Search for tag: "conversations"

Mitch: We are The Scope here at the AAMC Learn Serve Lead 2022 Conference, and we are having conversations about the future of medicine as a whole, how we educate, how we heal, how we treat, and the conversations are from the ground up. What are we doing to kind of completely change some of our approaches, our values? What it means to care and to be a part of medicine.

Today, we are joined by Dr. Adina Kalet. She is the Director of the Robert D. and Patricia E. Kern Institute for Transformation of Medical Education at the Medical College of Wisconsin. And Dr. Tom Hurtado, fellow podcaster from the University of Utah. He runs a great show called "The RealMD." Why don't you tell us a little bit about "The RealMD"?

Dr. Hurtado: "The RealMD" program is a professional identity formation program at Spencer Fox Eccles School of Medicine at the University of Utah. We focus on developing meaning, community, and purpose with our medical students. And we do that through sessions that we have with physicians, a workbook, and we also have a robust coaching program.

Mitch: So, I think what we kind of wanted to just talk about today is what are some of the ways that we can get into the actual core values of medical education and how that in turn changes medicine as a whole, the kind of doctors we can expect, etc.

Dr. Kalet, how are you guys kind of approaching that and trying to solve that?

Dr. Kalet: So, one of the wonderful things about being in the profession of medicine is that we have a foundation in character and caring that's ancient. It goes back to Aristotle, Hippocrates. So, it's not controversial to center character and caring in the training of physicians, but we have drifted . . .

Dr. Hurtado: Oh, I like that word, drifted.

Dr. Kalet: . . . away from that, I think, as the profession became more science-based, more technology-enhanced. And so, now it's a matter of returning to our core values, our core principles while we prepare young people to serve the public's health as physicians.

It's not controversial. It's just challenging. It's hard to do. There's a lot to do. It takes many, many years to make a good physician, to become a physician.

I would love to talk to you about professional identity formation. It's a developmental process. It starts very young and continues through to the end of your career, and it's always evolving and changing.

Dr. Hurtado: This idea of drifting, I guess I'm very intrigued by what you're saying. And it makes perfect sense that these aren't things . . . These fundamental things we're talking about that need to happen in medicine are not new, but we have drifted, we've forgotten. And the word that comes to my mind is, "What are we doing to reawaken these things?" These things we know to be a part of who we are as humans and also as, I think, care providers.

I mean, there are things underneath all of that. People have been caring for people forever, right? So, I guess my question that comes to my mind is, "What are you doing to reawaken people?"

Dr. Kalet: I think part of it is working with medical students very early on, even before they become medical students. People come to us with pure motivations, commitment, and potentially an understanding of what that requires, even as very young people. They just don't have any life experience.

And our goal, I think, is to vaccinate them, to protect them from the loss of their ideals, and what motivates them initially to enter a very, very challenging educational training process that takes a decade at the least. And so, to make that kind of commitment to be the kind of young person who wants to be a physician is a remarkable thing.

You work with medical students. Medical students are among our top 1% of American students.

Dr. Hurtado: Right.

Dr. Kalet: They're academically superstars. They're capable of great things. We just want to keep them connected with the why. 

Dr. Hurtado: Yes. I love this conversation so much. The thing in the literature that I've . . . In my work arriving at the point of starting medical school with more feelings of autonomy and then immediately starting to lose those feelings of autonomy, or engaging or not engaging in help-seeking, so becoming help-avoidant, to not want to appear vulnerable in the system, I look at, "Oh, those are just recipes for . . ."

Dr. Kalet: For the loss of ideals.

Dr. Hurtado: For the loss of ideals.

Dr. Kalet: The loss of values. Right.

Dr. Hurtado: Yeah.

Dr. Kalet: And because it's so competitive to get into medical school, we often select them based on their individual ability to perform.

Dr. Hurtado: Yes.

Dr. Kalet: What I say to medical students during orientation to medical school is, "That's what got you here, being a remarkable individual performer, but it's not what we need you to aspire to as a physician. You need to aspire to care for others, to do things in service of others." And that's not an abhorrent thing. We're just changing the rules, and we have to align medical school structure with that.

Dr. Hurtado: Exactly. That's what we talk about in orientation too. We say, "Look, obviously there's a knowledge and skill delivery that needs to happen here. And the body of knowledge that you're expected to remember and regurgitate on demand continues to grow and evolve and change."

Dr. Kalet: Right. And you have to figure out how to do that.

Dr. Hurtado: And you have to figure out how to do that. I get that. But the part where it really connects with me around professional identity development is this idea of keeping your meaning and purpose, and having a learning environment that supports meaning and purpose. And that is, to me, the other half.

I mean, maybe it's too bold to say that, but the other half of that education experience, whatever is happening, the touchstone that you must always come back to is "Why are you here, and who are you? Who are you becoming? And as you start to think, act, and feel like a physician, are you driven and connected to that higher purpose? And are you exploring that?"

I know that's nascent for a lot of them, that's a lot to ask, but it's creating a conversation that you hope as . . . Professional identity formation is this iterative process over time. If you can commit yourself to a process of meaning-making . . . 

Dr. Kalet: Right. Well, you just quoted the Cruesses, right?

Dr. Hurtado: I did. I should cite Cruess and Cruess.

Dr. Kalet: Anything by Cruess and Cruess. So, we've worked on a measure of professional identity formation, which is based on essays called "The Professional Identity Essay," where we ask students to answer nine prompts. We do it during orientation in medical school.

And those essays are analyzed for the structure of the language they use to explain to us why they want to be a physician. Basically, what we want them to be able to do is move from a place in their identity formation where they're looking outside of themselves.

Dr. Hurtado: External sources.

Dr. Kalet: Right. For rules and regulations about what it means to be a doctor to the point where they internalize that, and it becomes who they are, and they look inside themselves.

We can measure that. We know by the time they come to us very many of our medical students already have internalized . . . Many of them, not all of them. But over time during medical school, more and more and more of them become more mature. They're more internalized.

So, anything we can do to enhance that process by talking with them, by giving them opportunities to reflect, by giving them opportunities to talk to each other, to challenge each other about the why, the meaning, the reason they're spending so many hours a week learning molecular biology, and why that matters.

And we want them to meet the patients whose lives they're going to impact early in their career so that they understand the context why they're doing what they're doing, the purpose of it, the meaning of it, and to meet role models that embrace the best.

Dr. Hurtado: Positive role models.

Dr. Kalet: The best of what our profession has to offer. To also meet people who have stumbled and fallen. The idea of productive failure is something we talk about a lot, which is if you want to be an expert, which we have no choice as physicians but to strive to be experts, then you're going to have to push yourself until you fail. And you're going to have to learn how to learn from that.

Dr. Hurtado: And that goes against all of their training.

Dr. Kalet: Up until that point.

Dr. Hurtado: Up until that point.

Dr. Kalet: Right.

Dr. Hurtado: And yet in this moment you're saying, "Not only are we going to academically challenge you maybe more than you ever have been in a sustained way, but we're also going to ask you to find productive ways to fail or learn from your failures."

Dr. Kalet: And learn from every moment of that failure. And to do it together in teams with more senior, more junior people so that we're, as a profession, supporting each other. That's a model that is not in the traditional curriculum.

Dr. Hurtado: No, it's not.

Dr. Kalet: But it increasingly is in new versions of what we're doing. And at the AAMC-related medical schools, there are many great examples.

Mitch: And to be as kind of this outsider lay person, we have a show called "Bundle of Hers," and it's all about diverse women in medical school and their experience. One of the most responded to, listened to, the most emails we've ever got was an episode where we interviewed someone who failed out of medical school. And it was just transformative for these people. They were so fascinated to hear, "Oh, failure is okay. Failure is a part of learning."

Dr. Kalet: You survive.

Mitch: And so, just hearing how much people resonate with that idea and the fact that that's one of the key values that you're bringing in, that is going to mean so much to so many people.

Dr. Kalet: And the ancient philosophers had lots to say about that. This is not news, right? I can't quote it, unfortunately, but in the Kern Institute, we have a philosophies lab. We have a Philosophies of Medical Education Transformation lab because we want people thinking deeply about the ancient wisdoms, about the new psychology and cognitive psychology that suggests that in order to do this kind of work, which is so emotionally challenging and so intellectually challenging, to do it at your best possible level for your entire career. I mean, there's no room for error in what we do, and yet errors occur. And so, you have to manage all of that.

So, to prepare young adults for that takes attention to them as individuals. And I agree, I think the failure and survival stories are the most important ones.

Dr. Hurtado: Yeah. In "The RealMD" program, it's an acronym, and the E in "Real" is for excellence. And I think on the surface, people think, "Well, the traditional definition of excellence is obviously just perfection."

Dr. Kalet: Perfection in performance, but it's not.

Mitch:  Success, success, success.

Dr. Hurtado: We redefine it. And one of the most popular episodes of "The RealMD Podcast" was from one of our students who was a fantastic student, but tried to match into ophthalmology and didn't the first time.

And what happened in that process after not matching and regrouping and doing a research year, doing a research fellowship, and then coming back to it, in this case was able to succeed, but it took a lot longer. Not the way that was intended.

I think, "What is excellence? Is excellence an outcome or is it a mindset to continue to try . . ."

Dr. Kalet: Of a process. Yeah.

Dr. Hurtado: And commit yourself to a process even when an unexpected failure happens, or multiple failures, or the road . . . Which is never linear. It's expected to be linear.

Mitch: For anyone. Not just medical students, right?

Dr. Kalet: Exactly.

Dr. Hurtado: The road is not linear.

Dr. Kalet: The problem with medical students is they're so special that they . . . Many of them make it to their mid-20s never having faced failure.

Dr. Hurtado: Exactly. And that makes them fragile.

Dr. Hurtado:It does.

Dr. Kalet: And in fact, my favorite medical students are the ones who have faced some very significant challenges and have recovered. They're often much, much more mature.

Dr. Hurtado: Right. The resilience is developed.

Dr. Kalet: It's definitely developed. But if you don't let students stumble with support, then they won't learn that resilience, I don't think. And then the worst thing happens, which is in real patient care situations where things are complicated and chaotic, they don't have all the tools they need.

Dr. Hurtado: So, what sorts of interventions are you doing to awaken this?

Dr. Kalet: So, we're reforming our curriculum at the Medical College of Wisconsin to move from almost an entirely lecture-based, or largely lecture-based, curriculum to one where students have to discuss cases with their peers and faculty as the major educational activity.

They have to learn on their own, they have to identify their own learning needs, and they have to meet their own learning needs. They get assessed frequently, but not at high stakes so that they get to monitor and be accountable for what they're learning and what they know.

They have to demonstrate that they can perform the skills of doctoring early, so in standardized patient exams, in all kinds of simulations. It's not only about knowing, but it's also about being able to do and implement.

We ask them to write a lot more than I ever did as a medical student. To write stories, write about themselves, to reflect with specificity on their own strengths and weaknesses.

Those are the sort of fundamentals. That's a difficult curriculum to design well, to implement well. It requires a lot of faculty support, faculty development. But fundamentally, we want to put the responsibility for learning in the hands of the learners.

Dr. Hurtado: Yeah. Self-directed.

Dr. Kalet: Right. And not infantilize them by lecturing at them and then testing them, which I think we did for way too long, and we need to stop doing.

Dr. Hurtado: Yeah. How did this awaken in you? I mean, we know how training was. We're still struggling to break free from. When did this happen for you? What was your aha moment for professional identity formation being something you were going to dedicate yourself to?

Dr. Kalet: How far back can I go?

Dr. Hurtado: Well, you're going to have to go back a little bit if I'm asking this kind of a question.

Dr. Kalet: So, I can tell you this. I grew up in a family of refugees and immigrants, who lived through some really hard things and they had illnesses as a consequence. And so, I was surrounded by people who really needed the kind of health care that they deserved, the kind of health care I hope my students and residents deliver, but they didn't get it.

And so, I was motivated early to try to understand what it means to be a physician in that situation. I had traditional education, but I had a handful of mentors along the way who didn't let me off the hook.

Dr. Hurtado: Yeah, and a positive role model challenges you too. It's not just someone that's bright and rosy all the time. It's someone who is invested in you.

Dr. Kalet: Right. Invested in you and understands it's about who you are as a person.

Dr. Hurtado: And has a growth mindset about you, about where you're going, and wants to challenge you to get there.

Dr. Kalet: Right. And so, I had motivation, and I had a handful of teachers who believed in me.

Dr. Hurtado: That's awesome.

Dr. Kalet: A small handful, but . . .

Dr. Hurtado: That's all it takes.

Dr. Kalet: Yeah. That was early on. And then my medical education, I had some innovative educators in there. Not most of them, but some. And then I wanted to make sure the future was better than what I had experienced in medical school. Can I tell you a story about remediation?

Dr. Hurtado: Please. Yes.

Dr. Kalet: So, I'm also a quant. I have a Master's in Public Health, and I studied epidemiology and biostats, so I like to count and measure things. And we did a standardized patient exam in our medical school that I worked in before. It was a top-tiered medical school.

And once you start measuring what students can do in terms of communication skills . . . That was my area of interest. I thought communication skills is our primary method for doctoring, and so I thought we should be assessing it rigorously and measuring it. When you assess and measure those things rigorously, it's not like woe begone. Not everybody is above average.

Dr. Hurtado: That's right.

Dr. Kalet: And you identify some students who disappoint you.

Once you get into medical school, it's very hard to not graduate. We tend to graduate everybody who we let in. And so, we started to realize it was our moral obligation to remediate the lower end of that curve, the groups of students who just weren't up to par yet.

And in that work of working with individual students who just weren't getting it yet, we learned a ton of information about what's remediable.

How to work with people who aren't there yet, how to work with people who don't have skills? That's easy. Just teach them the skills.

They don't know stuff? That's easy. You just teach them the stuff.

Don't want to, don't believe, might have attitudes that are not consistent with being a good doctor? That's more challenging, but still remediable in the sense that by challenging their ideas and their beliefs and engaging with them, you can bring them on board.

So, we ended up writing a book on remediation because it was a complicated topic. And the professional identity formation was in that last group, right? Everybody else was motivated and meant well, were good people, and they just needed to learn something. But the ones that weren't quite bought in of what this doctoring thing was . . . Why should people be altruistic? Is that real? I had medical students challenge me, "Can you really be altruistic?" I said, "Well, that's the expectation."

Dr. Hurtado: Yeah. The expectation is a higher purpose.

Dr. Kalet: Yeah. I mean, there are easier ways to make a living. 

Dr. Hurtado: Patients first. Yeah, that kind of thing.

Dr. Kalet: And those were those students I loved to talk to. And that's where the professional identity formation piece came in, which is they realized they hadn't yet internalized what it meant to be a physician. They were looking outside of themselves for someone else to tell them what to do and how to be. And that doesn't get you through too far.

Dr. Hurtado: Right. And then you look at what are the, let's say, career fulfillment outcomes for that person? And what are the patient care outcomes for the person who's treated by a person who's unfulfilled and burned out and experiencing mental illness maybe related to the struggle of becoming a physician?

Dr. Kalet: Right. If you don't really want it and you're not internally driven to do it, it's very hard to do it well.

Dr. Hurtado: Yeah. Where do you hope this is headed?

Dr. Kalet: Our mission at the Kern Institute is to transform medical education so that everybody is . . . so that the character and caring and confidence are obvious to everybody. Our vision is that all Americans will have physicians who care and have a character in a system that cares. Those are not the same, but they're related.

So I think, because of what we said at the beginning, this is fundamental to the profession. If you train good physicians, this should not be controversial. And we just have to figure out how to align the ideal with what is possible. 

Mitch: Dr. Kalet, Tom, thank you guys so much for coming and having that kind of discussion. I think all the things that I at least have been hearing from the AAMC at the AAMC floor is just how important it is for us to really go back to care, go back to what it means to be a human, go back to what it means to be healthy, right? It's really quite interesting that we've somehow gotten away from it. And as we're rebuilding from the ground up, what can we do to kind of incorporate these very real values? So, thank you so much for having a conversation about that here.

Again, if you enjoyed the conversation today and would like to hear more, the episodes from the AAMC floor can be found at uofuhealth.org/aamc22.

And if you just like health content, podcasts, etc., we've got "The RealMD." You can check that out, as well as thescoperadio.com where we have tons of short-form health information, a big library of content. If you have any questions, we have our best doctors there. As well as a bunch of podcasts, long-form shows, talk shows, narratives, etc. that might just tickle your fancy.

So, again, from the AAMC floor at the Learn Serve Lead 2022 Conference, this is The Scope.

Listen to our other AAMC conversations:
• Rethinking Population Health Care and Education
• Reducing the Distance Between Patient and Provider
• Doing the Work: EDI as a Shared Responsibility
• The Power of Diversity in Medicine
• Grappling with Post-Pandemic Burnout and Trauma

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: It's the "Who Cares About Men's Health" Sideshow. My name is Scot Singpiel. I am the guy that brings the BS to the show. Also co-host Dr. Troy Madsen, the MD to my BS.

Troy: Scot, I'm happy to be here with you.

Scot: And Producer Mitch is in the mix.

Mitch: Hey, there. I'm back. Haven't had roller food in over two weeks.

Scot: Oh, nice.

Troy: Well done.

Scot: Nice. Yeah. Awesome. All right. On the Sideshow, we get an opportunity to talk about some things that will have to do with health, but it's not necessarily health issues that face men or it doesn't necessarily always tie back to the core four, but a lot of times it does.

Today, we're going to celebrate another success. We celebrated Mitch's two-year quit-iversary, but Troy also has had a goal, an objective, and achieved something pretty cool as well. Troy, go ahead and tell us what happened.

Troy: Well, Scot, we talked about this a little while ago. I mean, it's been about a year since we talked about it, but I ran the Boston Marathon. It happened. It happened a couple of weeks ago. It was one of those things that was out there and I'd qualified for the Boston marathon about . . . it's been about three years ago that I qualified for it. And then as you know, COVID happened and there was all that disappointment because COVID hit about a month before I was going to run the Boston Marathon in 2020, and the marathon was essentially canceled.

They did this virtual marathon where you just go out and run and they send you a medal. And then it was rescheduled . . .

Scot: Eh.

Troy: I know. It was kind of like, "Eh, well, I ran the Boston marathon." But it was about 15 miles from my house, so it wasn't actually in Boston. So it wasn't that cool.

And then they had rescheduled and we were looking at April 2021, and then they pushed it back to October 11, 2021, and it actually happened. And it was wonderful for it to actually happen and to be part of it and to be there and to run the Boston Marathon.

Scot: Well, congratulations. And you finished?

Troy: Finished. Yeah, I did finish. Yeah, it was . . .

Scot: How did it go?

Troy: It was great. I enjoyed it. Everyone was like, "Well, how did you do? How did you run?" Well, I ran 3 hours and 16 minutes. I was really happy with that. The fastest time I've ever run in a marathon is 3:07, so it wasn't that far off of it. And that time would qualify me for a future Boston Marathon, which is always an achievement. Any time you can qualify for the Boston Marathon, that's a big deal.

So I was excited about that, to qualify for a future marathon in 2023. I think it would count for 2022 as well just with that race. So in that sense, it was great, but the best part for me was I just enjoyed it. I did not wear a watch. I did not know my time. I just ran. I enjoyed it. It was a cool experience. And then at the end of the day, it was like, "Oh, cool. It was a good time too." So I was happy with it.

Scot: Were you kind of let down then after you crossed the finish line? I mean, was there a point of like, "Wow, this thing is something I've wanted to accomplish, something I qualified for, it's been two years, and well, that's that. It's done"?

Troy: It's funny. It was kind of a relief to be done. And the reason why it was a relief is because most marathons I run, I just don't tell anyone. And beforehand, I was getting some texts from people who were like, "Hey, good luck tomorrow. We're going to be watching how you're doing," and stuff. And I'm like, "Guys, don't watch. Please, don't watch." I don't want this kind of pressure. Come on.

Scot: By the way, I downloaded the app and followed your progress.

Troy: I know. And I'm so glad I did not know you were doing that because I was just like, "I don't want people to be watching what I'm doing. I just want to go out and run."

And it's funny, leading up to it, it was a little bit stressful. I had this great plan where Laura was just going to drop me off at the start line. We stayed five miles from the start line in Hopkinton, Massachusetts. And we get up that morning and she starts to drive me to the start line. We get one block from our hotel and the road is blocked, and I'm like, "What am I going to do?" They're forcing people off the road onto the highway. So I just jump out of the car. I'm like, "See you later. I am running to the start line."

I am not joking. I just started running up the road because I'm like, "I don't know how else I'm going to get there." Fortunately, some guy is driving up, just one of the locals in Hopkinton, and he's like, "Hey, you need a ride?" So he's like, "I can get you two miles up." So he drove me two miles. So I ended up running a couple miles just to get to the start line. So it was a little bit stressful getting there.

Scot: Wow. That seems strange that they didn't plan that better.

Troy: Well, it's probably that I didn't plan that better.

Scot: Oh, okay.

Troy: I should have known the road would be blocked off, but I just didn't find anything that said it would be.

And then the race itself was kind of weird. I liked the way it was, but it was different than usual just because of COVID and all the health precautions. They did not have a start time. There was no gun firing and everyone starting. I was in wave number two. They had several waves based on your qualifying time. And so, for my wave, you basically started somewhere between 8:20 in the morning and 8:40 in the morning.

And so you just kind of walked up to the start line, and I look around and there are people kind of looking around at each other, all nervous, like, "Do I start this?" And I just was like, "Okay, here we go." I just started running and just crossed the start line, and then it starts your chip timing. Just started running.

So it was kind of weird in that way, but I mean, it was a cool experience just because it was . . . everyone was spread out. I wasn't packed in with a ton of people.

And the crowds along the race, that's what they always talk about. The crowds were amazing. So many people were out. It was just a really cool feeling because you could tell the community support for Boston is just huge. And that's what really makes it special, to have all these people out there all along the race route just cheering. You could tell they were just celebrating having this race back, and it was really an amazing experience to be part of that.

I will say, though, my favorite part of the race if people ask, and I'm hesitant to admit this, but my favorite part of the race was about Mile 13. And I'm just starting to come up this hill and I just hear all this screaming. I'm like, "What is it?" I had headphones and listening to music. I'm like, "Oh, what is that?" I didn't know exactly what happened where along the route.

I take my headphones out and just loud, loud screaming. I come up there. This is Wellesley College. This is an all-girls college, and all these college girls, hundreds of girls -- and as this happened, I remembered I heard about this -- are on the route just screaming their heads off.

They're holding their hands out to give people fives as they're coming by and people aren't doing it. And I'm like, "I am giving fives to every one of these girls who's going to give me five." So I'm just going down the line and girls have their phones out just recording and stuff, and I'm just giving fives. It is the closest I will ever come to feeling like a rock star. That is the closest I'll ever come. It was awesome.

I admitted it to Laura afterwards. I'm like, "Laura, I gave fives to all the Wellesley girls." She's like, "Go ahead. You do that." So it was funny. It was just one of those things.

And again, afterwards, I remembered I'd heard about out that, just all these college girls out there just screaming their heads off. But again, it was cool. The crowds were amazing.

As you get closer to town, it's just incredible. These crowds are like 10 people deep. Even early in the race, I thought, "I don't deserve this. Come on, guys. It's Mile 3. You can't be cheering now. I haven't done anything." But you get closer to the end, just huge, huge crowds as you're coming in the city. Yeah, it is a really cool feeling.

So it was an amazing experience, but like I said, getting done, it was a little bit of a relief because it was like, "Hey, I had a good race." I felt good. I enjoyed it. Great experience to think back on. You always worry you're going to go out there and just feel awful, like have some stomach issue or something, but everything went great. So it was a fun experience.

Scot: Oh, that's awesome. Well, congratulations.

Troy: Thanks. Yeah, I was happy about it. It was cool. It was definitely one of the . . . Yeah, people talk about it as the pinnacle of . . . That's what you try to achieve as a marathon runner. People want to run Boston. It's like, "I want to qualify for Boston. I want to run Boston." There are a lot of other great races out there, but that's kind of the big thing. So it was a cool thing to experience. And not just to be there, but just to have a fun experience with the whole thing.

Scot: And what a great story too, like how you got there. And in case somebody is listening that doesn't know that story, Troy, tell how you got started running.

Troy: Well, a big part of running for me . . . We talked a little about it before. There was the vegetarian diet, and that had a lot to do with just getting my cholesterol checked many years ago. I mean, it's been 15 years ago now, and seeing just some really bad numbers and saying, "I've got to do something about this."

So that's when I started a vegetarian diet, but I didn't really start running consistently until . . . it's been almost seven years ago. So in March, seven years ago, I got to a point and I said, "I'm just going to try and run every day." And I said, "I'm going to do two miles a day. I don't care how fast I go. That's all I'm going to do, and I'm just going to do it."

Prior to that, I'd put on a decent amount of weight. And again, I'd had my cholesterol numbers checked and they had improved, but still not super great. So I started out just doing two miles a day.

And then after about six months of that, Laura, my wife, she was running a lot of marathons, like a ton of marathons, and she got me interested and basically got me to commit to running a marathon.

So anyway, I committed to that. And so at that point, I started to kind of increase the mileage and mix in some longer runs. It's sort of evolved from there, but it really just started saying, "I'm just going to try and do it every day, two miles," and then it just built from there.

Scot: And I love that because that's what's kind of known as a process goal. It wasn't an end goal. You never had the goal of running the Boston Marathon or running marathons or getting a particular time.

Troy: I didn't.

Scot: You just recognized a health issue that you realized that a little bit more activity could help, and you just said, "I'm just going to do this every day for a certain number of minutes or a certain number of miles," and you did it, and then it led to this. So I think that's such just a great story.

Troy: Thanks. I think that's the big advice I would give anyone too. It's not about the end point. For me, it was not about Boston. At no point did I say to myself, "I want to run the Boston Marathon." I just said, "I want to run." And it started out just little bits and then it became, "Well, I want to run a little more." And then it became, "Well, I've got this marathon out there. I've committed to do it, going to get through it." And so I ended up doing that and then enjoyed it.

So I think the biggest thing is just enjoying the process. And that's what I've found. As I started doing it on a regular basis, I just enjoyed the process, and that's what it's fortunately been for me. Sometimes the process is challenging, but I've enjoyed it, and I think, for me, that's what's helped me to stay consistent.

Scot: Yeah, it went from an extrinsic reason to an intrinsic reason, that you just enjoyed it. You just liked doing it. And I think for anybody listening, when you try to get into any sort of activity, because we know that you need to get about 30 minutes, a little bit of sweat in every day, you might stumble into something like Troy did that you then ultimately enjoy.

I don't know. It's kind of a chicken and the egg thing. Did you enjoy it because you were kind of destined to enjoy it, or did you enjoy it just because you did it long enough and you liked how you felt physically? I mean, who knows?

And I've actually even learned from you as well. I used to have these goals when I'd go into the gym to lift weights that I want to be able to bench press this much or squat that much. And as soon as I kind of let that go after we had these conversations, I enjoyed doing it a lot more. I don't hurt. I don't hurt myself and I feel better and I feel healthier.

So sometimes just promising that you're going to be part of the process is 90% of the battle. And you don't have to be a superstar at it. Just go out and engage it and sweat. Find that thing that you like. If it's not the first thing you do, maybe it'll be the second or the third thing.

Mitch: Along that same line, Scot, is that when I was doing my little 5k a little while ago, it was the same sort of idea. When Troy said that he ran the Boston Marathon and didn't even wear a watch, my kneejerk reaction was, "What do you mean you didn't wear a watch? How did you run it without knowing how fast you were going?"

But that's just it, is just enjoying the activity. When I was doing the 5k training, it's like, "Don't look at the distance you're running. Don't look at the time that you're doing. Just get in the habit. Just do it and find a way to enjoy it."

And that's been a big change and shift for me as I've kind of matured over the last couple years about my feelings about health, and I really think there is something to it.

Troy: I agree, Mitch. And it's funny because before I ran the race, I kind of thought, "Oh, I'll wear a watch just to see what I'm doing." Then I thought, "I don't want to." And I thought back because, again, I think it's so much about just enjoying the process and just enjoying the experience. And then as you do that and you really embrace it, I think the results follow.

Scot: So Boston is done. Does that mean you're done running then?

Troy: I'm done.

Mitch: Yeah, what's next?

Scot: Yeah, what's next? Because from a goal standpoint, a lot of times we make these goals, whether it's "I want to lose five pounds" or "I want to be able to do this one thing," and then you've reached the goal and then it's like, "Well, now what?"

Troy: I know. I've had that thought. It's funny. I have had that thought and it's funny because leading up to it as I talked to some people . . . and I can't remember how it came up. I mean, when I say that, it sounds disingenuous because runners always have a way of bringing up the fact that they run marathons. So maybe that's how it came up. But I have met people who have run Boston and who said, "Oh, yeah, I ran Boston," and then they've stopped running. They don't run.

And I have not wanted that to happen to me, so I'm still running. I'm still going. The thing that I've come back to is I really do just enjoy the process. I've always told myself I don't want this to be about a time, a certain time that I'm running, like a certain speed. I don't want it to be about Boston, about qualifying, and then once I had qualified, about running the Boston Marathon. I never want it to be about that.

I've told myself I want to be doing the same thing when I'm 80 years old. I love running these races and seeing these old people out there. And they're not running super-fast, but they're just scooting along.

Scot: They're there.

Troy: They're there. They're doing it. That, to me, is the pinnacle right there. I find that just remarkable. I hope that's me honestly, and that's kind of how I look at it.

Mitch: I love that because it seems like . . . I don't know. Maybe it's just how guys are. When I was growing up in high school and stuff, it's like, "I want to be the model on the front of the runners' magazine. I want to be the big beefy dude." And it's so cool to hear, "I just want to be the 80-year-old who's scooting and still doing what I love." That's so different that I like it. I like it a lot.

Troy: Just keep on trucking.

Scot: What I'm taking away from it, though . . . It might be the same. It might be a little different. It seems like what you're talking about is it's like more of a journey, and Boston was just kind of a stop on that journey. It's not an end point. It's not the destination. Any of these things we do, how can you make it into a journey and how can you have destinations you look forward to getting to?

Troy: Yeah, you're right. And to switch your analogy up a little bit, maybe it's more like a really long trail run and some of these things are some of the peaks on the trail run, and you take in the view and you're like, "Ah, it's amazing." But you know there's another peak. You're going to keep going. You're going to drop down a bit, you've got some climbs, and then there's something else out there, some other cool experience where you're taking in the views and just enjoying the rewards of it.

Scot: Or how Mitch heard your analogy, you reach the peak and then you go back down into a deep, deep, dark valley. And then you try to figure out how you're going to get out of it.

Troy: How do I get out it? But sometimes they are dark valleys. I kind of had that thought yesterday morning when I went out. It was raining out and the temperature was in the low 30s, and it was dark and I kind of did have that thought, like, "Do I need to do this every day? I did Boston. Do I need to do it?"

Scot: Your cholesterol does not know that you did Boston, so that's why you continue to do it.

Troy: That's right. My genetics do not know that I did Boston.

Scot: They don't care.

Troy: They don't care, yeah. And that's a great point too. They don't care. They're not going to be like, "Oh, you're good for life."

Scot: Yeah, you're kind of doing it for a different reason, and I think maybe Boston was just kind of a cool little outcome of the real reason why you're doing it, and that was so you can manage your health issue that you have and be that 80-year-old that is still out there and moving around.

Troy: Yeah.

Scot: Mitch, do you want to say anything to Troy before we wrap up? Do you want to give him your own personal congratulations?

Mitch: Oh my God. Yes. Congratulations.

Troy: Mitch, please do.

Mitch: It really is really inspiring, as someone who's trying to get back into fitness, who's been struggling in his own way or another, to have a different approach and a different framework. And I really appreciate you sharing that on this podcast in particular.

Just do it. Just find something you enjoy and do that every single day. That is so much different than, "You've got to kill yourself. You've got to be sore if you're going to get those gains." It's such a different approach to health that I cannot tell you how proud and appreciative I am that you have done Boston and were able to do that.

Troy: Well, thanks, Mitch. Well, I'm obviously incredibly proud of you and what you've done with your health change. I mean, it is inspirational too.

Scot: It is actually.

Troy: It is.

Scot: I'm just sitting here thinking, "I'm kind of the one that's bringing the group down."

Mitch: Come on, Scot.

Scot: This is why guys should talk about it, I guess. I didn't think I was competitive until very moment right here.

Troy: See, that's the point, though. It should never be a competition. I don't think it ever should. And for me, six years ago . . .

I have to say this too. So they had this board where people could put up pictures and messages to you near the finish line. So Laura posted a picture of me six years ago running with her. It was the furthest I had run at that point since college. I ran the second half of the California International Marathon with her. So it was me running with her and I said, "I'll join you at the halfway point. I'm going to try and finish. I don't know if I can." But I met her at the halfway point and I did it and I ran that second half with her.

And she posted a picture of that that said, "Look how far you've come." And the of picture me, when I saw it, I was like, "Oh, wow, I've lost a lot of weight." I was definitely in the overweight category at that point. But I think the larger point I'm trying to make here is you just say, "Hey, I'm just going to start small and just try and be consistent," and then I think, over time, that just builds on itself.

So I hope that's the takeaway for everyone. It's a message I think we've tried to share with some of our listeners and when we've had some of our listeners on here as well, of just the value of consistency and really just enjoying the process, and then I think the results follow from that.

Scot: Congratulations, Troy. This is a very exciting moment for all of us, I think. I was excited when you qualified and I was excited when you were able to finally run it, and I feel a little let down now, I guess. So what are you going to do next? No, I'm just kidding.

Troy: Well, it meant a lot to me, Scot, to get done, and Laura told me afterwards. She's like, "Scot was texting me during the race. He's like, 'Oh, look how fast he was going. Look at what he is doing.'" But it meant a lot. It did. I am so glad I didn't know you were doing that, but it meant a lot to me after. And from everyone else, like family and friends and everyone who reached out and supported me, it was really cool.

Scot: Yeah, it was fun. It was fun to support you.

Troy: Thank you.

Scot: Hey, Troy. Congratulations. It's just awesome having you on the podcast, and what an awesome accomplishment. And now we'll never speak of it again, I guess. I don't know. You said you were never going to talk about running again.

Troy: Well, Scot, I'm going to wrap this up and I'm just going to say thanks for your support, and I am looking forward to the day I get to track your Boston Marathon progress. I'm expecting it's going to be in three years, so let's do it.

Mitch: Oh, man.

Troy: No pressure.