“If you’re not at the table, you’re on the menu”: Advocacy, systems, and who shapes healthcare with Tammie Lee Demler
00:00:00 Speaker 1: Welcome to Therapist Confidential, a psychotherapy net podcast. And now here's your host, Travis Heath.
00:00:10 Travis Heath: Hello, everyone. Welcome back to the Therapist Confidential podcast. I'm your host, Travis Heath. And today we get the pleasure of speaking with doctor Tammie Lee Demler. And I'm excited about this episode for a number of reasons. Probably the the most important reason is your expertise, Doctor Demler. I mean, it's, um, it's really, really interesting and intersectional, the likes of which we haven't yet had on this show. So we get to talk about psychopharmacology, stigma, loneliness, and who knows what else we might talk about today. Those are just, uh, you know, a few topics that we might cover. Um, welcome to the podcast. Would you mind, especially because I was just teasing your expertise, right? Your training, your history and what you do a little bit. Would you mind introducing yourself to the people and telling them a little bit about who you are and what you do.
00:01:02 Tammie Lee Demler: Sure. Well, thank you, number one, for having me on your podcast. This is a a unique treat for me because I'm usually a podcast host, which we will probably talk a little bit about. Um, I am a board certified pharmacist, doctor of pharmacy. Um, I am board certified in psychiatry and geriatric practice, which is somewhat of a unique combination. When pharmacists are board certified, they tend to just go with one thing. But I needed both of those. I love both of those populations, so it kind of was a perfect marriage of expertise. I work at a state inpatient psychiatric hospital, which is a unique setting. Um, at least in our area, there aren't a lot, not a lot of those types of inpatient facilities. So many of your podcast listeners may work at a state hospital. It's there's a benefit to that. And there's, you know, consequences to that. So it's it's a mixed bag. But I love what I do. I will work there until I retire. And I'm hoping, um, you know, kind of probably six or seven years left, and then I'll maybe open a bake shop, something fun.
00:02:07 Travis Heath: Ah, okay. I know we'll have to. We'll have to do an episode on this. This sounds interesting. First, that makes me hungry. Second, it's always interesting when I'm speaking with people who, you know, our jobs can be pretty intense. What we do, right? We can deal with a lot of crisis. And just it can be a constant state of sort of acuteness and like what people say they want to do when they're in their sort of second or third careers. I was really interesting to me. Um, I have a friend of mine, and she says she wants to like, stock shelves at Walmart, like overnight. She goes like, that sounds amazing. Where I'll be sort of just left alone. I could put my headphones on, I can just stock the shelves, and then I'm done and I just go home. So it's always so interesting to hear kind of what we might want to do in our next life, so to speak. All right. Now, you told us a little bit about, you know, your sort of expertise and it's wide ranging. You know, you do research, you teach, you do media. I mean, you know, you've been in leadership positions. And I'm wondering before we get into like really focus in on specific content areas, if you can tell us what are the threads that connect all of these different aspects of your career.
00:03:25 Tammie Lee Demler: Oh, I could tell you this for four hours. It's interesting because many students, when we have a residency program also at um, at the University of Buffalo, which is where I teach, and I'm the program director, and that's part of when we we match with a resident. They ask me, like, where did you how did you get to this point? And psychiatry was never my favorite thing. It was never my favorite subject. It was ironic that I ended up where I am, but I think my mantra has always been based on where I am and how I got here is just to kind of let the current take you. I know it's not an exact answer to your question, but I guess I've let the current take me without fighting or resisting to where I should be, because I think ultimately, if we just let things kind of happen. Um, you know, I'm a spiritual person. I feel that there's a, you know, there's a reason where I'm going, there's a reason for that. But many people might feel it's like the the universe is leading you somewhere. And so I think that we need to be open to that. But nonetheless, you know, I started out with just as regular pharmacist, you know, and there's no disrespect to that. We need community pharmacist out there taking care of people. But I always just wanted a little bit more. So, um, I went and I at the time when I got my first degree, a doctorate wasn't required. It's now required. So I thought, you know what? If I'm going to teach students as a preceptor, I need to get the same level of degree. You know, that's expected. So I went back as a as a later learner. I already had little children and it was difficult to do that, but it was more rewarding. So I ended up getting my doctorate and my last rotation clinical rotation was at this hospital, a psychiatric hospital. And I thought, I, I will tell you, I cried when I opened that appointment letter because I'm like, what do I know about this population? That was sort of scary to me. It was unknown. Um, but I, you know, I went with it. I tried to keep an open mind and I ended up falling in love with the population. Uh, you know, all of it. People really wanting to hear what I had to say when I was educating them about their medication. People who were able to trust a pharmacist because perhaps their psychiatrist felt a little bit like they were, you know, maybe managing their trajectory a little bit too much. Pharmacists were able to just give them information, help them, coach them, support them, be their cheerleader. So I ended up it's very ironic. But again, I feel like there's a map to each of our lives. I ended up being offered the position of the director of that, that hospital pharmacy And Travis, I had never done that before. I was just from a community pharmacy. I did supervision and all that sort of thing, but not a hospital. But you know what? I'm like, I'm going to do it. So imposter syndrome being what it is, I went every day, you know, trying to do my best with this new position. And then I thought, well, I should probably seek board certification in psychiatry, so at least I'm on the top of my game. So I did that. And then I'm like, you know, management, you know, needs really I probably need to get a degree to ensure I'm good with this. So I got my MBA, which was another whole interesting journey. Um, again, a whole podcast worth of what I learned going through management because it was a whole different way of thinking about things. It wasn't medicine anymore. It was this abstract, sometimes way of thinking about elements that were different than what I've ever learned before. So, um, in the midst of all of that, I became pharmacist, the president of pharmacist of New York State, um, being one of only two women ever in over one hundred years. So the leadership and professionalism, being able to say, you know, if you're not at the table, you're on the menu was the mantra we had, because there's a lot of people, you know, listening on your podcast, whatever profession they're in, there's always adversaries out there trying to chip away, take away, shift burden onto you. And they've they have lobbyists that are that are spending twenty four over seven trying to do these things. And I never realized that. So, um, anyways, nonetheless, I was, you know, the president the leadership brought me into the media realm because I was I was always asked about pharmacy stuff, you know, at local radio stations would call and say, oh my gosh, we heard about this or that. And, you know, being able to comment on the spot was something that I learned. And I ended up on this TV show, and the producer loved my presence, I guess is what he said. I think he just needed somebody to launch his show. But I started out as a TV host, which I still do today, but then a local radio host who was, um, a little flirty. I'll say, um, liked, liked my show and asked me to come on and talk on the radio show. And then then my radio show launched. So I'm doing it's called seven one six together with Tammy Lee, and I interview people from all over the all over the I could say country, but I do, um, people who have community affairs stories, people that need to have a voice. Uh, so that's kind of where, you know, the commonality of what we talk about for being podcast hosts comes in. So I feel like I've done I think I've probably done it all except have a bake shop.
00:08:28 Travis Heath: Yeah. That's, uh. Well, you got to have goals, right?
00:08:31 Tammie Lee Demler: I know.
00:08:31 Tammie Lee Demler: Fun goals.
00:08:33 Travis Heath: So many different directions I could go.
00:08:35 Tammie Lee Demler: I know, I'm sorry.
00:08:36 Travis Heath: No, this is great. No, you know that you do this. The worst thing is if you're sitting there and you're like, oh my God, where do I go? Right? I have no idea what direction to go.
00:08:44 Tammie Lee Demler: And they're answering.
00:08:45 Tammie Lee Demler: Yes or no, yes.
00:08:46 Tammie Lee Demler: Or no.
00:08:47 Travis Heath: It's always great to have direction. You know, I, I'm really interested in your position as a little bit differently than, like, a psychiatrist. Right. As a pharmacist, you know, you were talking about how often you're in the position of giving information, for example. Right. And that interests me for our audience because I think psychotropic medication in our field. Um, let me say it this way. People often have strong opinions about it. And, and sometimes, you know, look, all of us have to take, uh, whether it's a master's level degree or a doctoral level degree, we have to take some class A class on psychopharmacology, right? That's usually it. Now, of course, in some states, psychologists, for example, can get prescription privileges, you know, and so so, you know, this is changing to a certain degree. But there are very strong opinions in the field about psychotropic medication, and often not a whole heck of a lot of formalized study around it, which can sometimes be a dangerous mix. But I find that a decent number of my colleagues are really skeptical of psychotropic medication, and in some ways it's it's almost, um, it's almost seen as as damaging. Right. And I think sometimes they get some things tangled up. There's, you know, the, the, there's the industry, right, that produces these drugs. And then there's actually the drugs themselves and the relationship that people have with them. And you know, what it does for their life. And I think sometimes they get those tangled up, right, that they don't like Big pharma. Right. Because they don't like big pharma. It's like, well, you know, these drugs are bad. And of course, it's interesting to call drugs good or bad, like moralizing chemicals is a strange thing to do anyways because they're just chemicals. But I'm wondering if you could sort of give us a balanced, informed perspective to clinicians that might say something like, I would, I don't want any of my clients on psychotropic meds. These things are bad for people. They're dangerous. They're part of big pharma. They're just bad. Someone who holds that perspective. What what might you say to them?
00:11:08 Tammie Lee Demler: So I have a.
00:11:09 Tammie Lee Demler: Lot of thoughts in terms of this response. And my first thought would be, and for your audience to know, I think I know that there is generally an opinion about the role of the pharmacist, either on a team or as, uh, as my brother in law, who's a medical specialist, a primary care, sometimes abrasive conversations that happen with a pharmacy or a pharmacist when they're trying to, you know, call in prescriptions or that sort of thing. And I just want people to know that are listening today that my philosophy is that I think we all have a very specialized role. I think it can be important to collaborate, and I am entirely, um, when I provide information to clinicians, regardless of what their degree is or regardless of what their practice setting is. In New York state psychologists can't prescribe, so to speak. But in other states, they can. So it's different based on probably your viewers and who your who's listening. But I just I think to start out is my informed discussion for people when I'm educating them is to provide information about the medications. So this is this drug. We were talking a little bit about that new drug out there. We'll maybe touch on it later. This is the drug and all you need to know about it, regardless of how you use it and whatever guideline this is or off label use that you do. This is the the medication information that you need to know about it. And to your point, some people are skeptical about medication being, you know, sometimes harmful, maybe not a tool that they would necessarily consider. I am also a deprescribing advocate. You know, if you've got seventeen things on board and you're having an adverse drug reaction, it's hard to know what's causing it if you're on seventeen medications. And for our older folks, uh, the number one problem we see is polypharmacy. And that's a that's sort of a trigger word. Some people react to that as a prescribing negative, because sometimes we have patients that need seventeen medications. I hate to say that, but in order for them to live their life and be able to get out of a hospital, you know, clozapine, bowel preps, you know, medications to manage EPs there, it is sometimes necessary, but it's not always necessary. And so when even family members ask, I always say, well, you know, if you're taking something, make sure you need to take it because everything has a consequence. Um, recently there was this conversation about Tylenol and autism, and people were very upset about it. And I had, uh, on my podcast, a specialist talk about this and pulling apart the study and why it's not a really a big worry. My point was, if you don't need Tylenol, don't take it because there's a risk of something always when you take a medication, period, regardless of whatever risk you think it is. And I'll just tell you a quick funny story. My first day in pharmacy school, back in a long time ago, the professor handed out this piece of paper and it had all of these side effects and consequences, and it was pretty scary. And they said to us, would you ever take this medication? And we're like one hundred percent no, it was for Tylenol, liver toxicity, liver failure. I mean, death was in there. It was a consequence of knowledge that I'll never forget because everything taken has a consequence. So make sure it's really something that you need. Did I answer the question?
00:14:26 Travis Heath: Sure, sure. Yes. Um, I mean, it was a broad question. Uh, but I really appreciate the answer. And, you know, I think it was interesting what you were saying about polypharmacy, right? Like, and I guess this isn't just about, you know, psychotherapy or for therapists, but there is this sense and I and you can tell me if this is inaccurate. I actually haven't looked at the data around this. This is anecdotal, but it would seem there are more drugs than ever before for all sorts of things, not just psychotropic medication. Right? And I think sometimes there's a worry about that, you know, like, do we need this many drugs? Um, you know, are these drugs actually better than the previous drugs? And then, you know, like, it's funny, even my thirteen year old and nine year old, they watch these commercials, of course, which talk about all the side effects of drugs, you know, and they ask this question, which it's a it's a really good question. You know, why would anyone take this medication if there's this many side effects? And of course, I explained to them why they might and the risk reward and all of those things. But I think there's this sense that like, and, and I don't know if, you know, in the United States in particular, now, you know, we have the weight loss drugs that are coming, you know, gaining prominence, right. More and more people are taking these. And there's this idea, I think, that there's a drug for everything. And, you know, you were talking about sort of the risks of polypharmacy. And I think the phrase you used was like deprescribing. And I'm interested if you especially from your position, if you could say a little bit more about maybe why you hold that position.
00:16:10 Tammie Lee Demler: So Deprescribing would be probably more related to my interactions and consultations with older adults. I would say that in in their lives, the population that has this prescribing cascade, you have a medication that's prescribed, that's necessary, and then you end up with a side effect that needs some intervention. So for example, I'm trying to think of. Let's just say, let's just say an SSRI. We certainly want our older adults to be, you know, free from depression. You know, the whole loneliness thing is another conversation we can have, but we have a lot of untreated, under addressed depression and older adults. In my experience, depression looks different in older adults, so we may miss it. But nonetheless, you prescribe an SSRI, then they're all jazzed up. They're you know, they're sometimes they're stimulated by them and they can't sleep. So you have an older adult saying, I can't sleep. It's I feel awful. What happens? A prescribing, you know, a prescribing, uh, whoever the prescriber is might say, okay, well, let's give you a sleep medication. Well, then where do we go? Travis, do we go to the ambiance? Do we go with melatonin? Um, we go with something because generally speaking, and I'm guilty of it, I, I don't want to go through a ton of, you know, if somebody said you need to do twelve weeks of physical therapy or you can take this pill, what are we going to pick? We have a very little time. You know, it sounds great to be able to do something holistically but realistically. Holistically doesn't always match our life. So I think relative to that, De-prescribing is like, what's the why are you taking all these things? Let's look at the root of the cause. Let's maybe go with a more sedating antidepressant. Then we can get rid of all the other issues that are coming to play. So when it comes to de-prescribing, that's what I tend to try to look at is what's the problem? Why are we doing all these things and kind of peeling that onion back to be able to say, let's try to not have all of these medications that you're on, because every single one of them has a consequence that's adverse and, um, expensive. Let's talk about the the elephant in the room. Relative to that, uh, many of our older patients will say, you know, this is not working for me. I don't feel like it's making any difference. Well, then you get really deep into the conversation, and they're taking just half a pill every other day because they can't afford the copay, or they're in the donut hole or they're, you know, whatever their situation is financially, they're altering their regimen and they don't want to hurt the they don't want to hurt the feelings of the prescriber. There's a lot of.
00:18:46 Tammie Lee Demler: A.
00:18:47 Tammie Lee Demler: Lot of data that shows older adults prefer to not, um, how would I say disappoint their prescriber? They want to make sure that they're on board, that they're not. You know, younger people probably don't care as much. But there's this, you know, this older generation that really wants to have this relationship and, uh, respect that their doctor said so. So they want to do it, but they can't because they can't afford it. So, um, you know, that part of my professional lobbying and legislation had to do a lot with the Medicare Part D issues that we're we're dealing with. And, you know, the formularies that change and older adults that are just swept up in this vortex and loneliness, they don't have people that they can consult with. They're stuck with whoever their professional entity is, which is wonderful. But having that be the only soundboard they have is scary to me.
00:19:40 Travis Heath: Mhm. Yes. You just mentioned loneliness.
00:19:44 Tammie Lee Demler: Mhm.
00:19:45 Travis Heath: This is something that interested me as I was going through some of the work that you've done. And uh, for people that may not be aware, you know, the uh, the surgeon general had named loneliness. Like, you know, I think it was a public health epidemic.
00:19:59 Tammie Lee Demler: Mhm.
00:20:00 Travis Heath: If I'm getting the language right, if I'm remembering the language.
00:20:03 Tammie Lee Demler: Yeah.
00:20:04 Travis Heath: And, you know, you wrote an interesting article on this and it's interesting to me because as a, as a therapist, I mean certainly there was like the pre Covid times and the post Covid times right. And there were some interesting trends even before Covid that were happening, you know, with regard to sort of what would we call it, like digital connection, right, where people would say, well, you know, I have one thousand Facebook friends or whatever it is, right? But how much of that is actually creating connection and is some of whatever it's creating actually contributing to loneliness, even though it seems like we're connecting with someone, right? So there was already a trajectory of some stuff that happened. Then there was Covid that came along. Right. We became a much more digital society in a lot of ways. And you know that now. I mean, I hear about loneliness. You just mentioned the elderly population. We hear about loneliness there. I've read articles specific to loneliness among boys and men, loneliness among teens. Right. And so you start to see that this is being written about, and it's happening to almost everyone in sort of every demographic, uh, group that you can imagine. And so at this point, epidemic is a strong word. But when I think about, at least anecdotally, what I see as a clinician, it does appear that loneliness seems to be on the rise and it seems to be just about everywhere. All right. Now with that, what's your understanding of what this loneliness epidemic actually is and what it means? And what do you think finally pushed this to a level that people had to stop ignoring it.
00:21:48 Tammie Lee Demler: Great question.
00:21:49 Tammie Lee Demler: And I.
00:21:49 Tammie Lee Demler: I fell upon this actually based on questions that were asked of me, um, relative relative to the older population specifically. And you know, how alienation and, um, this new, this new I don't want to call it a movement because that sounds positive. This estrangement, this, you know, cutting ties because toxic, um, the whole children and family estrangement is slightly different than what the Surgeon General is talking about. But this has kind of dovetailed into the loneliness conversation is that older adults are being cut off for reasons probably that aren't justifiable. Many times you'll argue, and I know people would say, well, there's abuse and it's toxic and blah, and I get it. And I'm not dismissing I'm really by saying blah, I don't I'm not dismissing that. But I think eighty percent of what we're talking about is really perhaps a disagreement, you know, um, a daughter in law that doesn't like her mother in law. I'm not sure of your age, but I can tell you that I when I had, you know, been in through, you know, daughter in law stages and trying to please a mother in law. I really just knew it was part of the. It was part of the fabric of life. You try to do what you can to make people happy and feel comfortable, and then karma will come back. And at some point in time, younger people will give you the respect. And that just is not what we're seeing. It's part of this, this epidemic. I think that's going to make it even worse. But back to your original point is that the Surgeon General came out with this report in twenty twenty three. You can Google it. It's a it's a it comes up right away when you when you when you look at it, it's a PDF. It's a sixty, eighty two pages of really information, good information, a lot of references you can dig into further. But the surgeon General started looking at this decades before Covid. Uh, it wasn't just a Covid response, and it was a lot of what they were describing is this lack of connectedness with civic organizations. Churches were one of them, you know, the good old fashioned Lions Club where people would just get together for a common purpose and feel like they were part of something. It started to erode twenty years before Covid even was on the on the map. So we saw this disintegration, for whatever reason, starting to happen. And the surgeon General in the report describes this vital components of social connection, which as your to your point, you can have one thousand people in your Facebook family or likes or whatever you call the connectedness the your friends. Right. And part of what they describe is that there's three things three vital components structure, function and quality. Structure, the number and variety of relationships and frequencies of those interactions. And they gave examples of household friend circles, mineral status function, the degree to which relationships serve your needs, emotional support, mentorship, maybe support in a crisis. And then last but not least, the quality, which is I think when you look at the number of friends you have, there's not a lot of quality in that. Is that the positive and negative aspects of relationships and interactions, what's the satisfaction of those relationships? What's the degree of strain and how much strain can it as acceptable and social inclusion or exclusion? Um, again, I am not I am not the expert in this, but just having pored over this number numerous times, it makes sense to me that people who have a thousand people in their friendship circle on Facebook have maybe one person that really is connected as a quality, functional structural entity that they can count on.
00:25:25 Tammie Lee Demler: Um.
00:25:27 Travis Heath: Yeah. Now, if I could, I wonder if you see a connection here or not, but tying together what we were talking about and what we were just talking about. Do you see loneliness being. Even if unintentionally, unwittingly? Do you see it being medicalized in any way and address that way, and medicalized in the broadest sense of the term, rather than addressing it more directly? And when I talk about addressing it directly, I suppose we could address it like interpersonally. But I'm also thinking about systemically, but I'm wondering, do you see it being addressed or at least attempted to be addressed, uh, through, you know, medical intervention medication?
00:26:10 Tammie Lee Demler: Actually, that's.
00:26:11 Tammie Lee Demler: The take I took when I had to describe this as a C program because I, I had, you know, this was of interest to the group that was that had asked me to develop it. But I you know, the take on it was the medication interventions that could be necessary in the landscape of isolation. And so we talked about depression. We talked about anxiety, we talked about all of the things that would maybe come with loneliness, you know, insomnia with those. We did create some degree of medicalization, as you would say, as to how to intervene if those things, those consequences of, of psychiatric or psychological impact required intervention, because at the point somebody presents with depression and they are isolated, the chances of their getting immediate intervention, immediate, having that issue addressed immediately, probably zero percent. They've probably been suffering with that for a long time. They've not had anybody say, hey, mom or dad or, you know, friend. Have you seen somebody about that. Have you talked to somebody about that? One of the things that I also do is I'm a mental health first aid instructor, and that's a curriculum, um, developed by the National Council. It came actually from, um, Australia came over here and to the United States. And we've had a bajillion people go through that program. I have not taught all those people. I probably taught a few hundred, but the curriculum itself is is more or less teaching people in the community. You don't have to have a medical degree to be certified in mental health. First aid is if you see something, say something. Now that's a kind of a word that we used in the past for other reasons. But looking at noticing your neighbor, noticing people that are in your workplace, noticing people that may be in your household that you just, you know, pass by in the middle of the night or, you know, kind of passing like ships in the night, so to speak. If you take a time to just take a breath and notice, are they okay? Have you noticed notice something? You know, they're looking more disheveled. They seem stressed. It's those little nuances of notice that can, I think, start to turn this around. And the curriculum really helps people who otherwise may not notice what an impending crisis looks like. They're not trained to know that this disheveled look, this, you know, meetings, absenteeism, presenteeism being present but not really there. All these things can perhaps be the the winning ticket for that person, getting them the right help, maybe not being able to fix it, but getting somebody the right help. And you know, you know, Lord be with us if somebody is suicidal. You may be that last person that can make the difference. You know, let's text this number. Let's call crisis services. Let's get somebody on the phone that can help us with this. Because I'm not I am not trained to do this. But somebody else that's easily within a phone call is. So I digress, but I'm just thinking that relative to, you know, your question, we can all contribute a little bit to making a difference if we just stop and just notice.
00:29:26 Travis Heath: I love this idea of noticing and it makes me wonder for clinicians, for therapists, what are the questions that maybe they don't ask that they should be about loneliness?
00:29:39 Tammie Lee Demler: I think the first thing that pops up into my mind is, are you thinking of killing yourself? You know, people are very uncomfortable asking that question. And the the National. Well, it's the American Foundation for Suicide Prevention is the organization that I bounce most of my questions about suicide, you know, back and forth. They've got a lot of research. They know a lot of, um, they just have a lot of data on suicide and the data and research shows and, you know, you could probably also chime in on what you know and what you've learned that if you ask somebody who's thinking about it, obviously it's not putting that thought into their mind, but they're relieved that somebody asked and they cared enough to think. And they most likely would say, you know, I have thought about it and I continue to think about it. I just haven't really thought of how I would do it. And, you know, some people may say, and I've thought of how I'm going to do it. I just don't know what time is going to be the right time to do that. And at that urgent emergency situation, you know, getting them past one day, getting them into a situation where a a skilled, trained. Clinician can intervene and make a difference is really so important. And that's the first thing.
00:30:52 Travis Heath: Sure. As we're talking about this, you know, there's loneliness. You know, we start using this language like we use depression or anxiety. And it can become colloquial language. Right? Especially now with TikTok and all the things, you know, this language just starts getting thrown around. And, you know, when I'm thinking about. So there's loneliness, there's social isolation. I mean, there may be other terms here, but let's just take those two. If we think about something like lonely versus socially isolated, because somebody could be lonely but still have social connection, but they're just feeling lonely in the moment or sometimes, you know, this is actually pretty wretched to to be around people and still feel lonely. I mean, that's its own special kind of torture. But I'm wondering about, like, the difference between something like someone who's feeling lonely versus someone who's socially isolated and lonely, or maybe there are some other terms that you might use that that I'm not thinking of.
00:31:52 Tammie Lee Demler: Well, I can tell you that I didn't come up with the definitions, but the Surgeon General has a whole page. And if actually if anybody's listening and they're interested on page seven, it's a glossary. And it takes away the subjective feeling of how you would self-define these, because I think if you were to write down a definition and I were to write down a definition, they'd both be different. So the Surgeon General defines loneliness, and they have references here that obviously they didn't just make this up by pulling it out of air. Um, loneliness they describe as a subjective, distressing experience that results from perceived isolation or inadequate, meaningful connections, where inadequate refers to the discrepancy or unmet need between an individual's preferred and actual experience. Now, that's kind of a soft, soft, and friendly. Lots of words to dig in there, but they all have meaning. Um, and I'll just I'll just quickly tell you, and I know my mom won't be listening to this, but my mom, she's an soon to be eighty year old woman, very independent. She lives on her own. Um, doesn't do anything. My dad died many, many years ago, and she's never dated or gone out. And she just says she's happy, but she's not. We know she's not. She's very, you know, needy. She's got probably she probably has a little depression. We try to do what we can to, you know, include her in things and making sure she's taken care of. But she calls herself lonely by choice. But it's isolation that has impeded her ability to really flourish, to be active. Um, you know, she's had a ton of medical problems. And, you know, I it really confirms to me the whole. And this is another conversation about the Ace trial. Have you heard about the aces? Yes. The adverse childhood experiences. Uh, she has everything on that list. And it's like she's had lung cancer. Cardiac bypass. I mean, she's had almost every medical illness, and she's got a ton of aces. So it makes me feel that that there's some absolute validity to that relative to my own personal walk. But loneliness being defined as it is different than social isolation. And I'll just read this really quick and then we can take it from there. Social isolation. According to the Surgeon General's report, objectively having few social relationships, social roles, group memberships and infrequent social interaction objectively. So that means it's not your subjective report of how you feel. Somebody says, Travis, you do not have many friends. You don't do many things. You don't go out of your house and you don't have a lot of social interactions. You're you're isolated. I'm not saying that you probably have a thousand friends and they're all good friends.
00:34:27 Travis Heath: I tend to keep a smaller circle, actually.
00:34:29 Speaker 5: Me too. Me too meaningful.
00:34:32 Travis Heath: Really meaningful relationships in my life. Yeah. Um, okay, I'm going to ask you one more about loneliness. I could ask ten more, but I'm going to hold myself to just one more question. I'm wondering what you think about AI and loneliness, because now, as a clinician, I see more and more people who are talking to ChatGPT or Gemini or whatever it is.
00:34:55 Speaker 5: Um.
00:34:56 Travis Heath: And, you know, some of the early research on this is interesting because it's showing that when people are feeling lonely And of course this is averages. So we're dealing with averages like with most quantitative research. Right. People fall anywhere on the spectrum. But on average when people were feeling lonely and they started talking to AI over a period of months, then they felt more lonely, right? Or more depressed. And it's interesting because it's so available, right? I mean, gosh, you just pull out your phone and you can talk to someone, but it's not a someone. But gosh, it sure feels like someone. And I know, like our the rational part of our brain could go, well, this is just a bot. Yeah, but dang, sometimes it doesn't respond like a bot. And and it, you know, it says all the right things a lot of times to make us sort of feel good in the moment. But the initial research is showing that actually people end up feeling more depressed, you know, over time with this. But I'm just wondering your sense, you know, with the work you've done around loneliness, the thinking you've done around it, your sense of how AI might interact with loneliness or and or social isolation.
00:36:04 Tammie Lee Demler: My my knee jerk reaction to the question is that, you know, in my personal circle, you know, again, I, my mom and older relatives that I have around me because the patients that I work with, they're not really connected. We they're, um, thankfully disconnected from all of that, you know, for many reasons. They they're able to see TV, they're able to listen to radio, but they're not accessing Facebook and all of these types of stuff. Right. I would say that the people that I have, I have known that are isolated and lonely, truly, objectively in our in our opinion and our observation, obviously, they are led down a path of believing this AI is actually happening. So I, um, they don't have people to talk to. They don't have a you and me to be able to say, um, you know, we, the United States, didn't purchase Canada as a, as the next state of our growth or whatever. But my mom listening to this AI stuff, it looks so real. I mean, you look at Facebook and the reels on Facebook, I get kind of I get into that dead scroll of continuing to look at these things. And I, I don't know sometimes if it's real or not. So somebody who's lonely, who has nobody to bounce anything off of, you know, more in a factor or not. I don't want to say gullible, but they're gullible by consequence. They're they're not able to depict what's real or not. And so that's stress and the amount of stress and disturbance that builds up. Um, I can see it in my mom by the time we end up, you know, having her over once a week for, you know, a meal, she's got this list of twenty things that she's worried about. The world is ending. You know, we better go do this or that because she has nobody to bounce ideas off of, and she's just getting the input. So, um, I don't know if you have a different opinion about that AI interaction. I don't know that necessarily. The older adults are interacting so much. You may have data that shows otherwise, but I know they're taking it in. They're seeing it and they're not necessarily. I have to ask my husband sometimes, like, do you think that was AI because it looks so real and we both kind of have a conversation about it. But if I were by myself and I just was in consuming it, I would be very stressed. My stress levels would be through the roof and unmanageable.
00:38:22 Travis Heath: Yeah, just in the last six months, I think there's been more of that. Is it AI question for me?
00:38:27 Speaker 5: Yeah.
00:38:28 Travis Heath: And you know, I'm forty five years old and for, you know, people of my generation, I've been noticing more just having conversations with AI about their life, about their worries about, you know, whatever it might be, which sometimes can be really useful. I mean, you know, they might be in a sticky situation, and AI helps them think through it like a thought partner that could be really beautiful, um, and useful. And then on the other hand, you know, sometimes it might be where they go when they're lonely, instead of actually seeking out some sort of human connection and that can, you know, have its downsides. And then there's just all the content like you're mentioning that's AI generated and or is it AI generated. We don't know. And yeah, it's and and it's not something that's hypothetical at this point. I mean, I feel like if you and I were having this conversation around AI and how it might interact with loneliness two years ago, it would have been more hypothetical for most people. But now it's here, right? And and so we're trying to figure this out in real time. And that's often how technology moves in the modern world. Right. Is it it gets moving and then we don't really have time to think it out because it's making money for someone, or it's going to make money for someone. That sounded cynical, but I think it's often true. And then we just have to figure it out on the fly. And so I think there's it's just interesting because when I think about loneliness, this wasn't an option even five years ago in this way where you could talk to a bot and the bot would talk back to you and damn it, it would sound like a human being. And maybe.
00:39:59 Speaker 5: Creepy.
00:40:00 Travis Heath: It is. Yeah. And and so, I don't know, I'm not smart enough to tell you all the impacts of that or how exactly it's going to go, but I can observe it and go, hmm, something's afoot here. Like we're we're going to have to pay attention to how this moves. And and for clinicians, this seems really important, right? Um, especially for therapists because, I mean, I think therapists have this fear that we'll be replaced by the bots. That's the biggest fear of the of most therapists, whether they'll admit it or not, you know, and and I don't know that that will happen. I mean, it will in some ways, but I don't think overall that's what will happen. But I think what might happen is that now we're going to be made privy to conversations that someone we're working with is having with a bot. And now there's a third party that's a part of this interaction, which I'm not prepared to judge now as good, bad or indifferent necessarily, but just something worth watching.
00:40:56 Speaker 5: Mhm.
00:40:58 Travis Heath: Okay. If I could change the subject just a little bit.
00:41:00 Speaker 5: Okay.
00:41:01 Travis Heath: So you did some cool research, um, out of your position at the University of Buffalo. And I think this will be of much interest to our listeners, where you were looking at how teaching can reduce, uh, stigma towards patients with mental illness. I'm wondering if you could talk some about this study and maybe what you learned, what was interesting and surprising about it?
00:41:24 Speaker 5: Oh, sure.
00:41:24 Tammie Lee Demler: So I don't I don't have the study in front of me, but from my recollection, uh, we did an initial it was a survey and surveys being limited by the fact that their surveys, we ended up getting some really good information from the students. And I believe there were like one hundred and thirty students in the class. Uh, there were two years. So the first year, let's call it twenty twenty three, just for the sake of it. We did this initial effort and what we we collected baseline perception of, um, Gun violence, you know, whether or not mental illness was, you know, correlated with violent behavior. There were a number of questions that we asked, um, sexual relationships. Should somebody who has mental illness, um, you know, when they're discharged, be able to, you know, have sexual relationships with people that they, you know, have relationships and such? But nonetheless, what came out of the questions that we asked ended up correlating to the next level of study that we did, because we ended up with this weird thing that popped up that we didn't expect, um, which had to do with voting rights. So we just snuck in this question that was just sort of a distractor, but after. So we did the questions. We got a baseline understanding. We gave no no opinions. We taught the class. It was an ethics class. So it wasn't a pharmacologic class, but they were pharmacy students. And we taught you know, we gave the data on, you know, violence and mental illness and that, you know, the the actual evidence is that people with mental illness are usually victims of crimes, not perpetrators. But the sensationalized media takes, you know, one bad situation and makes it worse. After the class, we took the survey again and we had a statistically significant decline in negative behaviors and thoughts. It was positive in that the people came away thinking better. But this voting thing was so strange like that, I know. Should people with mental illness be allowed to vote? And we didn't even talk about that. It was a distractor. After class, people were like, no, they should not be allowed to vote. We're like, what? So the next class, next year was the presidential election. People were all up into politics. So we thought, let's do let's take this and see where we can go with it. And it was interesting in that, um, after the class, we we asked two questions. Should somebody with mental illness be allowed to vote or, and then should they have the right to vote? Everybody everybody favorably improved on the right to vote. Yes. They should have the right to vote, but they shouldn't be allowed to vote because I think people and we didn't ask why there were no narrative commentaries allowed. But we believe we we believe that based on things that people had asked after class was that they might not vote in favor of the person that you think should be the president. You know. But the interesting thing is, and so this is I think you'll find this interesting, fewer Republicans than Democrats, many people not affiliated at all. You know, let's let's just say ten percent Republicans, let's say sixty percent Democrats. We ask the question, what what affiliation do you think people hospitalized for mental illness? What do you think their affiliation is thinking, that the ten percent would think sixty percent. Of course, they're all Democrats, right. And the Democrats would think they're all Republicans. It wasn't. It aligned entirely with what they self identified with. So ten percent they felt that it boiled down to they felt ten percent were Republicans and sixty percent were Democrats. Isn't that interesting?
00:44:48 Travis Heath: That's fascinating.
00:44:49 Tammie Lee Demler: I would have thought for sure people would have, you know, stigmatized the mental health person as being the not what they are.
00:44:54 Travis Heath: Right?
00:44:55 Tammie Lee Demler: Because they're, you know, air quotes. Crazy. I don't want to use that word. But that's how people were having a conversation about it.
00:45:02 Speaker 5: Okay.
00:45:02 Tammie Lee Demler: So interesting.
00:45:04 Travis Heath: Very interesting. I love when, um, even just in a conversation where someone goes somewhere I'm not expecting, I'm always excited as a therapist when someone.
00:45:12 Speaker 5: I'm working.
00:45:13 Travis Heath: On a direction and when research brings something up and I know, um, there wasn't like a qualitative section to this, but I'm just curious, how have you and or your research team made sense of this?
00:45:27 Tammie Lee Demler: So we realized the bottom line was that in ninety minutes of a class providing data not objection, not or not opinions, not a contrary conversation about it, if you just present facts and we all agree that these are the facts, that you can change the minds of people and, you know, try with whatever might we have with the politics and the and the situation that, you know, in our world right now, there's a lot of opinions that are just put out there without facts and people. The tolerance and the surgeon General's report about having conversations that are different than yours, your affiliation being different than than somebody else's, the tolerance has gotten so low that people self reflect and say they don't even want to have a conversation with somebody with a different opinion. So with that, with that noted, being able to not have a conversation about your difference of opinion, but these are the facts. This is like this is research. This says gun violence. This is what you know. You know more the victim than the perpetrator. You can make you can change the minds of people. And we showed it as a healthcare professional because healthcare professionals, if they're if they have stigma, they're not going to provide the same level of care. Um, this there was another study early on that kind of gave us the sense of this is where we wanted to go. That had to do with just behaviors of of. I think it might have been a nursing student cohort, you know, would you, would you roommate with somebody with mental illness? Would you be friends with somebody with mental illness? Would you marry somebody with mental illness? And that was very, very stigmatized. It didn't go to the next level of how can you reverse it, but it just showed that there is stigma quite a lot. And people that are going to be caring for people that have these disorders and this, these illnesses and that we need to what we can do is what we have to do, what we can do to change these opinions so that somebody who has lived experience of mental illness can feel that they're that they're not being looked at with judgment or, um, a stigmatizing behavior that you don't even realize that you have. Um, we all have something that we all have, something that makes us uncomfortable. Actually, I'll tell you a really quick little story if I can. When I was going through the mental health first aid training, um, I thought I came to the training without stigma. You know, I have people in my family with lived experience. I worked my entire career. I've worked with people with, lived, you know, with, with challenging diagnoses. But I was given a, a section of the, of the curriculum and you had to teach it. So it was like all these everybody in your class, you know. All right. I ended up with non-suicidal self-injury was my chapter. And I had to, with convincing, nonjudgmental behavior, non-judgmental. I had to convey this. And my instructor said you were oozing judgment. You were just oozing. I'm like, what do you mean? She's like. And she kind of laid it out. And it turns out that I have had bad experiences with people who have had self-harming behaviors that I was thinking was just attention seeking. I learned a lot about myself in that, in that curriculum. And I realized that, you know what? Maybe that one experience that I had tainted forever without my realizing it, this this particular diagnosis. And so I was able to self-reflect. I worked on it. Um, you know, what is what is non-judgmental behavior look like? You know, I really did, I think a good job of that. And now when I teach it, I share that when I get to that chapter, I said, you know what? I realized that this was a a trigger for me and that I had to work through it. So we all have it. We all have something, a bag that we carry, baggage somewhere from our past that makes us judgmental and we just need to be. We need to recognize it. We need to work on it, but we all have it.
00:49:10 Travis Heath: I couldn't agree more. Yeah. And I think, you know, working with, uh, students, you know, training to be therapists, thinking about my own sort of path to becoming a therapist. I mean, that's what I think we're most at risk for is going like, oh, yeah, they're judgmental. They're they're susceptible to stigma, but certainly not me. Right. And that's that's where the real work lies is in is in being able to do that. And also, you know, as you're talking about the research, I'm thinking even the term mental illness. To be honest with you, the way the term gets used these days, I'm not exactly sure what it means. Like, I have to inquire with the person that I'm speaking with. You know, when they use the term mental illness, what is what do they mean by that term? Like for some people, some people who are clinicians or highly educated in the area, they might be talking about like sort of major mental illness, they might be talking about any psychiatric diagnosis that's in the DSM. They might, you know, you're talking to someone else. I mean, mental illness may be something as as colloquial as like, oh, that person's acting crazy, you know what I mean? And I'm not trying to invalidate necessarily any of those ideas or perspectives, but it's just more that, to be honest, when someone uses the phrase mental illness, I'm not always sure exactly what they mean. These days. I sort of have to check in to to see what it is. When you use that phrase in your research, how did you operationalize it? Like what? What comprised mental illness.
00:50:43 Tammie Lee Demler: So because of my population that we that we, um, take care of my, my career population is really the serious mental illnesses. And again, that makes it even a little bit higher level layering. Right. Schizophrenia. That's that's the main population that I have contributed research and filled gaps of knowledge. And I'm really excited about everything that we've done really up to this point. Um, depression, anxiety, bipolar, those are really the four core elements. Everything else is a is a certainly a cascade from that. But you, you know, you talk about when you think about anxiety, people think throw that around as just a, you know, a very low level. I'm feeling anxious. Are you anxious? You know, it is a disabling, serious mental illness if you have generalized anxiety disorder. Social anxiety disorder. I mean, there's so many disorders that fit into that, that particular scenario as, as you know, PTSD is now in its own. But that used to be part of the anxiety disorders. Um, there's a lot of disabling consequences to that. And people sort of dismiss it. When you look at schizophrenia, people are, oh, man, that's really bad. But people can manage schizophrenia with medication, with support. Um, but those are the four, really the core mental illnesses that we speak of when it comes to serious mental illness. But you talk about there's a lot of things in the DSM, you know, the insomnia of many different varieties. Can is listed as a diagnosis. And how many of us have that? Uh, for whatever reason, you know, it's not a serious mental illness, but it's it's a mental challenge. It's a complication. It's a disorder. It's a it has a diagnostic criteria. And not many people think of that as a as a thing.
00:52:32 Travis Heath: Yeah. And then we get into like, the pathologizing of everyday life, right? Which is. Which is for another conversation.
00:52:40 Speaker 5: All right.
00:52:40 Travis Heath: Yes I am. I want to talk to you a little bit about this before we wrap up. I am always interested when people write about or study something that is a bit taboo or something that they're not supposed to be studying, you know, and we're not supposed to meaning, you know, based on the norms and the mores of the field. It's like, oh, you can't study that. It's not legit for some reason. And you did some work around, like studying the season of birth and schizophrenia risk, um, lunar and eclipse influences on, you know, psychiatric behavior. And this really raised my eyebrow because I was like, oh, this is interesting. First of all, I want to learn more about that research in general and what you found out. But also, you're not supposed to study like as a scientist. You're not allowed to study that, right? So I'm really interested that you did and want to know what you found out.
00:53:38 Tammie Lee Demler: Research to many people, sounds like you're in a lab and you're doing this really intense statistical analysis. And it can be very simple. It's observational. It is a slam dunk. When you look at something like seasonality of birth, there's no question about your date of birth. You know, you were born maybe on Christmas or whatever. So there was this hypothesis that has has somewhat gotten strength over earlier in time that people born in a December month or winter month, let's call it winter month, regardless of where you were, you know, on whatever hemisphere you are with your winter month of birth, we're more likely to have schizophrenia. And so that seasonality prediction has not really meant a whole bunch. But people were like, oh, when were you born? You know, kind of this interesting connection to that. And I said, let's just look at everybody that's been here in our hospital for the last ten years or more. What their season is, and it was an equal quadrant. It couldn't have been more perfectly quarterly. And we. It was published and I was it was so simple to be able to say this is refuted. And they were all people that lived in the Northern hemisphere. So it wasn't like they came from Southern Hemisphere and they just were transferred over here. It was really people that were born in this area, and so there was no debate about it. But when you dug into why people thought that there may have been this seasonality of birth, it was many different things. It was lack of vitamin D in the mom, you know, when she was carrying the baby, um, gestational exposure to pesticides in the summertime. Could that be it? People are so desperately looking for what causes schizophrenia that I don't discourage exploring unusual ideas, because same thing with autism. You know, the whole thing with, you know, the vaccinations, we don't know. Nobody can absolutely say that this doesn't contribute or Contributor. Cause we can say that when we look at, you know, data at a high level, that the chances of this, you know, causation and association, those are being very different words that they're not on the same level. You know, you can say, you know, windshield. Wipers going doesn't mean it's going to cause it rain. Um, I don't know if that makes it sense. Sensible, but.
00:55:54 Speaker 5: Sorry.
00:55:55 Travis Heath: You just broke up.
00:55:56 Speaker 5: I know, I.
00:55:57 Tammie Lee Demler: See that my my unstable.
00:55:59 Travis Heath: No problem. You were saying I probably missed, like, the last paragraph or so. And then you came back in talking about, uh, windshield wipers.
00:56:06 Speaker 5: Do you remember.
00:56:06 Travis Heath: What it was you were.
00:56:07 Speaker 5: Saying?
00:56:07 Tammie Lee Demler: What was the last thing you heard me say?
00:56:10 Travis Heath: Um, I don't know, because I just saw that I got, um.
00:56:14 Speaker 5: Distracted.
00:56:15 Travis Heath: Fixed on the windshield.
00:56:16 Speaker 5: Windshield. So I'll.
00:56:17 Tammie Lee Demler: Just. I'll go back to, um. I'll just go back to what? We don't know. So I encourage people to explore concepts because we don't know what we don't know. And I had just mentioned the whole debate about vaccines and autism and what causes it. People are so hungry to know what is the cause of this terrible disorder that we're looking for anything. And so I don't discourage that. But we also need to be recognizing that. Running based on what we've seen, is it possible? I guess it's still possible. Nobody's going to be able to absolutely say what is and what's not until we can able to until we have the ability to do that. But I think we still hunt for a cause and effect. Um, I mentioned the windshield washer or the windshield wipers. Um, oh, well, here's another example. This is this is even better when when people eat ice cream. The more ice cream people eat, the more shark attacks happen, right? You've heard that, right? It's because it's summer. And of course people are swimming, so duh. Yeah. Anyways.
00:57:22 Travis Heath: No, I love those, I love those, and as as human beings, We tend to want to find cause and effect relationships. Right? Uh, and I was just really interested in, you know, you actually doing the research on this and exploring the things that, you know, um, many people may not take the time to explore. It just gets dismissed. The idea just gets dismissed without any empirical evidence to the contrary. Right. All right. I just have one more thing that I want to ask you about. And you teased this to me a little bit before we started recording. And then even in the show, you did a little bit. I'm a sucker for, like, new information and, you know, uh, things that are sort of on the cutting edge of things. So you mentioned a new antipsychotic medication, and I'd love to learn more about that, because to be honest, when you brought it up, I was completely ignorant to its existence.
00:58:22 Tammie Lee Demler: So it has gotten a little bit less traction than I thought it initially would initially when it was launched. And I'll just tell you, the brand name is Coban. It's an antipsychotic, very novel mechanism. It's almost well, it's entirely muscarinic, so a lot of anticholinergic effects. It doesn't have dopamine involved at all, which is dopamine has been sort of our, um, a pro and a con. Right. We get the EPs with dopamine antagonism. So this is pretty much I would say what I've seen EPs free, uh, because it works in such a different way. It's it's a combination. It has a xanomeline, which is an agonist at M1 and M4. If you're into the muscarinic receptor, uh, the nerdy level that I'm at when it comes to learning those things. But trospium, which is actually already on the market for other indications, helps to also engage those muscarinic receptors. So the novel mechanism is very different. I will just mention clozapine has a lot of muscarinic activity that makes its action unique, so we were excited that this may bring to the table some of the clozapine benefits. We haven't seen it play out though, because the side effects of this medication are very gi irritating and more than I've seen with anything else that's really been launched. People. It's so it causes so much nausea that people are almost afraid to take the next dose. And this is the deal. You can't take it with food because if you take it with food, generally, I would tell you it would decrease the absorption or it would increase the absorption. But it's more complicated than that. If you have food of any sort, whether it's fatty, healthy, regardless of what it is, you end up reducing the trospium part of it by up to ninety five percent and the xanomeline stays somewhat unchanged. So you're getting this very skewed effect of this medication. When you take any medication, you take food with it at all. And we know from our experience that people will will take it with food because they think it will make them feel better. What's the harm? I'm just going to take it with a nutrigrain bar. It'll make me feel better. Well, not really, because you're going to be getting this unbalanced mechanism of action and I it doesn't really tell you what the side effect would be with an enhanced degree of xanomeline without the trospium, but it certainly won't work to the degree that we know it should, and the contraindications are numerous. I'm not trying to talk people out of prescribing it, but a ton of anticholinergic effects. You know, people who have any urinary retention, any kind of glaucoma that's not treated. And there's a lot of issues relative to the liver and bile ducts and that. So I would say this might have a role with somebody who never had benefit with what's available. Maybe try clozapine first, because that seems to be something we can control other than the dyscrasia potential. But even that the Rems has come off of clozapine. Yay! That is going to make it so much easier, we hope, and less bureaucratic for people to get access to clozapine. But it's, you know, combination. It's a it's out there. It's available. I don't know what the deal is for people's coverage, though. I would think it's probably not something that's going to be easily covered by Medicare Part D, but I'm speaking on that, which I don't know for sure. But Medicare Part D is always a little fussy with new brands. So, um, check it out if you're interested. But the name and it's out and available.
01:01:49 Travis Heath: I've enjoyed this conversation immensely. Um, I could have two or three more just based on the notes I've taken, you know? So maybe we'll have to do this again.
01:02:00 Speaker 5: I would love that.
01:02:01 Travis Heath: I really appreciate, like, your breadth and interdisciplinary knowledge. I think it's really cool. Um, the connection between psychopharmacology and mental health that you have and then, you know, the work that you're doing around stigma and, you know, it, it it just strikes me that I'll tell you the type of person I am. And I don't know if you are. I'm. We'll see. I have a hunch I get bored easy, like I like to do. I like to stay engaged with new ideas and different topics. Like rarely do I read books about therapy. Now, I haven't read books about therapy very often. Occasionally for the last three to five years. I'm reading books and all sorts of different other areas. And then actually, that informs my therapy practice quite nicely, because there's a lot of overlap that sometimes people don't even realize. But I always appreciate it. Maybe it's just because how my brain works, people who look at things through an interdisciplinary lens, people who might go down roads that they're quote unquote not supposed to or that others aren't going down. And I get some sense of that with you that perhaps, um, you like to explore things from maybe different angles than what you're quote unquote supposed to be doing.
01:03:19 Tammie Lee Demler: I think you have it. I do get bored easily, but I also have to hold myself back from doing too much. You're probably guilty of that as well.
01:03:28 Speaker 5: Oh, yes.
01:03:28 Tammie Lee Demler: Um, so I've got to be very I've got to say no more. I've got to say no more meaning. Like I can't say yes to everything. But if I hadn't said yes, I would have gone down this river. Current. Back to the original statement. Um, I feel like I'm where I am, and I'm supposed to be because I let the canoe go down the current down the river where I was supposed to be. So I. I'm somewhat opposed to saying no, but I have to start to think about that a little bit as, uh, as I, I start to do things that I like to do more and maybe weeding out the stuff that's not as good for me. Um, but yeah, I love, I love learning, I love, I love learning and then sharing that information. I think that if I could say what my strength is, it's being able to digest and give key messages to people. It's surprising how key messages just get missed. You know, I think when again, back to, you know, giving prescribers information and clinicians information we the key messages are principal. Those are, you know, going into more high level conversations. You have to know the key messages first and what the the basic building blocks are. So I'm good at giving basic building blocks and reminding people, even if they know what those are, to bring them back back and to be able to. Because usually the key building blocks don't change. Guidelines do how we use things that do, but the basics of medications don't generally change.
01:04:51 Travis Heath: If you ever master the art of saying no, let me let me.
01:04:55 Speaker 5: Know, would you? I will, I will.
01:04:58 Tammie Lee Demler: This has been great.
01:04:59 Travis Heath: Yes, doctor. Tammie Lee Demler. It's been awesome. I do look forward to speaking with you again down the road. Thank you so much for your time, for your insight, for your stories, and hopefully we'll talk again soon.
01:05:12 Speaker 5: Sounds good.
01:05:12 Tammie Lee Demler: Thank you so much. Take care.
