Episode 60: Burnout
Are you constantly exhausted? Do you find it hard to concentrate and take in what you read? Do you have symptoms of poor sleep? You may have burnout. To understand what burnout is and what can be done to manage and prevent it we spoke to Prof Gordon Parker of the Black Dog Institute and University of New South Wales.
Dr Moira Junge (Health Psychologist) and Dr David Cunnington (Sleep Physician) host the monthly podcast, Sleep Talk – Talking all things sleep.
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Audio Timeline / Chapters:
- 00:00 – 27:41 Theme – Burnout
- 27:41 – 28:32 Clinical Tip
- 28:32 – 31:02 Pick of the Month
- 31:02 – 32:45 What’s Coming Up?
Next episode: Lucid dreaming
Links mentioned in the podcast:
- Prof Parker’s profile from Black Dog Institute
- Burnout – book
- This Way Up – online mental health courses
- Perfectionism workbooks
- PTSD – podcast episode
Professor Gordon Parker AO is Scientia Professor of Psychiatry at UNSW, was the founder of the Black Dog Institute and its initial Executive Director, Head of the School of Psychiatry at UNSW and Director of the Division of Psychiatry at Prince of Wales Hospital. His positions with the Royal Australian & New Zealand College of Psychiatrists include being Editor of its Journal. Positions with legal organisations include the NSW Guardianship Board and the NSW Administrative Appeals Tribunal. In 2004 he received a Citation Laureate as the Australian Scientist most highly cited in ‘Psychiatry/Psychology’. In 2018 he received the prestigious James Cook Medal from the Royal Society of New South Wales. His research has focussed on the mood disorders. He has published 23 books and over 1,000 scientific reports.
Dr Moira Junge is a health psychologist working in the sleep field, who has considerable experience working with people with sleeping difficulties in a multidisciplinary practice using a team-based approach. Moira is actively involved with the Australasian Sleep Association (ASA) and a board member of the Sleep Health Foundation. She has presented numerous workshops for psychologists and is involved with Monash University with teaching and supervision commitments. She is one of the founders and clinic directors at Yarraville Health Group which was established in 1998.
Connect with Moira on Twitter – @MoiraJunge
Dr David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to SleepHub. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is an International Sleep Medicine Specialist, Diplomate Behavioral Sleep Medicine and Registered Polysomnographic Technologist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep.
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Intro: Welcome to Sleep Talk, the podcast about all things sleep brought to you by SleepHub.com.au. Here are your hosts, Dr. David Cunnington and Dr. Moira Junge.
Dr. David Cunnington: So welcome to Episode #60 of Sleep Talk, the podcast talking all things sleep. And welcome to another episode, Moira.
Dr. Dr. Moira Junge: Hi. Hi, Dave. Hi, everyone.
Dr. David Cunnington: So in this episode, we are going to talk about burnout. And the reason I wanted to talk about burnout is, it is something that I’m seeing a lot of in my practice. I don’t think it’s something that’s new in my practice necessarily. But certainly seeing a lot of people who at face value present with what I think maybe a simple sleep problem and we will do some work entirely up sleep but then find there’s still significant symptoms, still feeling very tired. And then may try to think about, “Well, how can I improve that? What else might be going on?” Burnout is one of the things that I think of in terms of a subgroup of people who may have burnout as part of their initial presentation.
Dr. Moira Junge: Yeah. And I would agree and I would say it has been functioning of the COVID-19 pandemic for sure. But as you are – but it has been there the whole time. It’s not a new thing. Perhaps, they used to be able to cope with it better and then – but their coping mechanisms aren’t there.
Dr. David Cunnington: Yeah, it’s a really good point because that’s what’s kept us both busy over through the pandemic is yeah, people’s normal coping mechanisms have all been taken away.
Dr. Moira Junge: Going to the beach or in your 5k zone or going for a weekend away or just things that used to set excite people have really contributed largely and we will get into more discussion of that, but it had contributed to it. But I would agree, there’s a high degree of burnout.
Dr. David Cunnington: So to help understand burnout and what it is, we spoke to Professor Gordon Parker who is a Professor of Psychiatry at the University of New South Wales and Founder of the Black Dog Institute. Gordon has also recently published a book on burnout.
Thanks very much for joining us, Gordon. And I’ll start off by asking you, what is burnout?
Gordon Parker: Well, there is an official definition that has been dominant for some 40 years. And essentially, it’s a set of three principles of symptoms. And those symptoms are exhaustion, secondly, originally called depersonalization but more commonly called loss of empathy, and in fact, in the medical profession, that’s being described at times as compassion fatigue. And thirdly and predictably, reduced work performance. That triadic definition of three symptoms has dominated research for as suggested for years in that there is a measure that uses those three domains and over 90% of published papers used that particular measure, the Maslach Burnout Inventory. Our research challenges that model.
And I should also point out that ICD-11 has largely accepted that triadic model, so our research certainly identifies exhaustion across the day and is pretty well unremitting.
Secondly, the concept of loss of empathy, we have a richer and broader descriptor. People more report on lack of feelings. They just don’t get any joy out of anything. Eventually, if the Wallabies ever win, it’s not going to make anyone say Woba Woba! if they’ve got burnout. And so, they tend to become fairly introverted, keep to themselves, avoid socializing because they’re not getting anything out of it.
So I think the broader construct is rather than just loss of empathy and in fact, I’ve seen many medical practitioners who say with burnout, their empathy has actually increased towards their patients because they now have an understanding of what psychological distress can feel like.
The third component is a very important one and that’s cognitive impairment. And what would people with burnout will say is, “My capacity to remember to retain information is compromised and when I read, I find that I’m more scanning rather than reading in any depth.” And that cognitive impairment is evident in many previous research studies. So it’s not unique to us.
In addition and predicatively, there is compromised work performance. You couldn’t imagine it otherwise. And in addition, there’s a tail of other psychological symptoms, which is not surprising in the sense that you got a primary condition, you would expect it would cause distress. So about 50% of people will report symptoms of anxiety or depression, insomnia is very common despite feeling exhausted.
And in relation to that last point, they will often say that they don’t find sleep refreshing, and after that can come a whole set of fascinating physical symptoms. So that in fact, in a book on burnout, we have a final chapter written by somebody who just in essence, crushed to the ground when she was taken to the ED, her blood pressure was something like 60/40 and her pulse rate was 140, Arianna Huffington of Huffington Post fell over and cracked her head and she fell to the ground. So it can come on in very physical ways, not necessarily symptoms but immune functioning can also be compromised so people would tend to report more infections.
The other aspect of our model compared to the dominant model that is influenced so much thinking for 40 years is that there are two components. The first is that work has been seen as the central driver of burnout. And the implications for a long period of time, if not the explication, was that affected people in formal workplaces. And what we find is that people who have demanding home responsibilities such as a mother looking after a disabled intellectually-challenged child, a mother again maybe looking after children but also frail relatives with say, dementia, and maybe also trying to hold down a job. So when it’s in the home, the features were exactly the same. So we broadened it from the workplace to suggest that it can also occur in the home environment.
And the other aspect is we know most psychiatric and psychological conditions can be positioned as diathesis-stress disorders, meaning predisposing and precipitating factors. Usually, the diathesis-predisposing factor is a genetic one. In this instance, we put down personality. And as I say, previous formulations having known personality, just saying it’s basically the reaction between work situations impacting on the individual.
What we find is that burnout is most likely to be experienced by those who are good people. And by that, I mean reliable, conscientious, dutiful, if not perfectionistic. And that’s a very important component of the model because if you’re wanting to manage burnout, it’s not just a matter of looking at the work stress and coming up with de-stressing strategies, but there is also a great advantage to consider what personality nuances maybe involved.
So, dutifulness perfectionism is the most common and then after that would be Type A personality. So that’s the model that we have employed in the last couple of years.
Dr. David Cunnington: It’s interesting a lot of those symptoms you described overlap with people that might be seeing me in my office coming with insomnia and we identify perfectionistic traits for example as a risk factor for insomnia wherein people might report cognitive impairment, difficulty with memory, the type of things you’ve described.
Gordon Parker: Yes.
Dr. David Cunnington: And often for me, these trying to tease out when is it that insomnia, when does this start and finish just as a sleep disorder versus when is it going to be a much broader thing and occurring as part of burnout because those symptoms overlap so much? Have you got any tips for me on how am I going to tease those two things apart?
Gordon Parker: Right. Well, I think I will approach the question in a broader way if I could. We developed the Sydney Burnout Measure which captures all those symptoms and domains that I’ve talked about. And what we find is that it has got high sensitivity. It will pick up people who truly have burnout but its specificity is modest at best. And that holds for all measures of burnout but that is rarely considered, acknowledged, or recognized. People can come along and report those classic burnout symptoms that I’ve just described but they may more have anemia or they may be on chemotherapy. All sorts of other psychological and physical explanations can come into play.
And therefore in the book, as a consequence of this problem with specificity, we say that in fact the screening or the questionnaires should then be viewed as a screening measure. And then after that, we try to encourage people when they read the book to employ clinical reasoning. Is this more likely to be explained by some physical state or is there an alternative diagnosis? And it may be insomnia. It may be depression. It may be a whole series of things.
And that’s where – obviously, that’s where it gets difficult. But one of the key components of being a thoughtful medical practitioner is to have the capacity to employ patent analysis. And it’s a really fascinating phenomenon. But I went around and asked a whole series of senior doctors, basically guys in their late 60s and 70s, physicians, not just psychiatrists, physicians in all realms and I said, “When was it that you hit your diagnostic peak?” And they all said in their 60s.
Basically, they are saying it took a minimum of 30 years to be able to do the patent analysis at a high level. And if you respect Malcolm Gladwell’s aphorism of 10,000 hours phenomenon, that fits fairly well. So in a sense, your question invites a more expanded answer. When a patient presents with a set of symptoms, the key issue is to make the most likely diagnosis and then come up with a whole set of differential diagnoses. And that is clearly the task with burnout. You have to exclude physical explanations and you also have to exclude other psychological explanations, and the most common one is depression.
Dr. David Cunnington: So if I’m then saying to a patient, “You know what? It just doesn’t smell like insomnia, there’s more to it than that,” is that me reaching into that patent analysis in my experience? Because that’s often how I’m reflecting back or thinking about things with patients is they will be describing the sleep disturbance, the daytime impairment but me going, “No, there are other bits that don’t fit as part of this pattern.”
Gordon Parker: Yeah. Yeah. I mean I have a tendency as a clinician, if I’m really confident and I’ll apologize beforehand and I’ll say this sounds really arrogant, but I’m a 100% that you got X, say bipolar disorder. If I’m not so confident, I would say, “Look, I’m pretty confident, 50% confident you got bipolar disorder. But there are a couple of reasons why I’m not totally confident about it. When we go through the symptoms, you’re missing a few. There’s not a family history or whatever.”
And I think that’s the way in which most medical practitioners work particularly if you are working in a field where you haven’t got a blood test or an x-ray that’s going to give you a definitive diagnosis. And that’s where patent analysis really comes into the issue. If you are wanting to clarify the likelihood then if somebody gives you a set of features that sound like burnout then obviously, you would want to chase the issue of work stress, their form of work or at home, and you’d expect the individual to describe fairly severe, if not horrendous work situations or an incredibly harassing or bullying boss or organization or they’re in a major conflict over the core values. So you expect that they’re going to be describing work stresses.
And a sense of learned helplessness along with it and you’d expect they would come up with all the symptoms and when you ask questions such as, “What does it all feel like if you have a holiday or you have a decent break?” in that instance, you would expect the person while they’re still in a burning out phase with some elasticity, just for that simple question, they would say, “Oh yes, if I had a week off or if I take sick leave from work and don’t go in for a week, I did feel a lot better.” So there are certain clues as you work your way through the diagnosis and differential diagnoses as it applies to all aspects of medicine.
Dr. David Cunnington: And what do we know about the biology of burnout? We don’t have biomarkers in a diagnostic sense but is there some physiological characteristics that seem to occur in burnout?
Gordon Parker: A whole series of changes occur in the brain. So basically, it’s the fight/flight mechanism comes into play and then you get the HPA axis involved and both of them are in overdrive. And there’s a very interesting story in regard to cortisol. If you look at the studies of cortisol in burnout, you get about 50% saying cortisol is high and 50% saying cortisol levels are low. And then most people say, “That’s because it’s difficult to know when to measure it, what time of the day we need to measure it, saliva, blood, whatever, whatever.”
But in fact, our work suggests that Hooke’s law is probably in operation. Remember when we went to school and we are told that it gets straight to the body within its level of elasticity and it would bounce back. But if you stretch it beyond its level of elasticity, it wouldn’t bounce back. And I think that corresponds to the burning out phases and burned out phases.
And our hypothesis at the moment is that during those burning out phase, you got high cortisol levels and then in the burned out phase, you get very low cortisol. And that’s something paraphrases adrenal fatigue by a particular individual.
So the effect of all those interruptions then affects multiple areas of the brain particularly the amygdala, the hippocampus, prefrontal cortex. You get structural changes. You get functional changes. Even the length of thalami get shortened. So there’s quite a profound effect on the brain both structurally and functionally.
Importantly, a Sydney journalist, Shannon Harvey, who is experiencing burnout, wowed herself up to everything you can think of and practice mindfulness and meditation for a year. And basically was able to show that every biological parameter that was compromised at the beginning, she improved including the thalami’s regrowing, if you like. But during the actual burning out phase, neuroplasticity is slowing down, the BDNF level is dropping, and so on and so forth. So the impact on the brain is major and that I think goes a long way to explaining the cognitive impairment that people report.
But while it is severe and diffused, a multisystem in the brain if you like, the key point I’d like to emphasize is that it is reversible.
Dr. David Cunnington: Yeah, and that is a very important point and certainly gives people hope and gives people that incentive to, OK, even if I make some changes, I will be able to move forward.
So on that note, if people do think they are experiencing burnout, what should they do?
Gordon Parker: The first thing to do is to consider what is it about your work that is excessively demanding, putting on pressure on you and making you feel that you just can’t get time away from it all. And so in our book, we have an appendix and people can simply go through and tick all the boxes that apply to them.
So the first thing is to identify your triggers. Get them in a pretty black and white way and line those ducks up.
The second aspect is to consider de-stressing strategies. In one of our studies, we talked to many hundreds of people and we said, “What’s most helpful?” And they said, having a holiday, exercise, and then after that came mindfulness and meditation. After that came 20 other options. But certainly, having a break and having stress-reducing strategies, and mindfulness and meditation are probably the best but not for everybody. For someone who is very Type A, may not going to get into mindfulness and meditation but yoga or exercise mindfulness might work for them. So the second component then is the de-stressing strategies to be employed.
And the third one and I think many ways this is often the most important one is addressing the personality style. I get quite a lot of people in the public service from Canberra who are absolutely burned out. They’ve got harassing bosses and they come along and it’s an impasse. They’ve been to HR but HR is probably on the side of the boss. They’ve tried taking sick leave. They’ve tried being this. They’ve tried being that. But because they’re dutiful, they don’t even consider the option of getting out of their job.
So perfectionism can be not only a driver to burnout, it can be a big preventive aspect to not getting out of the work when in most – in some circumstances, the most appropriate thing is to actually leave the job. So it can either redress the work triggers and drivers where times it’s important to get out of the actual environment.
So dutiful and reliable people just don’t want to do that and so in a sense, you often have to try to lever them out and just say, “Consider another life. It’s not a loss.”
So we have a couple of chapters on perfectionism and we also have a really good clinical psychologist who is managing people with perfectionism and OCD every day of the week and he has written a very I think useful overview of the strategies that perfectionistic people should employ as a way of de-stressing. So it’s a model that addresses the diathesis-predisposing factor, the personality as well as the precipitance.
Dr. David Cunnington: What about at broader structural levels and not on an individual level, but for example, the culture of public service that will drive people in that way? And we certainly have this culture where we value industriousness and busyness and don’t value self-care. Are there things as a society structurally wise we can do to help reduce the burden of burnout in society?
Gordon Parker: I think I can best approach that by pointing to the huge interest in burnout currently. And if you look up books on burnout, you will get sort of 60 books all published in the last 5 years. If you look at the statistics, they show that roughly 30% of workers would experience burnout over their lifetime. Even high rates in health practitioners, doctors and nurses, all formal carers whether they are health, whether they are teachers, whether they are vets, and most importantly and intriguingly, even with clergy. So the caring professions are overrepresented.
In recent years, within each profession, there have been a number of profession-specific nuances that are really driving burnout. But if we take a broader perspective then really the answer is a very predictable one, it’s the increasing technological imperatives that have come across our lives and interfered with our lives over recent decades. And people are writing books expressing concern about this 20 years ago but it has actually got a lot worse.
So basically, the real risk is that we are constantly on, that is people can reach us on our mobile phone or some other technique 24 hours of the day and we don’t turn them off. And that’s in a sense crept into it a technological consciousness. It’s a way in which we see the world. The demands of technology have made us feel that we have to keep busy and keep doing something.
And that’s why in Huffington’s book, she talks about executives who got irritated with having to pee for 30 seconds because it was taking too long and how others would be on their phone while they are reading a goodnight book to their kids. The increasing requirements are multiphase. The intense preoccupation of being on your emails, on Zoom, all day long, far more demanding than the previous existence of chatting to other people socially.
So there’s no doubt that the technological imperatives to be always available caused us to feel that we must always be on and not step away from it. And when you look at the average adolescent over a dinner table or walking down the street with their phone in their face the whole time, this is going to get a lot worse.
Dr. David Cunnington: So thanks very much for those insights. That has been really helpful.
Gordon Parker: Thank you, David.
Dr. David Cunnington: That was really great to be able to interview Gordon. How does that help in the way you conceptualize what’s going on with some of the people that we see, Moira?
Dr. Moira Junge: There’s more to discuss and it’s great that we have this – posting the discussion around – it is a lot about – but I would still say that it’s not discreet. I don’t think he implied that it’s discreet because I think there are people who have burnout who absolutely could still have a mood disturbance and anxiety and insomnia aside from among other things and being perpetuated by perhaps the burnout.
So yeah, what about you? What are your reflections?
Dr. David Cunnington: Yeah, it’s a really good point that clinical practice and what people present with is not as clean as saying someone has got a single problem and they fit into a single box. And it is a bit like peeling the onion and working out what the different layers are and trying to address those layers. And I do find the concept of burnout helpful for people. We are seeing and recognizing, that’s a layer, we might get sleep OK but there’s still fatigue there. And it’s not – the target is now to change sleep from being OK to absolutely perfect to fix the fatigue. It’s let’s manage the fatigue by looking at, well, what maybe factors perpetuating burnout, what are some other general self-care strategies that might help in changing those fatigue symptoms.
Dr. Moira Junge: Yeah. I think it’s a good point. I think especially the listeners who are maybe new clinicians, I remember me maybe 15 years ago being really fantastic in thinking, “I’m really good with my CBTI and helping people sleep getting much better.” But then I thought, “Why do I feel exhausted?” Yeah, it would have been useful to have this kind of discussion then. That’s why of course, why we’re having – why we bring this to the podcast – to have these discussions because that’s the point sometimes if they sleep fine, they have stressors and find that the fatigue and the lack of – low empathy, low energy, low confidence, all that sort of stuff is still there.
Dr. David Cunnington: And it also raises the question of what’s this term nonrestorative sleep thing? That can be one of the things in burnout. But it’s also one of the symptoms of insomnia.
Dr. Moira Junge: I’m going to say it’s part of the diagnostic.
Dr. David Cunnington: But it implies that the fatigue is because sleep is not doing its job and it puts the owners back on sleep. And that’s also something I find a challenge clinically because sometimes I think yeah, sleep is OK. It’s working OK. What about all these other factors over here that may be adding to fatigue? They’re calling nonrestorative sleep or nonrestorative sleep just keeps the focus back on sleep and puts all the blame on sleep.
Dr. Moira Junge: And I think that maybe back in the day, there was – well, at the moment, for instance, psychology, a lot of people or maybe the sleep clinicians and sleep physicians aren’t working alongside psychologists, for instance, might be very hard to get people in to see psychologists but realizing that yeah, to start having these discussions themselves and say, “Well, we could maybe think about how much of it could be burnout,” and start doing a bit of that initial education or self-awareness in the clients if they do indeed to go and see a psychologist. They might be able to do a lot of it themselves and not necessarily stuff that Gordon was talking about. Perhaps, addressing things in their workplace or addressing things, the care and responsibilities outside of how much sleep they’re getting.
Dr. David Cunnington: If people are looking for more information, the book that we’ve been referring to is called Burnout and it was published by Allen & Unwin and authored by Gordon Parker, Gabriela Tavella, and Kerrie Eyers.
Dr. Moira Junge: So Dave, what’s the clinical tip?
Dr. David Cunnington: We have covered it somewhat already but really thinking about if someone is presenting with sleep problems or if you yourself have sleep problems and are exhausted during the day, just thinking about, well, could it be that that sleep disturbance and exhaustion maybe something like burnout rather than necessarily being driven just purely as asleep is not working, therefore I’m tired during the day. The answer is to fix sleep.
And for a lot of people we see, the blind spot when I’m trying to manage insomnia is what they do during the day, whereas in fact, the night is really the mirror of the day. And so, just recognize if there are things going on in your day that may be turning up that nervous energy or causing it to be low in energy, they may well also be causing changes in sleep and changes in how you feel throughout the day.
So what’s your pick of the month, Moira?
Dr. Moira Junge: Well, I want to talk about a website called THIS WAY UP and it’s run clinical psychologists, psychiatrists, researchers, and technicians based at the Clinical Research Unit for Anxiety and Depression, a joint facility of St. Vincent’s Hospital and University of New South Wales in Sydney. And I’m not sure how much I’ve talked about it before but it’s very timely at the moment, we talk about burnout and talk about people who are really quite distressed in the global pandemic and waiting for this thing and how to get people in to see into health professionals.
So it’s a self-help online free course for a range of things around – there’s a course on depression and worry, anxiety. There’s one on insomnia. There’s on posttraumatic stress disorder. There’s a whole lot of things that you can refer people to. And we will put the link to that in the show notes. And the wonderful thing is that most of it, all of it in fact is for free.
Dr. David Cunnington: Yeah. It’s a really great resource. I must admit I use that quite a lot. And as a clinician, I can refer people in and it allows me to then track their progress through the program. And for patients themselves or people themselves with sleep problems, they don’t need to be referred in. They can actually self-refer and go straight through this podcast.
Dr. Moira Junge: That’s right. Yeah, sign up themselves. So yeah, I often talk about it if I’m doing any let’s say, public messaging if I’m on the radio or those sorts of things I do sometimes. It’s a really good resource. And it wasn’t free. It was only during COVID that it became free.
What about your pick of the month, Dave?
Dr. David Cunnington: So my pick is a course on perfectionism. We’re both going for the delivery.
Dr. Moira Junge: Oh, we’re going to courses.
Dr. David Cunnington: So this doesn’t sort of interactive course like THIS WAY UP. This is more a workbook-based self-help program on perfectionism run or offered via the Centre for Clinical Interventions which is run by the West Australian government.
And again, that has come up because a common thing we see for a lot of people is yes, they’ve got sleep disturbance but one of the things underpinning that sleep disturbance maybe traits of perfectionism, also a strong thing underpinning risk of burnout. So as a tool to try to help address that, it’s a really nice self-help resource.
Dr. Moira Junge: Oh, good on you. Yeah, I do a lot of – I have a lot of worksheets and a lot of really good information from that CCI of WA.
So, what’s coming up in future episodes, Dave?
Dr. David Cunnington: So in the next episode, we are going to talk about lucid dreaming and we’ve done a great interview with a neuroscientist who works in this area so look out for that episode.
Something I’m also seeing in clinical practice and as part of my own professional development, reading around to try to sort of think about, is people with early life trauma or developmental trauma and the impact that has on sleep later on in life causes people not only with insomnia but also with fatigue and sleepiness during the day that as a consequence of early life trauma. So that’s sort of summarized in a diagnosis called complex PTSD. So although we’ve also done previous episodes on PTSD, I might try and work up an episode to look at what is complex PTSD and what are the sleep manifestations of that later in life and then approaches to treating that.
So thanks a lot for listening. Send us any suggestions that you have. We love to feature early career researchers and email us at Podcast@SleepHub.com.au.
Dr. Moira Junge: And of course, if you like the podcast, review us on iTunes, subscribe, tell your friends and work colleagues about the podcast. We love to share the news about the importance of sleep and hear these wonderful international experts.
Outro: This podcast is not intended as a substitute for your own independent health professional’s advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition.