks for having me, David.

David Pace 1:54

Yeah. So, as I mentioned in an email to you yesterday, my first introduction to psychedelic-assisted psychotherapy was in the prime video movie or series, legal drama on CBS titled “The Good Fight” with lead actress Christine Baranski. She plays an attorney who is having major anxiety over the run up to and the result of the 2016 presidential election. And I’m sure there are a lot of misconceptions about psychedelic-assisted therapies. And I’m sure Christine Baranski perhaps didn’t help that, but maybe she did. I don’t know. Can you give us a brief background on its history? Bring us up to date?

Ben Lewis 2:36

Sure. Happy to. I’m not familiar with that show, so I’m not certain how psychedelic-assisted therapies were presented there. And I think you’re right. There’s a lot of media attention currently on this topic, and that is a mixed bag. Some of that is accurate, some of that is not-so-accurate. And also a time where there’s a lot of hype and perhaps some overpromising on this set of therapies as well. And so I do think it’s a nuanced, middle ground message in terms of kind of the state of the science and in many ways, nothing new. Psychedelics have been around for millennia and have been used in different ways by different indigenous groups for spiritual and ceremonial purposes, often in group settings. And there had been a really robust period of clinical research in the 1950s and through the 1960s in psychiatry, looking at psilocybin and mescaline and LSD, specifically for mental health purposes. And a lot of those studies were very promising for a range of conditions, studied for alcohol and substance use disorders, studied for depression, studied for existential distress associated with end-of-life for terminal illness at that period of time. And yeah, a lot of very promising results and all of that really came to an end in the early 1970s when these compounds were all rescheduled, put on schedule one during the Nixon administration, and effectively that shut down any clinical research for the next 40 years or so, 40 to 50 years. And really more recently in the last decade, and then more more significantly in the last five years, there has been a real resurgence in interest in clinical trials looking at a range of different classic psychedelics, including psilocybin and LSD.

David Pace 4:49

So you’ve got two clinical trials going on right now. Is that correct?

Ben Lewis 4:54

Well, let’s see. We have a number of them. Actually, we have we have. ..

David Pace 5:02

Well, let me tell you the first two that I think you’re doing based upon my research. One is, I think what you were just talking about, although it says that it’s in combination with mindfulness=based stress reduction to address burnout and depression in frontline health care providers. Is that clinical trial over?

Ben Lewis 5:25

That’s correct. Yeah. We have finished that trial. We’re currently writing up the results. We ran that trial over a couple of years. And you’re right, that was a study looking at the combination of group psilocybin-assisted therapy and mindfulness based stress reduction – MBSR, which is annualized eight week mindfulness training program, and that’s run through our Resiliency Center. So we used those resources and enrolled physicians and nurses who were dealing with depression and burnout related to the COVID 19 pandemic. And yeah, really, really fun and challenging and interesting study. We randomized participants to either just receiving the mindfulness training. So people either did an eight-week mindfulness training protocol or they did that same program with a high-dose group psilocybin session and asking the question, are there differences between the groups in terms of, you know, severity of depressive symptoms, severity of burnout? We looked at a range of outcomes related to just mindfulness. Like, is this a helpful thing as far as mindfulness training? So yeah, we finished that study.

We did another group trial with psilocybin for patients dealing with depression associated with cancer. That was our first psilocybin trial here at the U. We finished that a few years ago. We’re running a few other studies, actually. We’re running a trial for treatment-resistant depression with psilocybin, and we’re running a study for postpartum depression. Also not using psilocybin, but using a sort of novel, short-acting psychedelic called 4-HO-DiPT. And then we have a couple studies with ketamine, assisted psychotherapy going on right now.

Ketamine vs psyilocybin

David Pace 7:24

So ketamine is, I understand, is FDA-approved in certain settings, but not necessarily for some of the stuff that you’re doing clinical trials in?

Ben Lewis 7:36

Yeah, that’s correct. Ketamine is used clinically. Currently, it has an FDA approval in its Spravato® formulation, which is a nasal spray, and that’s approved for treatment resistant depression. Ketamine is used in as an I.V. infusion, also for depression. This style of working with ketamine that I’ve been doing clinically in that we’re doing research with is ketamine, assisted psychotherapy. So a little bit of a different framework for using that medicine. And in also to be clear, ketamine is distinct from other classic psychedelics. It’s distinct pharmacologically. The risk profile with ketamine is pretty different than, say, psilocybin. Classic psychedelics, like psilocybin, are still on schedule one, so we can’t use them clinically. Really, we’re using them only for research purposes and you have to go through hurdles with the FDA and the DEA, whereas ketamine is clinically available. And so in certain respects, easier to to study, currently.

David Pace 8:43

So I’m interested in this interface or how mindfulness might inform the use of these psychedelics, because I think a lot of us are familiar with mindfulness.

David Pace 9:00

Is that is that designed to process the experience? Because we’re really talking about having an experience or what? Yeah, people used to call a trip, maybe they still do, right? And so is the mindfulness really to like in a guided way to try to process the experience, whatever that might have been for the individual. Is that the intent?

Ben Lewis 9:23

Yeah, it’s a great question and I think there’s different angles for thinking about that. I think there are experiential elements of overlap between states that people can access through mindfulness meditation, in psychedelics. Certain kinds of non-dual experiences are overlapping with those practices. There’s also, to your point, questions about how to adequately prepare somebody for an experience with something like psilocybin where they maybe have some tools for navigating what can be a challenging or difficult or very unusual experience.

And then on the flip side, there are questions about how do we integrate or sustain those kinds of benefits that might happen. Right? And I think in a complementary way, there are questions: Are those kinds of experiences with the psychedelic? Are they helpful in sustaining or growing or developing a mindfulness practice? So many of those questions, we don’t really have great answers to right now. This is not super well studied, but most of those questions really inform the motivations for a study like this.

David Pace 10:45

What are the group-based interventions that you’re talking about?

Ben Lewis 10:49

So one real challenge with, say, the majority of psychedelic-assisted therapies in clinical trials is that they’re typically individual format, so they involve two therapists per participant. And it’s a long session, right? It’s an eight-hour dosing day typically with psilocybin. So a long, long day. And it’s bookended by preparatory sessions and then integration sessions on the flip side. So it’s very resource-intensive, and so like to move a single participant through that protocol that might be 20 hours times two, so 40 therapist hours. And there are just really significant questions how might we scale this or make this accessible for the ability to treat more people down the road? So there are research questions, there is a safe and feasible to do, and then there are there are questions just in terms of scalability when this rolls out is a form of clinical treatment.

Ben Lewis 11:58

So the group models we’ve done and this has been novel in terms of the research we’ve done here has involved the full-group format. So we’ll have a group of say, five participants and we’ll do group preparation where, you know, people are engaging in a group format, kind of moving into the dosing-day session. And then we have a full group dosing session where everybody’s in the same room. We have music played over a speaker system to do that and then group integration, and that has not been done in the modern era. So we’ve done two trials with that model so far, and they’ve been small studies, but they’ve been feasible, they’ve been safe, they have seemed in certain ways to suggest some unique efficacy of that group environment for people with this kind of experience.

David Pace 12:55

So it sounds to me like you’re talking that this is not like a one on one talk therapy thing, but there’s a kind of a social element to this kind of therapy that might inform or aid what results you’re maybe gunning for.

Ben Lewis 13:14

Yeah, exactly. I think part of, for instance, depression and burnout can be a real sense of isolation, a real sense of disconnection. And so it has felt like that group format makes a lot of sense in a lot of ways as far as targeting those kinds of conditions. And insofar as that group format dosing session, it’s not especially interactive. It’s a pretty internal experience. People are wearing eyeshades. It’s, you know, there’s not a lot of interaction per se on that day apart from before and after the dosing sessions.

David Pace 13:58

So it’s not like a group therapy scenario where you’re sharing stories.

Ben Lewis 14:03

Not during the active drug effects, but certainly before during preparatory sessions and then subsequent integration sessions. Yeah, it really does have a group therapy feel to it.

David Pace 14:17

So the brain chemical that we’re working with, at least in ketamine, is called glutamate.

Ben Lewis 14:25

Yeah.

classic psychedelics

David Pace 14:25

And is that different than what you’re using with the other psychedelics?

Ben Lewis 14:29

Yeah. Good question. And ketamine is distinct. It works differently in the brain. It works on the glutamatergic system by targeting NMDA receptors. And that’s very different than something like psilocybin, which is considered a classic psychedelic, and classic psychedelics really refer to psilocybin, LSD, DMT, mescaline. So like a family of different compounds that all act on the serotonin 2A receptor, so a different receptor subtype, different certainly duration of effect with those compounds, different experiential effects, presumably different clinical effects, and some overlapping elements too. So there are overlapping elements in the kinds of therapeutic approaches that we might use. They’re overlapping effects for what people might experience on those different compounds with some distinctions.

David Pace 15:31

And they’ve got to be extremely unique to each individual. Isn’t that part of the difficulty in measuring and assessing the value of these psychedelics?

Ben Lewis 15:43

Yeah, exactly. Those experiences are really different for everybody. They tend to have a quality of ineffability, so people can’t really describe or characterize or put into words what that experience was like or meant to them. And are quite varied, unpredictable. And there are many questions as to what is the relationship between the experience itself and therapeutic outcomes. We don’t know the answer to a lot of those questions. Most studies to date have shown that certain kinds of experiences that people have — the higher the magnitude on those experiences — the more significant and sustained the therapeutic effects. And that’s been studied primarily in terms of this concept of mystical experience. And there’s a range of questionnaires that get used to, you know, imperfectly characterize what people might have experienced. And most of the studies to date have have really shown that the higher the magnitude of mystical experience that people experience during the session, which is really characterized by a sense of connection, a sense of ineffability, a sense of sacredness, a sense of deep personal meaning, those experiences seem to predict therapeutic response, which is like an interesting and like very unusual thing in psychiatry.

spiritual enhancement

David Pace 17:24

So, yeah, you walked into your typical psychotherapist office and, maybe I’m speculating here, but I’ve had some therapy myself, and you start talking about spiritual matters, spiritual enhancement, which is what these drugs can can do, along with a whole list of other maladies that it can address. Although spirituality, I guess, is not a malady, but a condition, I guess is the better word. And you can’t get very far with a lot of psychotherapists if you start talking about religion or spirituality, in my experience. And so this is kind of like you were hinting at just now, it’s like, we’re not in Kansas anymore. That’s right. In some way. Is that must be kind of exhilarating.

Ben Lewis 18:21

Yeah, well, exhilarating, scary, uncertain, right. Like, and it brings in all of these elements that science has historically been somewhat antithetical to. Right. And for new, really good, deep reasons, though, I would say, I mean, I don’t think there’s anything about spirituality that is not open to scientific study, and I don’t think it necessarily has to be woo-woo in ways that preclude thinking carefully about it and studying it and taking it seriously as an avenue, an important vein of human flourishing and well-being.

Ben Lewis 19:06

There’s a there’s a philosopher, Thomas Metzinger, who wrote this great essay called “Spirituality and Intellectual Honesty,” which I always come back to, and this essay really argues that spirituality and science share this common underlying value of intellectual honesty, a sort of radical kind of honesty. And I sort of like that framing for spirituality. But yeah, I don’t think it’s very easy in the field of psychedelic science to strip out elements of spiritual experience for people. That’s an important part of what people experience, and it seems to be important as far as what happens for them therapeutically.

David Pace 19:56

Yeah, well, I think it’s an opportunity to bridge a divide that maybe doesn’t really need to be there. Actually, there’s a lot of literature, I won’t say a lot of literature, but some literature now around the “spirituality of science.” And of course everybody just kind of around here, kind of ducks, ducks and covers when they hear that, you know, especially when you’re in an environment here where religion is very the civilizing force of the state. Right. In many ways, politics and otherwise. But yeah, I think it’s an opportunity, and I’m glad that you suggested human wellness because of course that’s what this podcast is about. So we’ve approached this, just as a little back story to this podcast, we’ve approached this with eight dimensions of wellness that the National Institutes of Health, have established, one of those of which is spirituality. So it’s kind of nice to see. And of course, the irony of all of that is that they’re all related, right? And so it’s kind of superficial in a way to break it out into components. And we found that out very quickly ast year, didn’t we Ross because every time we tried to talk about social wellness, we very quickly started talking about physical wellness, mental health. In a way we went. So maybe we should have all been taking a trip. I don’t know. Maybe that would have helped.

Ben Lewis 21:27

I could see a utility in sort of dividing different categories because there are ways in which we might neglect certain aspects that, when framed in a certain way, maybe become a little bit more salient, right?

David Pace 21:40

Well, and the notion of holistic health, you know, and wellness is huge right now, somewhat of a buzz term. But I think it’s worth unpacking really a lot because there are these segmented, siloed disciplines that we’ve had traditionally. And the modernist experiment, if you will, since the Enlightenment, we’ve kind of broken those up into silos, which is a danger. So again, it must be a bit exhilarating for you to kind of see these connections coming together and seeing opportunities to explore them.

from Maine to Iowa Medical School

Ben Lewis 22:25

Absolutely. I mean, I went into psychiatry in the first place because it seemed to offer this broader way of thinking about humans and approaching various ways in which people suffer or struggle, and this for me has been a really wonderful way of kind of connecting with that original motivation for me.

David Pace 22:51

Tell us a little bit about your background. Where are you from and where did you go to school and and what was your journey into psychiatry? Did you decide you wanted to be a medical doctor to begin with, or did you decide that you wanted to be a psychiatrist right out of the gate?

Ben Lewis 23:05

Yeah, I had a little bit of a yeah, and not a not a very direct path, I guess. I grew up in Maine mostly and went to undergrad in Cambridge at Harvard University and studied English and philosophy. So medicine was not really on my radar at that point in time, although my father was a physician. So it was it was on my radar to some extent. I met my now wife during undergrad and we subsequently moved to Iowa City when she got into medical school. And it seemed to me, Jeez, that doesn’t look so bad. It seems to be fine what you’re doing there. I think I could probably do that as well. And so I took pre-med classes and, and then eventually went to medical school at the University of Iowa with much less ease than my partner.

David Pace 24:00

Well you were a Humanities guy.

Ben Lewis 24:02

Humanities guy.

David Pace 24:03

The dangers of humanities.

Ben Lewis 24:05

You know, prior to that, I had been first volunteering and then working in a research lab at the University of Iowa that was at that time run by Antonio Damasio, and they were doing a whole range of really cool projects around emotion and consciousness and autobiographical memory. And I really liked that. I really liked the way we were engaging with study participants. I really liked thinking about the brain. I liked kind of all of the philosophy of mind stuff that went into that. So I was thinking, you know, in relation to medical school, something about the brain: neurology, psychiatry, and then just really liked psychiatry a lot more in school.

We finished. My wife did a public health degree, so we finished at the same time and then couples-matched here for residency back in 2008. So and then have been here since then a little, little while.

David Pace 25:08

Yeah. So let’s talk really quickly before we pivot to maybe what most of our listeners want to know. Like, am I a candidate for this? I’m interested in the conditions that it looks like PTSD is one of them. I wanted you to expand on those kind of hard core conditions that people are suffering from, that this therapy or therapies could could help.

Ben Lewis 25:55

That answer is a little different depending on which compound you’re talking about. And so, for instance, starting with ketamine, really the bulk of the evidence for ketamine is in treatment-resistant depression and treatment-resistant anxiety disorders. And so that’s mainly what we treat in our clinic right now, looking at psychedelics like psilocybin or LSD. Again, these are still predominantly in sort of research phases and have been studied for depression, including treatment-resistant depression; have been studied for substance and alcohol use disorders; have been studied for anxiety. They have been studied for end of life, existential distress or anxiety and depressive symptoms surrounding fears around death and dying. You mentioned PTSD and that’s really referencing MDMA. So, again, a somewhat distinct chemical, not a classic psychedelic.

David Pace 26:59

Tell me again what MDMA is.

Ben Lewis 27:00

MDMA, the street name or the street drug name for MDMA is ecstasy or Adam. And, you know, has had a history in the club drug scene. And MDMA has been studied extensively at this point for PTSD, post-traumatic stress disorder. And there have been two completed phase three trials for MDMA, assisted psychotherapy, for PTSD. And in fact, that compound was just reviewed by the FDA this past summer, this past July. And the FDA said, no. The FDA did not approve MDMA assisted therapy based on two phase three trials that had been sponsored by Mapp/Lycos now, which was a big deal and a disappointment and in many ways spurred a lot of discussion, a lot of strong feelings there. Certainly problems with the approach to certain elements of the approach to those trials. So the FDA and the preceding advisory committee meeting, they put their fingers on some very legitimate concerns and issues and came down pretty hard against approving that medicine, requesting that that company completes another phase three trial, really digging into some safety data prior to approving that medicine. So that was a was a pretty big deal for the field as a whole. And certainly pushes back the timeline of that style of treatment being available for people clinically.

David Pace 28:49

Yeah. I was reading in the “Lancet” regional health journal out of Europe, but I guess it was just almost exactly a year ago when it came out. But they were talking about the, first of all, the need for new therapies in this way. They were talking about how many people suffer from mental illness in Europe. And I’m sure that it’s just as bad here. I’m trying to find that statistic readily. But they also were talking about how complex the treatment protocol is of these sorts of attempted therapies, and definitely that there needs to be more trials and so forth. They’re being obviously cautious, which is why I suppose we have these trials and these institutions that try to keep us on track. But I guess I was just struck by what a problem mental illness is. And I don’t know, maybe you could talk briefly about that and the kind of the broad picture of mental illness as we move forward through this technological age, which I think is being linked to some of the isolation that people are feeling and the despair and the confusion, maybe.

Yeah. Can you speak briefly about that broad picture of mental illness in the United States, maybe in particular?

Ben Lewis 30:31

Sure yeah, I think you’re totally right. You know, there are certain things we can do in mental health fields and in psychiatry, and there is just an ocean that we’re not really able to effectively do a whole lot about. And for me, that has just taken an increasing toll as a psychiatrist over my career, where I’ve practiced predominantly inpatient, adult psychiatry. PTSD, for instance, our current treatments are inadequate, and there’s really no other way to to say that a huge fraction of people are not helped by the medicines that are available. A huge fraction of people are not able to really complete or adhere to the evidence-based psychotherapies for PTSD, and the impact of that condition over time — which is a chronic condition — hose impacts are just huge and growing. And to your point regarding the milieu we find ourselves in now, where we have sort of increasing sense of existential crisis; we have an increasing sense of disconnection in large part levied by our technological devices and the way we were living in modern society; many features of mental illness appear to be getting worse.

And so a huge motivation for me with this field is this hope surrounding a style of treatment and a way of engaging that, yeah, holds promise of being effective in a sustained way for people. And for sure, many, many questions still to be answered and still pretty early on and in understanding that. But I think enormous promise is there, especially for very difficult to treat conditions.

David Pace 32:31

Yeah the single dose psilocybin is that what it’s called has been incredibly promising at least in the studies that they have done. Maybe not as big of the study as they need, but it’s apparently, according to The Lancet, it’s just striking at how those single dose experiences can shift, get people out of their “stuckness.”

Ben Lewis 32:56

Yeah. Yeah. And I think it’s a different model than taking a medicine every day forever. Right. It’s a discrete number of sessions: one or several. And again, like a lot of of questions still, there have been studies looking at, for instance, treatment-resistant depression. And there are still a number of questions in terms of how long are those benefits sustained and that differs for different patients. Right? But yeah, no, I think you’re totally right. There’s been a lot of like early, very, very promising results with this style of treatment.

David Pace 33:36

So I found the statistics that I was referencing earlier from the Lancet article, almost 1 billion people, they estimate, have mental health conditions globally. And in the European Union alone, mental health problems affect more than one in six people and the economic cost exceeds 4% of the gross domestic product. So we’re talking about a major crisis or opportunity to rethink something.

Ben Lewis 34:05

Exactly.

David Pace 34:08

So there’s PTSD, there’s depression, there’s alcohol use disorders, addictions, social anxiety, like the kind that Christine Baranski was having in her show. And I think it’s very telling that we’re talking about this just weeks before the election, again, I’m sure a lot of that has happening. And again, enhancement of spirituality being another condition that this can deeply affect.

Is this for me?

So here’s a couple of questions for you. I think we’re kind of wrapping up here. If someone were to ask, am I a candidate for this kind of therapy, what would you first ask them?

Ben Lewis 34:50

Yeah, I think as far as enrolling in a clinical trial, a lot of those parameters are very, very narrow. That’s a very limiting aspect right now for people who are interested in accessing this kind of treatment. It’s also a really interesting time and that there are legalization measures afoot in states where this is now clinically available: Oregon and Colorado. So there are a range of pathways and, you know, they’re not all aligned with similar thinking necessarily or similar models.

But engaging in clinical trials with classic psychedelics is hard. I mean, they’re very limited and they’re hard to get into and very specific and pretty narrow and also very intensive for participants. So that’s a real challenge. There’s many more people that are really interested in these kinds of treatments than we have availability for in trials or like in clinical avenues. And then it gets interesting as well because there’s a whole host of underground avenues that people people access this to. And those are heterogeneous in terms of what that looks like and in terms of safety.

So it’s tricky. It’s tricky to navigate in this, tricky to advise people on this topic.

Looking at ketamine, yeah, that that is much more accessible. So ketamine is available clinically. People are receiving ketamine infusions and ketamine treatments. Ketamine assisted psychotherapy is clinically available for certain conditions. So that’s much more of like a available clinical avenue for people right now.

David Pace 36:44

So it really it’s it’s very individual, and it’s very just depends on the diagnosis of the psychiatrist which. I assume you have to have a prescription to get into these trials and to get some help.

Ben Lewis 37:00

So yeah, to enroll in a trial. Basically, people just need to go through a screening process So people can contact our study coordinator team to to be if they think they’re eligible for a trial on, say, postpartum depression or treatment resistant depression can either reach out to me. We have information for our study coordinator contact and that would put somebody on a list of people to be screened and that would include like reviewing medical records, sort of consulting with their outpatient providers, reviewing medications, reviewing other health conditions that might be like an exclusion criteria, making sure they’re not on any like conflicting medications.

David Pace 37:51

So yeah, a lot of questions to answer. It’s very interesting to have this available to us in our backyard in a way.

So we are observing here at the University of Utah Mental Illness Awareness Week this week. So we want to thank Dr. Ben Lewis, professor of psychiatry here in the Department of Psychiatry at the Huntsman Mental Health Institute for joining us today. And we will put some of these resources in our transcript with some links that maybe you can share with us.

Ben Lewis 38:35

Sounds great.

David Pace 38:36

Yeah. So thank you again, Ben. Anything else you want to say before we sign off?

Ben Lewis 38:40

Yeah. Thank you, David. Yeah, Pleasure talking with you. Thanks for the opportunity.

David Pace 38:43

Thank you.