Joy Rounds

[Intro melody into roundtable discussion.]

Juan Carlos: And we are here at the Baylor College of Medicine, Resonance podcast. I am one of your hosts. Juan Carlos Ramirez.

Delia: And I am your other host, Delia Rospigliosi. 

Juan Carlos: And Delia is also the lead writer for this episode. And in today's episode, we will be talking to Dr. Mariam Hull, a pediatric neurologist with a fellowship in movement disorders. She has been with Baylor for residency, fellowship, and is now a current attending physician here at the Texas Children's Hospital. And in today's discussion. We are going to include her experience and her training at Baylor, the field of pediatric neurology, all of its ins-and-outs, and her research and the implications of Covid-19 on movement disorders, and her personal take on wellness in medicine. 

Delia: Yeah, so pediatric neurology is actually such an interesting field. It's centered around treating neurologic symptoms in children as a result of infectious, genetic, and other causes. Physicians involved in this field have to hone their physical exam and their diagnostic skills, and they’re masters of observation. Dr. Hull attended the University of Nebraska Medical Center College of Medicine after which she went on to a pediatric neurology residency at Baylor College of Medicine, and she stayed here ever since. She completed a fellowship in movement disorders at Baylor, and she's now a faculty member working in her movement disorders clinic. Her other research interests center around clinical work such as studying treatment options, for various movement disorders, and she's recently captured the attention of the media for her work on functional tics and their spread through social media. 

Juan Carlos: Well, you know, when I think of a pediatric neurologist, I mean, it's a little scary, right? Because it's you know, it's such a delicate time in someone's life. It's the child, but it's also the parents, right? It's just, to be able to manage all of those things and in her field of work with these movement disorders that’s…

Delia: Yeah

Juan Carlos: So impressive to see someone working, uh, and doing it and having an impact in such a such a very efficient way. 

Delia: Yeah, she juggles so many things in the practice, and it's really cool to hear about and yeah, she's had some interesting media presences that we're going to get into. So, Dr. Hull has a really interesting career to talk about. 

Juan Carlos: Yeah, and then without keeping you too much in suspense, let's talk to Dr. Hull in her field of work.

Delia: Let's get into it. 

Juan Carlos: Cool. 

[Interlude melody]

Dr. Hull: Hi, everybody. 

Delia: So today, I guess we can just start with talking about your background. You've hinted that you have sort of an alternative background, maybe a little bit different than the traditional path. So, just tell us about you. 

Dr. Hull: Yeah, so I was born in Egypt, and then my parents immigrated to small-town Iowa, for unclear reasons as to why they chose Iowa in particular, but I ended up going to Nebraska for medical school. Before that, I didn't exactly know what I wanted to do in medicine. I had probably some hints along the way that I was going to end up in neurology. I had a roommate in college that had epilepsy and got really involved with the Epilepsy Foundation kind of at that point. But, went to medical school and initially had thought I wanted to do OBGYN. Did my rotation there for, over there it's when you're a third-year medical student--that's when you start your rotation. So, did that one first and hated every minute of it,

(All laugh)

Dr. Hull: and the residents were miserable, and I was miserable with them. So then I thought, well, maybe I want to do Psychiatry. I've always been interested in kind of that field and so did that one next. And realized that I would take the work home with me to the point where, you know, I felt like I was such an empathetic person that in the end of the day I would just feel so emotionally drained. And so thought, man, there's got to be something better than this, or maybe I just don't need to be seeing patients. Maybe that's not meant for me. And so, then I had started thinking I was going to go into radiology, and I remember it was the spring of my third year that I was doing Pediatrics. Never thought anything of it, and part of that rotation we had to do a-- some subspecialty blocks. And so, the subspecialty block that was chosen for me was pediatric neurology just by chance, and I loved every minute of it. The diseases that we were studying were interesting, the patients were just awesome to see, the families were awesome, so at that point, I just knew that that's what I wanted to do. 

Delia: Sounds like so much is just chance where we end up.

Dr. Hull: Definitely. But I think everybody, you know, when you find that field, that just clicks? It's just such an awesome experience at that point on. 

Juan Carlos: What would you say was the-- I guess the more precise thing that clicked for you? 

Dr. Hull: Well, for me it was-- it was a particular patient encounter. So, it was a little girl. Who came in with history of NF1. New onset seizure. And, um, when we did imaging at that point, saw that she had a stroke and had Moyamoya. And so then I was like, what are all of these things? What is this NF1? What is Moyamoya? There's genetics involved? And then there's critical care involved? All in the same patient. And then what do we do about things long term? And, you know, she had-- she needed rehab afterwards, so how do we coordinate all of that? So it was that particular patient encounter that just hooked me. And, you know, when I would go home, I would say, well, what else can I learn about her and the diseases that she has and the things we’re diagnosing her with? And I'd start looking things up on PubMed and then when you look up one thing you want to look up another thing, and it just kept flowing. Which, I'd never felt like that before. 

Delia: Just that insatiable curiosity, I guess? 

Dr. Hull: Yeah. 

Delia: And you had a little of everything. You've had the psychology aspect and the Radiology aspect. 

Dr. Hull: Yeah. 

Delia: Yeah. 

Dr. Hull: And I mean, I think all of the things that I was most interested in before I'm able to see in pediatric neurology, right? I mean, we look at our own imaging all the time. We do have a lot of psychiatric things that come up in neurology, too. So, all of the things that I had kind of hinted at being interested in ended up, you know, coming to fruition just in a much more interesting way, I think. 

Juan Carlos: Sounds like a very powerful motivator. 

Dr. Hull: Yeah.

Juan Carlos: To pursue something. 

Delia: One thing that has come up, even when I've been talking about pedi-neuro with people and we’re, like, discussing what we're interested in is that people's first reaction is that it's a sad field, that it would be just so sad, and “how can you deal with that every day”? How do you respond to that? And has it been just so different for you or… 

Dr. Hull: It has been different for me, and I think, um, you know in the past it probably was, right? You know, we do deal with neurodegenerative conditions all the time. We do deal with things that have, you know, long term implications in terms of quality of life and limitations and your function, but we're also, you know, changing people's lives. In just the last decade we've come out with, you know, gene therapies for SMA, for example. Whereas, before you would get that diagnosis, and you know, it's the kind of a-- it's a lifelong diagnosis. And you know that you're going to be limited in terms of lifespan and quality of life. And right now I'm co-PI on a gene therapy trial for AADC deficiency, which is a neurotransmitter disorder where we are actually injecting the gene therapy straight into deeper structures in the brain. Before, these kids would have severe hypotonia, severe intellectual disability, can't even hold their head up, and seeing these patients-- they get the therapy, and they're starting to have more head control. Some of them are able to sit independently. Some of them are able to walk independently. Some of them are have started talking. I mean, we're changing lives, and I don't know if there's many other fields that you can say that. That you can--you can see these things changing, and you can see the advances being done and you get to be part of it. 

Delia: It's almost like science fiction. (laughs)

Dr. Hull: It is! It is.

Delia: Wow. Um, since you talking about your research, what aspects of pediatric neurology do you find the most fascinating in your research? Or what are your--where are your interests? 

Dr. Hull: Yeah, so I specifically focus on movement disorders, so anything in the movement disorders, that's kind of what piques my interest. Um, I will say that with my training-- it happened to fall during the pandemic. And so, a lot of my research has kind of involved that aspect of things and how the pandemic has led to increases in something called, functional neurologic symptom disorder and functional movement disorders. And then, in particular as of late, there's been a lot of interest in functional tics that have increased. Thought to have some contribution of social media at least in that setting. So, I think in terms of research interests, it's sort of what has come up, but I've also been very interested in obviously genetic conditions that cause movement disorders, trying to find genes that cause movement disorders that we haven't been able to find yet. So, those are kind of the whole gambit of things. We do have a couple of things that we’re working on with deep brain stimulation as well, as well as some other interventions like Botox injections for certain pediatric movement disorder conditions, so it's been really fun. 

Delia: So, it's safe to say the field is evolving really fast right now. 

Dr. Hull: It's evolving really fast, and there's just so many things you can --so many things you can do. It's whatever piques your interest. There will be something there for you. 

Delia: Papers like the Wall Street Journal, the New York Post--they've been name-dropping, you Dr. Hull.

(All Laugh)

Delia: Do you want to tell us a little about that? I have to ask, what has it been like to see your case series go so viral? 

Dr. Hull: Yeah, so it's been really interesting, and I was actually really surprised how much media attention has come from this. So it's been in regards to functional ticks, in particular, mostly being seen in teenage girls where they'll have explosive onset ticks. So movements and sounds, and many of them have particular patterns. So things like bizarre, non-patterned phrases. A lot of them will have a very typical neck tick. Many of them have particular phrases that are patterned. And it seems to stem from exposure to social media of some sort. So, I think, right now, the most common things that teenage girls these days are on is TikTok, and so that's been probably the most common offender, but things like YouTube and other social media platforms have been implicated, too. And essentially what happens is, for unclear reasons, they may see or be exposed to similar types of movements and sounds and then catch them, themselves. And, it is functional neurologic symptom disorder, so it's involuntary. It's not like they're, you know, consciously producing these movements and sounds. It's a response to some sort of psychological factor so, the way their mind is processing thoughts and feelings, and it's manifested by involuntary movements and sounds. We think that there's some component of modeling because it seems like what they look at looks very similar to what they have, but it's just been spreading so fast. And we think it's because in the setting of Covid, you know, people are home and are on their phones or computers and watching a lot of those types of videos. And whether they realize it or not, they've modeled said behaviors. So, I had spoken to the Wall Street Journal about this phenomenon a little bit and a couple of other, you know, media outlets and then ended up on the Doctor Oz Show, 

(All chuckle)

Dr. Hull: which aired in January, which was a really interesting experience. But, they’re interested in this. It's-- there's even in-- and it's a worldwide phenomenon, too. So, even in Germany there's one particular YouTuber that they've kind of name-dropped as—well it seems like they all --that have this thing, have watched this, this YouTuber, but there's so many of these now. If you, if you pull up TikTock, and you look up, “#tourette” or “#ticks”. I mean, there are billions of videos out there, and then there are some of these, um, some of these TikTockers will have millions of followers and millions of views for each of these videos, too. So- 

Juan Carlos: Some of those unprecedented consequences of social media, right? 

Dr. Hull: Right.

Juan Carlos:  You know, it's another reason why I guess it's --it's just adding to, you know, when parents are afraid of their children being on social media, it just adds another dimension-- 

Dr. Hull: Mhm 

Juan Carlos: --that is really tangible. But I was curious, I'm sure this is a very multifactorial 
Phenomenon, but is there a particular age group? That is more vulnerable to--? 

Dr. Hull: It seems like it's teenagers that have been most affected by this, and we've seen that even with functional neurological symptom disorder in general. So pre-pandemic, common symptoms would be, you know, at least with functional movement disorders, it would be tremor or you might see some functional myoclonus or functional dystonia, so it may look different in other people. And then, other things that you see commonly in pediatric neurology are pseudo seizures, or non-epileptic events. So those things had been much more common, and they are common in, again, teenagers. So, there are a lot of theories as to why that occurs. Some thought is that, you know, in, during the teenage years, is when your frontal lobes are really starting to mature, and your frontal lobes, help you with executive function. They help you with coping. They help you with managing your everyday life and the stressors involved with life. And so, when these kids are exposed to something that their brain, may not know how to handle, then, it leaves them at higher risk of having some of these involuntary things happen to them. Now, that's not to say that adults don't develop this. Adults develop this all the time too, but young children don't seem to, so we think that it has something to do with that particular stage of development. 

Delia: And so usually the research around like functional movement disorders has been like it'll be in the family or something you see, but I guess like the real change now is that you could get it from a total stranger across the world just watching enough hours of it, I guess? 

Dr. Hull: Well, if you go back, historically, I mean, so this has been going on for centuries. You know, back in, if you think about the Salem witch trials-- that was mass hysteria. And so, it used to happen in close knit groups. I think besides what's been going on now, more recently, in the earlier 2000s there's a group of high-school girls in Le Roy, New York, that developed involuntary movements and seizure-like events. And again, there it was a close-knit group. So, the girls were friends or would at least see each other on a frequent basis. So you’d need that interaction, and now it seems like you don't need in-person interactions to have this type of spread. You can just be spread through visual media. 

Delia: It's terrifying. 

(All Laugh)

Dr. Hull: It is. It is terrifying. 

Delia: An argument for screen time limits. 

Juan Carlos: Yeah. 

Dr. Hull: And making sure that parents are aware of what things their children are watching. 

Juan Carlos: It is this, on the surface it seems like you wouldn't, it wouldn't really-- how do you, you know, as a parent, how do you even, you know, think of that as a consequence, you know? 

Dr. Hull: I think that's hard because it's not been seen before. So, I mean, in terms of the effects of social media. There's lots of data on, you know, decreased self-esteem and increased risk of things like eating disorders in particular in females and increased depression, but this phenomenon hasn't been seen spread that way before, so I think, you know as a parent, it's hard to imagine that something like that would happen, but it's happening. 

Juan Carlos: So, like, how do we, like maybe not how do we stop it, but how do we curve that? How do we get ahead of that? 

Dr. Hull: I think mostly parents need to be aware of what their kids are watching, and a lot of the platforms do have some form of parental-linked accounts. So, parents can link their accounts to their children’s, and then they can see what's being watched and monitor things closely. And then, just being aware that, you know, hey, if you're concerned that something is changing or something is going on with your child, then see somebody; ask for help. But that's essentially where it needs to start is making sure that you know what your kids are watching and being very clear as to what their limits are. 

Juan Carlos: This kind of gives a new, uh, I guess meta layer to prevention. Preventive medicine is the best medicine or you could-- this is another level. 

Dr. Hull: Yeah, it is another level. 

Juan Carlos: Wow. It's problems in the 21st century. 

Delia: A modern iteration of an ancient, ancient disease, I guess. So this is one way, I guess, Covid has affected your research and kind of the direction it's gone. Have there been other ways that, notably, you felt like Covid has really had effects on your research or the direction of your practice? 

Dr. Hull: Not really in terms of research aside from that. I mean, we were just seeing so much of functional neurologic symptoms disorder. We—our numbers doubled in that time frame, and that's essentially what would come in for most of the new onset ticks in teenagers-- would be this condition. So, I got really good at being able to figure out which one is which. Which one is Tourette syndrome, and which one is this other condition. Then you have this rare group that technically has both, and that can sometimes be tricky. Thankfully, so in terms of my training, I was technically the first pediatric-movement-disorders-trained person here at Baylor. Doctor Parnes, who's my mentor-- he did the adult movement disorders training, but there wasn't someone--there wasn't another ‘him’ that was here. So, nobody that was solely seeing pediatrics. So, I split my time 50% adult and then 50% pediatric during that time, and in that, since I was the only fellow and the first fellow, he was able to make the schedule such that all of his telemedicine visits would be during the time that I was in the adult clinic. And then, same thing for the adult. When I was on adults, I didn't have to worry about any telemedicine patients, so my exposure to-- to movement disorders was not dampened by any means. Which I'm very thankful for because I know a lot of other people didn't have that same experience. And I mean, I can't imagine trying to evaluate someone's tremor through an iPhone conversation because most of our patients are our on their iPhones when they're checking into telemedicine. They have poor connections, and they may be in their car, for example, so you can't analyze gait. So, I was very thankful that I didn't need to deal with that sort of growing pain. 

Delia: So speaking of differentiating the two, I don't know if this is like something that's so detailed to be hard to get into on just this podcast, but do you have any initial kind of how you approach differentiating between the functional movement disorder and the Tourette Syndrome? 

Dr. Hull: Yeah, so it's hard, and--and that's the first thing to know is that it's okay to refer if you-- if you're unsure because it does take a lot of training to be able to differentiate. But in terms of my approach, the first thing that I look at is when was the first time there was ever, ever any involuntary sound or movement. So, Tourette Syndrome, often times it's three, four, five, six, sometimes up to eight years old is when you first start noticing ticks, and it's typically a gradual onset. So, they might have a little blinking here, and then a few months later maybe that got better, and now they've got some neck movements or shoulder movements. So that's kind of how it progresses. Now with functional ticks, on the other hand, they tend to start in teenage years, and usually a rapid onset. So, they'll tell you, you know, one particular day, boom, like a bolt of lightning, I all of a sudden had, you know, neck jerks, arm movements, coprolalia, saying bizarre phrases, and they just rapidly went back-to-back-to-back-to-back. Some of them will even say that it's almost like it was seizure-like when it first started. So that doesn't happen with Tourette Syndrome, but that happens with functional ticks all the time. Other things on history, too, in particular, so functional ticks can often have specific, unusual triggers. So, some of them will say, you know, when I'm-- if I hear loud sounds, then they'll happen. Or if I --if I'm cold, or if I'm in large crowds. That also doesn't happen with Tourette Syndrome. I had one patient, that anytime she heard a German word. She would have a quote unquote, “tick-attack”, which is also—"tick-attacks” are a phenomenon that's pretty unique to functional ticks, where they have almost seizure-like episodes of several different movements and sounds that happen, kind of back-to-back where they can't function. 

Juan Carlos: It's very interesting that these triggers happen. It almost seems like, it makes me think of like, traumatic, maybe a traumatic experience married with it, you know, like a PTSD, but a very niche, a very niche space. I don't know. That's quite interesting. 

Dr. Hull: Yeah, there have been lots of studies that have looked at childhood trauma predisposing people to developing this condition, and it does seem like they’re at much higher risk. But with this particular population there, there haven't been any clear traumas that we've been able to associate-- at least in terms of a clear pattern. I mean, there are a few here and there that they did have some sort of very traumatic experience and then, this thing started, but most of them there haven't been-- hasn't been a clear trauma. Aside from, you know, the pandemic itself, right? That is a traumatic experience for most of, you know, kids, their whole worlds and our whole worlds turned upside down really fast. 

Juan Carlos: Yeah. 

Delia: So you've worked with kids and adults, it sounds like, very in-depth. What really pushed you into, you just love pedi neuro, if people ask you, peds or adults? Like, are they the same just little, or what makes you feel so special? 

Dr. Hull: Yeah, I wouldn't say that they're the same just special because the pathology that you see in pediatrics is so different, and the treatment approach is also very different because instead of just dealing with you know, one or two people, you're dealing with an entire family unit. And so, I think that's probably the thing that pushed me most towards pediatrics and especially when you know, in a child if you're able to do something about whatever issue they're coming in with and change their quality of life, that's a lifetime change for them. Whereas an adult, you know, if an 80-year-old comes in and they have Parkinson's disease, for example, you know, sure you can help them get a good quality of life, at least for you know, maybe another decade or two, but it's not a lifetime, which is just so different in kids. And it's so rewarding when you're able to do that 

Juan Carlos: Different impact. 

Dr. Hull: Mhm. 

Delia: In what is, I mean, a very stressful field, I remember being on your team in the hospital, and you talked about something called your happiness rounds? 

Dr. Hull: Joy rounds 

Delia: Oh, sorry. Joy rounds. See? This is gonna be good. Talk about it because it was a very memorable experience. How did you come up with that? 

Dr. Hull: Yeah, so I've been very interested in wellness and resident and physician wellness and resiliency. When I was in training, I had some colleagues, not in the same program as me but in the adult program, that you could see how burned out that they were feeling. Burnout is a huge problem for physicians, and some of them even quit. I mean, they got into residency, they started, and it was just too much. Some of them needed to take some time to, you know, prioritize their mental health. For me, that pushed me to want to do something more about it, and so, I started a couple of little wellness projects and did start a wellness curriculum as part of our residency program, at least on the pediatric neurology side. And then I was able to go to the AAN Live Well Lead Well program, which is a program that's solely focused on physician wellness. And there I was a group in a group of like-minded, you know, trainees and some faculty that, you know, wanted to prioritize this. And one of them had brought up, you know, it would be great if every day we thought about what we're thankful for or what, what makes us happy. And so, then we as a group had talked about well, what about “joy rounds”? So thinking about in the last 24-hours, what brought you joy? And I don't think we do that enough as in the medical field. You know, we get so busy, and we get so involved with you’re taking care of patients, which is great. But you have to remember what you're doing it for. And you have to really remember, you know, even though you might be on a 30-hour call, there's got to be something in the last 24-hours that made you smile, brought you joy. And when you start your day with that tone, it just makes such a huge difference, and the more you do it, the more you'll realize that it really does. When I first started doing it, I had first started doing it as a fellow on service, and I remember getting some of the faculty, you know, rolling their eyes, saying, “let's just get going”, and then some of the medical students and some of the faculty after being on service with me, would start to say, “wait, wait, we can't start until we do joy rounds. I've been looking for something to bring me joy every day so that I could talk about it”. So, I mean, it's just one little thing that you can add to your day that takes minutes, if anything, that will really shift your mindset from, “I'm tired,” or, “I'm stressed,”, or, “I don't know what to do,” or you know, whatever things that you have going through mind which are 100% valid when you’re, you know, in our training, to, “what brought me joy?” 

Juan Carlos: Yeah, the small victories 

Dr. Hull: The small victories.

Delia: It's harder than it sounds because I remember being on your team, and I was like, oh man, I didn't think about this yesterday. Now, what am I gonna say? Usually I would default to like dinner last night or something.

Dr. Hull: But dinner’s okay.

Delia: And I'd be all nervous, and I would just start trying to present, and you be like, whoa, whoa, whoa, whoa. Whoa.

(All laugh) 

Delia: Going too fast. We have to start with joy rounds. 

Dr. Hull: We have to start with joy rounds; that's how I like to start my days. 

Delia: I love it.

Dr. Hull: So it's all of those little things that, you know, add up. It's obviously not going to solve the issue of burnout, but I think the more we are mindful about those things, the more resilient you become. 

Juan Carlos: So once you started implementing this, did you kind of see it sort of tip the scales towards like a happier environment, perhaps if we were a little more eager to share and be happy? Was it a noticeable..? 

Dr. Hull: I would say that, within a week you could you could definitely-- you could feel the energy even change. 

Juan Carlos: I’m sure that something like that would also change like the cohesiveness of the team and everyone involved. Just happier, right?

Dr. Hull: Yes. Yeah, definitely. 

Delia: You learn something personal about each other on the team.

Dr. Hull: Right. 

Delia: That you'd never know, like who has kids. You wouldn't share that maybe usually 

Dr. Hull: Exactly, it promotes camaraderie. It promotes mindfulness. It does so many things with just that five minutes of, “hey, let's talk about something nice”. 

Delia: I love that you started doing that as a fellow. You, it's not like you waited until you were an attending and you had like, you were at the apex of, you know, the hierarchy. It shows you can start something even kind of at the ground roots, and it can cause change. 

Dr. Hull: Yeah. Yeah, it's, you know, we don't realize how much of an impact we can make. I think, even, you know, you guys doing this podcast? Like this is amazing. How many other places are doing something like this? So, you're not limited in where you are and your training or where you are in your career. As long as you find something that you're passionate about and want to start implementing change, just go for it. 

Delia: I did have another question for you about your training because you have a very unique path in that you were resident a fellow, and now an attending here in the same program. What do you think that's done for you or how has that been for you? 

Dr. Hull: Yeah, so it's um, it was sort of an interesting path for me. I ended up at the program here because when I did my sub-I in pediatric neurology at the University of Nebraska, the person that I trained under had said, “if you're going to go anywhere to train for pediatric neurology, you have to go to Baylor, you have to go to Texas Children's”. So I took that to heart and thankfully got in here, and I still had it in my mind that I wanted to do epilepsy. So, with my pediatrics training and then I did my neurology training, I had started to apply for epilepsy in my second year of neurology. And then, it wasn't until the fall when I had done my movement disorders rotation, which is actually an adult rotation with a few days of pediatrics here and there, that I realized that that's really where my passion lay. And so, I think with that, you know, I was able to already form a lot of those-- the mentorship opportunities and build those relationships that allowed me to be the first pediatric movement disorders fellow here. And I will say, you know, pediatric movement disorders is not a very common field. There aren't a lot of programs out there for it. There's just a handful, at least in the US, and so when I started looking at other programs, I realized that man, if I want clinical experience, it's going to be here because even some of the busiest pediatric movement disorder centers, their fellow, their fellows would have two full days of clinic per week. Whereas I had four full days and then another half day on top of that every week, and it was all in person and it was all full of patients, so I got--I saw everything. And I can say that I've been exceedingly thankful for that. And the same thing goes for the child neurology program here, too, it is probably one of the busiest child neurology programs. And so, you will see the most rare things. You will see the common things, and you'll see a lot of them. And I am not one to learn from reading from a book, so here you will learn by seeing patients. And, I ended up staying here as faculty I think just because, you know, I had already built those connections, like I talked about before, but also, you know, I spent all of my training here so had the longest interview out of anybody else. So they had a good idea of what my work ethic was and what my patients think of me, and so it turned out perfect. And I mean, we've got the patients. There are so many pediatric movement patients that our clinics are full. 

Delia: You can't beat Texas Children's volume. 

Dr. Hull: Yeah. You can't beat the volume here. That's for sure. 

Delia: I'm glad you've had a happy training here. That's a good, a good review for the program. For sure.

Dr. Hull: It was the best you can get for sure. 

Delia: Do you have any other questions? 

Juan Carlos: No, well, I guess I something that kind of stuck with me from the beginning, when you were describing your, your experience in the OB Gyn, and then you mentioned that you would go home with it. But then you also talked about the other side of that is, like, you're excited about pediatric neurology, and you would go home and think about it, but it's entirely different, you know this is sort of enriching and nourishing you. So is there a sort of, obviously that's like a two way thing, right? One could be good, one could be bad. Is there a way to sort of balance? 

Dr. Hull: I think that's just going to be per the individual, right? Some people are going to see patients with anxiety and depression and all of those things, and then come home and sure they'll feel that but they’ll say well, I want to learn more about well, you know, they tried all of these different classes of medicines, maybe are there other things that we can look up? Versus for me, I just felt emotionally drained after that. So I think that's just up to, you know, any given person, right? So somebody else might see kids with neurodegenerative conditions or weird genetic conditions that lead to, you know, all of these sorts of neurologic issues and intractable epilepsy, and go home and say, ahh, I can’t. I just can't. It weighs heavy on me. Whereas for me, well, let's learn about it. 

Juan Carlos: Yeah, I guess it's perspective. 

Dr. Hull: It's perspective. 

Juan Carlos: Yeah, so I guess given that perspective, are there, I guess, any parting words of advice or wisdom to aspiring neurologists. 

Dr. Hull: For aspiring neurologists. 

(All Laugh)

Dr. Hull: Well, aside from joy rounds, and incorporating joy rounds every day. I would say, you know, find something that just excites you because in the end, you know, you're going to work hard. When you're in neurology and medicine, you're going to work hard, you're going to see tough things, but explore around while you can and find something that really excites you, that makes you want to go to work the next day and makes you want to make a difference, makes you want to learn things or change things. So that's what I would say. 

Juan Carlos: That sounds like very wonderful and fair advice. I guess that's as fair as it could be in this line of work. 

Dr. Hull: Yeah. 

Juan Carlos: Well, it's been absolute pleasure. 

Dr. Hull: Thank you. Thanks for having me. 

Delia: Thank you so much for taking the time. 

Dr. Hull: No this was great. This was really fun.

[Outro melody.]