Healing in Healthcare with Dr. Kara Pepper (Episode 92)

Introduction and Kara Pepperu2019s background 0:00

I am thrilled today to have Dr. Kara Pepper on the podcast. I have been consuming her Instagram posts and just really impressed with the value that she provides, the insights. the fun aspect to her posts. So it's great to have you on the podcast, Dr. Pepper. Yeah, thanks so much for having me. And what a great name. It's just like the best doctor name. Yeah, things you do for love, right? My maiden name was one of those that no one could pronounce, and so Pepper became it. So yeah, Dr. Pepper. This is honestly our first time meeting, although I feel like I know you a little bit through your posts.

Can you tell our audience a little bit about who Kara is and how you became a physician? Yeah. I would describe myself as someone who's eternally curious. I love learning. I love connecting with people and autonomy is probably my leading core value. So long before I was a physician, I was a professional ballet dancer. And when I could not dance anymore because of eating disorder-related injuries, I obviously just went to med school because I could totally escape in this profession and feel like I was helping people.

So I brought all my perfectionism and workaholism with me into medicine, looked great on paper, did very well, went to a great residency, joined a great practice. And about seven years into my career, I couldn't get out of bed anymore because I was so profoundly burned out. and really felt like a failure, like I was totally ashamed that I couldn't get my act together. If I just tried harder, perhaps I could do better. I took a sabbatical and then spent the next seven years trying to like fix myself so that I could withstand environment that was really no longer designed for me, that practice that was perfect at 30 was no longer perfect at 45. So I left after the pandemic and started my own practice and now I'm licensed in 18 states.

I do mostly eating disorder care, but I take care of adults all across the spectrum of disease. So I coach and I take care of patients. That's my life now. Wow, that is so inspiring. I'm curious if you could explain a little bit about your medical practice because I'm just going to say what my preconceived notions were about eating disorder care. We talked before we started recording that I actually did two weeks during my psychiatry rotation on the eating disorder service. And it almost convinced me to go into psychiatry because I found the patient population fascinating.

I found the patients to be smart, interesting. I probably, in retrospect, felt a kinship. I related to them because a lot of their behaviors are rooted in perfectionism. So I ended up not going into psychiatry and I became an emergency physician. So I've assumed there's no way I could help patients with eating disorders, but it sounds like there might be a way to carve out a practice. Can you explain a little bit more about what you do clinically to help patients with eating disorders? Yeah, I will start by saying that anyone who's taking care of patients is taking care of folks with eating disorder behavior, every single one of you.

And I will be the first to tell you I missed many of these patients early in my career because I just wasn't looking and I frankly didn't have the time to ask the right questions. But my practice is an outpatient practice. I do telemedicine, like I mentioned, and I see people in person in my Atlanta office, and it's in the outpatient setting. So my role is collaborative with dietitians, therapists, and sometimes psychiatrists. to help people readjust their relationship with food, body, exercise, and the maladaptive behaviors that got them there.

And my job is to say, are they sick or not sick? And just like with a pneumonia, for example, if someone's not able to get better in the outpatient setting, we will often offer that they go into a hospital. So there's intensive outpatient treatment programs, IOPs, there's partial hospitalizations, PHBs, and then there's inpatient or residential care. And there's people who work at those variety of levels of care, but I do the outpatient teamwork. And because of many reasons, there are less and less of those other options.

And so a lot of very sick patients are being managed by folks like me in the outpatient world. Wow. And I want to go back to your story. Did I hear correctly that you also have an eating disorder? Yeah, so I was a ballet dancer, like I mentioned, and certainly lots of pressure to have a particular physique.

Eating disorder care in outpatient practice 4:47

And the eating disorder criteria have changed tremendously in the past 20 years, so I never really got a diagnosis at the time, even though I certainly did not have a healthy relationship with food. I had a lot of food rules. I had total exclusion of food groups. I had a lot of guilt around the food that I ate or overexercised in order to compensate for the food that I ate. And anyway, so yes, those were probably we would call those orthorexic behaviors at this point in time. But yeah, I certainly was on the spectrum of eating disorders.

Just like we know that high blood pressure is a spectrum. You don't have to have a blood pressure of 180 over 100 to call it that. There's like a spectrum that gets you there. I think the take home is that we think of thin white cis hetero young women as the prototype for eating disorder. That's about 5% of the total of folks who end up with eating disorder behaviors. So most people are in quote normal or elevated BMI ranges. They have all different types of behaviors and that's why a lot of folks are getting missed because they don't have the stereotypic outdated look of someone that we would think would have an eating disorder.

Yeah, I think that's such an important message because we talk about the obesity crisis in America all the time. So what you're saying is there can be eating disorder behavior really at any weight, size, however someone looks. Absolutely. It does not discriminate. And largely folks who are marginalized, men are missed, the LGBTQ community are missed, people in different body shapes that are not under the BMI range are missed. And so, yeah, they can show up in anyone. Well, you just said it can show up in anyone.

Is there any data around if it shows up in healthcare professionals or physicians? Yeah. So, I mean, in line with some of the topics that we talk about here on your podcast with perfectionism, I mean, eating disorder behaviors are ways that folks, there's many reasons why people develop them, but particularly for the means of avoiding feelings of discomfort or the sense of control or because they have neurodiversity and there's sensory issues related to food. eating disorder behaviors are very common in people who are under stress in the healthcare system.

And in fact, there are specific programs designed for healthcare workers because we know that this is such a common problem where the groups and the treatments are built around healthcare workers. So not just physicians, although we know it's not uncommon in physicians, for dietitians and therapists and nurses and other healthcare workers as well. So a big part of your kind of shifting gears coaching practice is about perfectionism. Before we dive fully into that, I guess the first question I have is all eating disorder behavior rooted in perfectionism?

Like what's the overlap of that? No, it's not. There's a lot of reasons why people may develop eating disorder behavior. There's genetic components, there's environmental components, the big factors that physicians and societal norms encourage people to lose weight. I mean, the origin story for so many of my patients is that my pediatrician told me I need to lose weight and I developed these behaviors and I see them in my adult clinic. And so there's the groundwork, perhaps the risk factors, if you want to think of it that way, that kind of prime the pumps.

Certainly trauma, I think, is like 90% of folks with eating disorder behavior. And we absolutely know that health care workers experience trauma. But anyway, once that starts and then people have the initial weight loss, there's something that gets unlocked in the brain that tends to perpetuate that. And when I give you this story, it's really talking about people with restrictive food patterns. There's many different types of eating disorders. It's not undernourished folks. It could be binge eating disorder.

It could be bulimia. And then ARFID, which is avoidant restrictive food intake disorder, There's several different types. There's a fear-based type. People are worried about getting contaminated or choking. There's folks who just have an apathy or disgust around food. And then there's folks who have sensory issues. They don't like the touch, smell, taste of foods. And particularly for folks on the neurodivergent spectrum, we see that more commonly. So there's many different types. So I guess that's to my point earlier, if you're waiting for someone to be really thin to make the diagnosis, you're going to miss a huge spectrum of folks who are struggling with food.

Well, let's pivot now into more of your coaching practice. And the vibe I get is that you work with clients that are hyper-functioning, perfectionistic tendencies. Can you expand on that? Who's your ideal coaching client? Yeah, I think that everything that we do in life, the things that really motivate us, we do them because it either breaks our heart or it sets our soul on fire. And I think my story of profound burnout and feeling so lonely and like I was the only one struggling with that, which was clearly not the case, but it was my perception, that kills me to watch physicians who have sacrificed everything come into this field and feel like they can't practice medicine anymore.

Eating disorders beyond stereotypes 10:11

And so the origin of my coaching practice was really to help facilitate transition and burnout, but it's really evolved into helping people find real solutions around perfectionism, imposter syndrome, career change. And so I work a lot with individuals, groups, and then leadership teams. to help build programs around that. So for me, the coaching practice has evolved because I really do love making systems changes at this point and the group work I find to be so fascinating because when you watch some other totally amazing human struggle with the same things that you're struggling with, it's like the see one, do one, teach one thing that we talk about in medicine, you're like, oh, it's not just me.

Like actually a lot of other people are really struggling with this. And so, yes, the exhausted perfectionist who thinks that they're all alone and thinks that they have to give up medicine. That's really kind of my sweet spot. I love taking care of those folks. Well, let's dig in a little bit to perfectionism. This is a topic near and dear to my heart. I was identified as a perfectionist in, I believe it was fifth grade. My fifth grade teacher sent me to the guidance counselor and I very much got the message that something was wrong with me and that I needed to stop this behavior that was causing attention, not the good kind of attention that I wanted for my teacher.

And I was really floored by it because up till this point, I had thought that everything that I was doing was great, but I had gotten a lot of feedback that it was good. And so looking back on that fifth grade guidance counselor experience, and I think everybody's heart was in the right place, but I don't think it was very helpful. And now after years and years of doing the work, my analysis on that is the approach, whether they meant it or not was kind of shame-based that there's something wrong with you and you need to change the way that you're acting.

And I feel like the perfectionism has like ebbed and flowed. And it probably, after hearing you speak about it so far in the podcast is making me think that It probably rears its head under times of stress that it's a coping mechanism that I gravitate towards. There's periods in my life that I'm like, I'm not a perfectionist. I mean, how can you be a perfectionist in an ER doc? Like emergency medicine is like the most messy place to practice medicine. And in some ways I gravitated towards emergency medicine because I recognized that.

Like there's no way to be perfect. You have to figure out a way to be good enough. So I've just kind of spilled the beans on my perfectionism story. And I'm curious if you can kind of maybe provide a little bit more to the audience about what do we know about perfectionism from a neuroscience standpoint. And there's probably some people listening with kids, like they're probably wondering like, well, shoot, am I like turning my little kid into a perfectionist? Like kind of unpack any part of that you want to.

Yeah, I'd like to at least dispel the myth that perfectionism is what makes us successful. It's actually a thing that holds us back tremendously. There's a real difference between being a high achiever. And of course, in medicine, we want to deliver excellent care to our patients. We want to be good at what we do. But that is a very different mindset than perfectionism. Perfectionism is a set of adaptive behaviors that just help us avoid things that feel uncomfortable. So, if we think, well, if I can just get all of my charts done, then I can finally relax.

But then inevitably, we don't get all of our charts done because there's a never-ending inbox that happens. And then we say to ourselves, well, I didn't work hard enough, or what the hell is wrong with me, or this practices. not great, and there's too much work to do, the system's broken, and then we start to judge and shame ourselves for not actually achieving that goal. And then we make another promise to say to ourselves, well, if I can just get it right tomorrow, then I can feel better. It's this never-ending cycle of eternally being stuck.

Perfectionism, burnout, and coaching 14:38

It's like pinning our worth, our happiness, our success to something that's not actually achievable because it's a fantasy. That is very different than saying, hey, I want to do great work for my patients today and I want to take good care of them. High achievement comes from a place of growth mindset. It accepts failure. It learns from failure. It allows us to be more curious and tap into our intuition and problem solving. And so perfectionism really holds us back because it keeps us stuck. It makes us worry about being an imposter in an environment that we're in.

It keeps us procrastinating. It keeps us from actually taking risks. And so we just stay stuck. And so to answer your question very shortly is there is a real difference. And perfectionism, I think to your point earlier about being over controlled or a means of control, It makes us feel like we're doing something, but until we recognize that it's actually delaying our success, delaying our progress, that's the gap that needs to be filled for I think for people to be able to move through that. Well, I was just finishing some revisions in my book and I reached out to a therapist colleague and she specializes in trauma and she had some really helpful feedback because there was a section in the book that I was trying to delineate a little bit on when is it time to go to a coach versus a therapist.

What her response was, healthcare professionals in particular, we have a high trauma burden. We're exposed to a lot of trauma. And her feedback was when you look at like trauma therapy right now, a lot of the trends based on literature is that it's a mind issue, but it's also a body issue. So a lot of the therapies coming out for trauma are rooted in bottom up therapy versus top down therapy. And my experience, which I talk about is in the book is through EMDR. So I've done for listeners, most of them would know I brought this up before eye movement.

Desensitization and reprocessing sounds really like woo-woo and get kind of a little crazy when you hear it for the first time. Essentially, the therapist takes you through exercises either moving your eyes or listening to sounds or there might be a somatic thing and helps you process various traumas. And when I went through this process, we were able to uncover essentially the specific things that happened in childhood that the perfectionist mindset was really rooted in. And it was the self-protection that something happened.

It was bad and scary. And if I do these behaviors, I will protect myself from it ever happening again, which again is not real. But I'm curious. With your eating disorder practice and then also your coaching practice, certainly a big part is getting your mind right, making those mindset shifts. But how much are you recommending or when do you start to incorporate this bottom-up approach, whether it's EMDR, dance therapy, music therapy, anything that is more on that somatic side? I will say that everyone deserves to have a coach and or a therapist.

We're recording this on the first day of August. We're right in the middle of the Olympics. People like Simone Biles, who are the greatest athlete of all time in her sport, she has multiple coaches to help her be better and do better. And so I think that anyone who wants to grow should have access to that. That's my blanket statement. In terms of a clinical practice and my coaching practice, Often people come to us as physicians or come to me as a coach because they're in crisis. They're like, I have this problem that needs to be fixed.

And that's overwhelmingly the people that I take care of. But there's also people who come and say, I just want my life to be better because why shouldn't it be? I'm worthy of that. And I'm curious what else is possible for me. I'm curious what kind of job is possible for me. I'm curious like what it would be like to be a new leader. So they're open to possibility. It's not coming from a place of crisis. And really the answer, like for all of us who live in our brains, we can think and think our way through this, but the truth for us often lies in our body.

And I think the vagus nerve that I've read one time of our vagus nerve that literally innervates our gut feelings about things. 80% of the fibers are ascending, meaning our body is designed to send so much information upwards as opposed to our brain sending it downwards. And so if you want to know, for example, if you're like, I can't decide if I should quit my job or if I should pivot my career in some way, and you've circled around this decision over and over again, your body will tell you. It will give you the information that you need if you like ask it the right questions.

And so I'm a huge fan of somatic work. With that being said, for folks who've had trauma, their bodies are not safe, especially if there's been physical or sexual trauma. And so doing one, making sure that someone's nourished. I mean, that's the medical part of what I do in my life, but also making sure that they have a safe place to process trauma, which I do not think coaching is appropriate for trauma work. and then allowing them to start unpacking that with some of these modalities. Somatics may be a little later in their journey, but our bodies will give us the information.

So I'm a huge fan of the somatic work that gives us the information, both therapeutically and from a coaching standpoint. I love that quote that you said that 80% of the vagus nerve signals are going ascending, giving us information. And I use this analogy in the book, I paddleboard. And there's many times when I'm on my board, my body senses that I'm a waves coming or I'm about to fall before my brain does. And I've actually tried to use that as a form of conditioning or like teaching myself that my body does know things and it's smart and it's also rapid.

Like the responses that it gives me is very fast.

Trauma, somatics, and listening to the body 21:08

So instead of turning those signals down all the time, pausing, like, ooh, what was that feeling? What's this gut feeling that I'm having, this intuition or this whatever it is, and just kind of sitting with it for a minute. And it doesn't mean you always act on every signal that you get, but at least having that curiosity to be like, let me see what this was about. Yeah, and for any of your listeners who are, like, eye-rolling at this conversation, like, that's cute, but, like, that's not real life for me.

Like, just acknowledge that we have been intentionally trained to ignore our body's signals. Like, we are not allowed to go pee when we're seeing patients and there's one more lined up. We're not allowed to eat when we're hungry. We've not been allowed to sleep when we're tired. And we've been told that's what makes a good doctor. And I think you get to decide if you want to continue to believe that. And our bodies are sending us signals all the time. We've just been conditioned to not listen anymore.

And if you're feeling lost and your brain is not giving you the answer, I bet your body knows what's right for you. And so there's safe ways to kind of enter this. It doesn't have to feel totally out of control if this is outside your comfort zone, but there's ways to just get curious about the signals that your body's telling you. And that usually leads you in the right direction. I find it so ironic that as a physician, we spend so much time talking to people about how their bodies feel, asking about the symptoms and all the detail that we can do to try to elucidate a diagnosis from their descriptions.

And meanwhile, most of us are walking around completely turning off any signals that are very own bodies giving us. And I kind of feel like this phase of my career with being more in tuned with my body is totally made me a better physician because I'm just more receptive to hearing what other people are describing about their own bodies. Yeah. Yes, absolutely. And it's interesting. I think I talk a lot about the difficult doctor-patient relationship. We all have patients that we don't necessarily want to be best friends with.

They may rub us the wrong way. We certainly do that to our patients, the two-way street. But if you have a patient who's asking you for something, and you find that you're getting really annoyed with them, or you're like, ugh, this is just one of those, and this is heavy use of air quotes, those patients, whatever those that means to you, Your body is sending you a signal. It's usually some sense of resistance. It could be like a heaviness in your gut. It could be like a tightness around your throat.

It could be like a vibratory or like kind of agitated sensation in your chest. I mean, people will describe it in different ways. But your body is saying something's not right here. And it's really interesting because when we use our clinical skills of uncertainty, for example, we love uncertainty. We're like, oh my gosh, this doesn't sound like something I've heard before. I want to get curious about it. Our bodies are sending us the same signals as well, and it can give you information to be like, actually this may not be about the patient.

This is about me not knowing what the answer is for this patient and I just feel very frustrated. Or this patient is asking for something that I think may be harmful for them and I don't love confrontation and so I'm not sure I want to actually have that conversation with them. Or this patient reminds me of someone who was harmful to me in the past and I just recognize that it's provocative for me and I just need to set some boundaries or at least be candid about whether or not I'm the right person to cure for them.

But our bodies are sending us signals. We just haven't always been given the tools to interpret what those signals mean. And so our natural reflex is to just make it about our brain and keep moving. So I think our bodies are like amazing super powered clinical acumen tools. Totally agree. Well, I want to give some practical strategies to somebody that might be listening. Maybe their perfectionism is creeping back up or it's starting to create some maladaptive issues in their lives. What are some practical strategies for people with perfectionism?

I would start by just recognizing that you're totally human and this is something that a lot of people struggle with. It could be perfectionism, it could be over drinking, it could be over working, it could be scrolling social media, but all of these are ways that we avoid discomfort. And so that's really the first question, which is how do I think my perfectionism is helping me and how might it be harming me? What is it keeping me from? Is it keeping me from connecting with other people? Is it keeping me in a constant cycle of self-criticism?

Is it stalling me out? I can't get the work done? What are the ways that perfectionism is actually derailing you? And ultimately, some people may believe that it is helping them more than harming them, which is why it continues. But once we recognize that there is a cost to this rigid, controlling, fantasy-based perfectionism, it's usually when we're able to start pausing and saying, is that still true and what's the next right step? There's something you said earlier in the podcast that I want to lean on a little bit more.

You linked perfectionism in this behavior to maybe a lack of self-worth. And I think self-worth is this really difficult. And one way it's simple, but on the other hand, like to actually believe that you're worthy and believe in your own self-worth. I don't think there's an easy path to that, but for somebody that's been in the hole of shame and judgment, maybe that's been their whole life dating back to childhood. And maybe they've even done some things that have really impacted others in a negative way, further decreasing their self-worth.

How do you begin to build that self-worth up and this idea that your worth is not tied to achievements and it's not tied to anything that you've done before or that you'll do in the future. That it is this inalienable right is the way I like to think about it. But I can know that intellectually, but to make my heart believe that sometimes is hard. Yeah, we could, I mean, people spend their whole careers answering that one question, right? How do you improve self-worth? I will at least just tell you a story from my standpoint.

I'd heard about the concept of self-compassion for a very long time and I would have a lot of like eye rolling around it like that's cute for a spa weekend but like in my real life there is no compassion because it is an unrelenting need to see patients to take care of my family like there's no space for self-compassion in my life. Self-compassion felt very weak and like cute. And there's an author and researcher in Texas, Kristin Neff, who wrote the book titled Self-Compassion.

Self-compassion, worthiness, and recovery 28:38

Then it talks a lot about that. But then in 2021, she released a book called Fierce Self-Compassion. And it's really aligned with the social justice movements, with the MeToo movements. It's the yin to the yang. It's the fierce, white, hot advocacy that we're so familiar with in medicine. So I really got to a place where, in the pandemic, my suffering was so profound. I was so burned out. I was so exhausted. I had been so afraid of dying or killing someone that I loved with COVID. I had been coming home day after day, absolutely depleted, no room for anything else in my life.

And when I finally was like, this is not it. I know I've worked really hard, but like this is not the life that I worked for. And I don't want to feel like this for the rest of my life. It was in that shift to not say medicine equals suffering, but like it's okay for me to not be miserable and also practice medicine. It was this glimpse of your self-compassion. Specifically, it was acknowledging that I was suffering and saying, perhaps I didn't have to suffer that much. I would not have used the words, I am worthy of having a life where I do not have to suffer like this.

But it was like, I just don't want to do it like this anymore. And when we acknowledge that we are suffering, it allows us to say, what else? Or we can even borrow that skill that we have that we advocate for our patients to say, like, how could I possibly advocate for something different for me? And borrowing the thing that we're so good at with our patients and applying that to ourself was this glimpse of pure self-compassion that really helped me say, my life is going to be over at some point, and I will absolutely regret looking back on this season and wasting it in this place of misery where I just think this is what medicine is supposed to look like.

And it was in those moments that I was able to say, I don't know the how, but I know this is not it. So I'm going to take that next step to say, what could my life look like? And that's what ultimately led me to leaving and starting a practice where I practice and I love medicine again. Love it. Like first year med student love, can't wait for Mondays. Love the work I do. It's not easy work, but it's great work. And all of that would have not been possible if it weren't for that little possibility that my life was worthy of not being miserable all the time.

Wow. I mean, there's so much there. It sounds like the road to worthiness is paved in self-compassion. That's a key ingredient. And it sounds like it's also a daily recommitment. For folks who have made errors, which is 100% of us, some are big and some are small, but particularly for those moments where we just feel like, oh my gosh, here's proof that I am not worthy because I made this mistake. The thing that's very helpful for me to remember is I made the best choice I could with the knowledge and skills I had at that time.

Like, back when I would, like, lose my temper with my children when they were three years old, like, I was doing the best I could. It wasn't perfect, but I was doing the best I could under those circumstances. When I missed the diagnosis with that patient and the patient experienced harm, I was doing the best I could with the information and skills I had at the time. Like, that is absolutely true, even if I still feel bad about it. And that helps crack open the door to self-compassion to be like, of course I didn't do this on purpose.

Like, I would never harm someone on purpose. But it is possible for me to, like, at least allow myself a little compassion in saying, of course I did the best I knew I could at that point in time. Yeah. I think that's such a powerful message and probably the one as we start to wind down the podcast to leave people with. Brene Brown has this great podcast on unlocking us. It was towards the end of the last time she was recording a bunch of episodes. And she really digs into this concept of, do you believe that people are doing the best that they can?

yourself included and you have to think about it for a while. You have to really kind of ask yourself because as a perfectionist, I'm very able to go, I don't think that person did their best. But when you sit down and like really digest it, it's like, honestly, we all are doing our best. And it's kind of frustrating when you find out when somebody does something harmful, like really that was the best you could do. But then we, with self compassion for others, we realized that, yeah, that probably was their best based on their trauma history, based on the resources that they have in their life.

That was the best that they could do at this time. And that's really helped me. move out of that judgment phase, whether it's directed towards other people or myself. And it's like, well, if that was my best, what do I need to do better next time? And most often for a physician, that's rest. Yes. I was going to say sleep. Yep. Start with rest. That's always a good one. Well, as we wrap up this recording, which has been just a complete joy, we'll move into some rapid questions. What are you most excited for in 2024? All the hiking trips that I have been taking.

It's my drug of choice to get out on a mountain. So I'm doing a ton of hiking. In fact, in three days, I'm leaving for Glacier National Park. Amazing. And then are there any conferences you're going to or any conferences that you've been to that you would recommend to this audience? Yes, I have niche conferences specific to my clinical practice. So eating disorder conferences, there's a mass cell activation conference, which I'm super stoked about. And I'm going to hike out in Portland next month.

I'm going to some coaching conferences. specifically run by Physician Coaching Alliance, which I'm a part of, that helps continue education for physician coaches. And then lastly, I'm a huge fan of going to a wellness conference, because why wouldn't you want your employer to pay for your recovery?

Rapid-fire wrap-up and resources 34:48

And Kathy Steppen, who is Institute of Physician Wellness, she does amazing conferences at Maryville. And so I've been to probably four or five of hers, and those are always good ones. I love it. This is great. I love this question because I think for a lot of us, we get kind of in the same conference loop. And one of my goals for 2025 is to start going to some different conferences, just meeting some different people and expanding my heart and my mind. So awesome. Is there anything you'd like to share with the listeners about anything you're offering right now for coaching or where people can connect with you?

Yeah, if you can remember my name, you can find me on social media or my website. It's Kara with a K. Kara Pepper MD is my handle. Of course, I'm working with one-on-one folks and groups around perfectionism and imposterism and career change. But I have a special heart for folks who are really struggling privately with substance use, particularly alcohol use. I've been sober since 2021, and what wires together fires together. So if we're using perfectionism to avoid feelings of discomfort or overworking and burning out, and that has helped how we're avoiding feelings of discomfort, alcohol is absolutely one of those things that runs in those circles.

So in any case, if you feel like you're struggling by yourself, I'm always happy to to support you in that way. It's been incredibly powerful for me to voice these things publicly and get hundreds and hundreds of messages from physicians and other healthcare workers saying, me too. So my best advice for anyone who's listening to this podcast is if you're struggling in any way, whether it's hiring a coach or a therapist, is just to tell one person. And if it feels too scary to tell one person, just write it down and send yourself that email in the future so it'll get delivered so you can't deny that you've gotten this thing outside of your head.

It's in conversations and sharing stories that we actually heal. So reach out. Oh, so beautiful. Well, thank you, Dr. Kara Pepper, for everything that you're doing for patients and for healthcare professionals. You truly are changing the world, and it's been an honor to have this conversation with you. Thank you so much.