All right, thanks everybody for being here, to all the attendants here in person, and also those who are viewing us on demand. This is a project that I'm really proud of. I'm really proud of all the people that are working here with me today on this, and they have some really wonderful things to contribute all for you. So, let's, I'll tell you the name of our session. It's Fertility Preservation and Family Planning in Residency and Beyond. What Residents, Faculty, and Administrators Should Know. I'll introduce myself. Oops, sorry. I'll introduce myself. Stefana Morgan, I'm an Assistant Professor of Psychiatry at UCSF. I work at the General Hospital on Inpatient. And next are our three presenters that are residents. They're fantastic, and I'm really, really proud and excited for their future. We'll start with Isaac Johnson, and Dr. Ruby Luna, and Dr. Martha Vargas, and I apologize, Dr. Isaac Johnson. And then I want to present our discussants. We have Dr. Evelyn Mocklin, who is an Associate Professor of Obstetrics, Gynecology, and Reproductive Sciences at UCSF, and the Medical Director at the UCSF Center of Reproductive Health. We're very lucky to have her here. Donate her time. We appreciate you so much. And finally, but not least, is Dr. Albert Ning Zhou, who is a Child and Adolescent and Adult Psychiatrist, works at the San Francisco Department of Public Health, and is a volunteer faculty at UCSF. All right, so our objectives are to have you understand the concerns and family planning goals of psychiatry trainees and faculty, to learn how to assess their understanding of these topics, to promote the education of fertility issues and fertility preservation options and other ways to build families in our diverse trainee population, and also how to foster a discussion of these really complex, triggering, and fruitful topics. So we'll start first by an introduction. Let's see. I haven't gone past my allotted time. That's good. We'll go to... Next, we're going to have Dr. Ma Clinn is going to discuss infertility and family planning. Then we're going to have a couple of anecdotal stories, some narratives about the lived experience in infertility and LGBTQ-focused family building paths. And next, we're going to discuss our cultural psychiatry workshop at the UCSF Department of Psychiatry. We're going to discuss its major findings, and then the advocacy that it led to, and the changes that it caused in policy, etc. Well, it didn't cause, but some of us here caused it. All right, and finally, we'll just end with some Q&A, concluding comments, and that's it. Thanks, everybody. Hi, everyone. So as Dr. Morgan said, I'm Evelyn Ma Clinn. I'm an associate professor of OBGYN at UCSF. I'm sort of wondering if I might be the only OBGYN at this conference, but I often say that I practice gynecology, given the nature of what I do. So I'm honored to be amongst you all. I'm going to be talking about infertility, fertility preservation, family planning, and really sort of giving the background for the rest of the group to talk about the importance of this, and advocacy, and really sort of a call to action for trainees and residency program directors to really fight for coverage. Sadly still, after 10 years at UCSF, I have nothing to disclose, and I do have a disclaimer about gender language. You'll see that I strive really hard to use gender-neutral and gender-inclusive language. So instead of saying female and women, I will say people with ovaries or people with eggs, assigned female at birth, or I will say cis women, cis men. But in case I slip up, I do mean those who are assigned female at birth if I reference female or women. Before we get started, I just want to take a quick poll of the audience today, just with a show of hands. How many of you know someone with infertility or who has pursued fertility treatment? Okay, that's almost everyone here, if not everyone. So that just highlights how common infertility is. So by definition, infertility is a disease, and it's defined as 12 months of actively trying to conceive. But we know that there are many, many people who have infertility that can never meet that specific definition. So there are people without a uterus. There are people without ovaries. There are all sorts of combinations of things. So this definition actually doesn't even capture everyone that needs fertility treatment. Globally, one in six people have experienced infertility. It used to be one in eight, and then the WHO recently just updated that data, and it's one in six. In the U.S., it's actually closer to one in five. So extremely common. Millions of people across the world have infertility, unfortunately. We are still lacking markers for general fertility. Often people will come to see me and say, I want to check my fertility. There's really no single—the best determinant of fertility is actually trying to conceive and seeing if it works. We have markers for egg quantity, but we have no markers for egg quality. But if we take all comers, not knowing who their partners are, what the uterus looks like, what the sperm looks like, by far, the number one predictor of fertility by far is the age of the egg. So we have a couple of curves which are often, depending on the audience, can be quite depressing, and we'll talk about what the options are. As egg age increases, fertility rates go down. Infertility rates go up. Miscarriage rates go up as the age of the egg increases. The other graph here looks at the chances of spontaneous conception per month in the first six months of trying. So you see a 25-year-old, when they first start trying, will have about a 25% chance per month. So even at 25, it's not an 80% chance per month. And then by 40, that drops to less than 5% chance per month, and that goes down as time goes on. So it's not a fixed probability of success because the people who had higher fertility were taken out of the group, and those who are struggling will have a lower chance after month 6, month 12, and beyond. Physicians are at even higher risk for infertility, and this is multifactorial, but we know one of the biggest things is the length of time for training during prime reproductive years. On average, physicians delay childbearing by seven years. Physicians have higher rates of infertility, higher rates of miscarriage, and higher rates of pregnancy complications. Specifically, those in surgical subspecialties have higher rates of major pregnancy complications compared to those who are assigned female at birth in a non-surgical specialty. One study referenced here surveyed over 2,000 cis women physicians, and 66% said that fertility preservation should be discussed during med school and or residency, but hasn't been. So why is infertility important? It's important because it affects millions and millions of people, and it is a disease, but it's also a disease that has multifold impacts for relationships and for that individual and for that couple. Socially, we know it puts a huge strain on the relationship if they're partnered. It can end in divorce depending on the community, a lot of cultural stigma and social stigma, and potentially violence as well. There's a huge mental health impact. There are studies showing that people with infertility experience as much stress as someone diagnosed with cancer. And unlike cancer, where most people with a diagnosis of cancer are not sort of afraid of any sort of taboo or stigma with announcing that they have cancer, they usually can tell employers, get time off for their cancer treatment, tell friends and family, and receive support, infertility is often a very lonely, isolating experience because of the fear that there may be some stigma about what you did or didn't do. It often invites, you know, usually people, if you have someone who is diagnosed with cancer, you don't say, you should have done X, Y, and Z or not done X, Y, and Z to get cancer. But unfortunately, infertility often invites unwanted, well-intentioned but unwanted advice. Take time off, be less stressed, none of which has actually proven to help with probability of success. There's of course a professional impact, missed days of work, all of the fertility treatment appointments are plentiful and are very with short notice oftentimes, and we'll talk about that in a second. So a lot of unplanned missed days of work, reduced productivity, burnout. And of course, unfortunately, a huge financial impact. I put here just general costs of an IUI cycle, an IVF cycle. You can see it's very, very high cost. And unfortunately, many people, depending on the circumstances, require multiple cycles. So someone could end up spending $50,000 to $100,000 or more on their fertility treatments before they're successful. And unfortunately, insurance coverage is very limited. Sixty-six percent of residency programs in the U.S. offer very limited coverage and less than 50 percent cover IVF. And most don't cover fertility preservation. Infertility is also an equity issue. Physicians as a group are more likely to experience infertility compared to non-physicians. Those who are assigned female at birth, one in four require assisted reproductive technology to conceive. We had already mentioned that surgical subspecialties tend to be at higher risk than non-surgical specialties. Certainly we know residents are at a huge disadvantage in terms of access to fertility treatment, given the fact that they work 80 to 100, usually, hours, depending on your specialty, per week of work, which really, you know, when you can barely have enough time to sleep or eat, you're not going to have enough time to make to an appointment that is, you know, between the hours of 8 and 5, usually. Plus high debt, low income equals sort of no time or money to really access fertility treatment. And then, of course, our LGBTQ and people who want a single parent by choice are at a disadvantage because they definitively will require ART to have biological children. And even in states, so there are a number of states that have mandated fertility coverage. But even in those states, often they require 6 to 12 months of trying before you can get your coverage. And so if you have, let's say, two cis women who want to conceive, in order to access their coverage, they have to have, if they're under 35, 12 months of inseminations. So they have to pay 12 IUIs plus 12 vials of donor sperm before they even get access to infertility coverage, which by that point would be a year later, but also thousands and thousands of dollars later before they can access that coverage. So if age is the number one predictor, then what are our options? What can we do? For those who are not in a position to actively try to conceive, fertility preservation is a great option. We can freeze eggs, we can freeze embryos, we can freeze sperm. The focusing on egg and embryo freezing, this is a, you know, sort of menstrual cycle 101, but a typical menstrual cycle, pituitary releases follicle-stimulating hormone. Every single month, anyone with ovaries has a certain cohort of eggs called antral follicles that the body sort of allows us to pick from. The pituitary only releases a very small dose of FSH because it wants us to have one baby at a time. And then all the other follicles sort of undergo atresia. So we don't utilize all the follicles that we have that month. So the foundation of egg and embryo freezing is that we use higher doses of FSH, same hormone, looks exactly the same, to rescue all of the follicles that that person has that month. This involves daily self-administered sub-Q injections of hormones, FSH primarily, for 10 to 12 days. There are a number of ultrasounds during those two weeks. So they tend to be every other day and then every day towards the end. So this is again getting back to missed work and, you know, surgeons or anybody who rounds start at 7 in the morning or 7.30. We open at 7 in the morning, but that's still, you know, nurses who start their shifts at 7.30. It's a lot of appointments. But they're required and necessary because we have to monitor the follicular growth. And then the retrieval is done when most of the follicles are ready. And we don't know that until two days before. So you have two days notice to take the day off because that procedure is done under anesthesia. It's a very minor procedure, but it is still under anesthesia. We do a transvaginal ultrasound-guided aspiration. And it takes us 30 minutes, but you have to have that day off because you've gotten anesthesia. It's very safe and effective. We have over 30 years of data at this point. And most of the data suggests that we can keep these frozen for probably an indefinite period of time. The oldest embryos that have resulted in a live birth is over 30 years. The babies were actually delivered October of 2022, frozen in 1992, the embryos, and resulted in healthy twin live births. So we think they can stay in liquid nitrogen for probably an indefinite period of time. The process can be started immediately and takes only two weeks to complete. So again, a very stressful two weeks, lots of appointments, lots of needles. But it only takes two weeks to complete that initial part. If someone has a progesterone IUD, like a Mirena IUD, it does not need to be removed. That's a common misconception. I hate to remove IUDs if you don't have to because now the FDA just approved it up to eight years now and it's retroactive. So if it doesn't need to be removed, we can definitely do this. We never do anything with the uterus for a fertility preservation cycle. So the IUD can stay in. And for my transgender and gender diverse people who have been on testosterone, based on our limited data, including at UCSF, we've found that those who stop testosterone for a few months before doing an egg retrieval cycle have similar outcomes as a cisgender control cohort. Whether people need to stop testosterone is one question. I've had people continue and still successfully retrieve eggs. We don't have really quality data on that just yet. But certainly prior to testosterone use does not preclude someone from undergoing this process. For those who are ready to build their family, the two main options are IUI, intrauterine insemination, and IVF, in vitro fertilization. And which route we go really depends on the desires of that couple and the availability of the eggs, the sperm, and who is carrying the pregnancy. So for instance, two cis women, if they want to use their eggs and carry themselves, they would purchase donor sperm, usually anonymous, or it can be a friend, direct a donor. And we often would do inseminations timed to either their natural cycle or on a little bit of medication. But that same couple might want to do, and often want to do, what we call reciprocal IVF, where one partner is the egg donor. We use donor sperm, make embryos, transfer an embryo to partner B to carry. And certainly two cis men will use donor egg, their sperm, surrogate to carry. Now IVF, just as a really, really brief overview, I mean it's really just the science. I'm going to do this day in and day out, but it still amazes me that we can do all this. But we can inject sperm into eggs. We can help fertilization. We have these really fancy time-lapse imaging incubators now that basically track the embryo development. And we can go back and scroll back and look at, you know, exactly how many hours after fertilization, what it looked like, and how it cleaved, which is just so cool. And we can biopsy the embryos, the cells around the embryo called the trophectoderm, which become the placenta. So we're purposely not biopsying the cells that become the actual baby, what we call the inner cell mass. But we can biopsy the trophectoderm and send it for genetic testing. So we can screen for chromosomes. We can screen out aneuploidy. We don't have the ability to alter the genetics, but we can find out the genetics. So we can figure out if there's any trisomies or monosomies. For my patients who have a BRCA mutation or any other genetic mutation, let's say the two partners have cystic fibrosis, recessive genes, we can screen the embryos and selectively only transfer an embryo that is unaffected or just a carrier only. Focusing on the aneuploidy part, you can see here again, this is again why age is the number one predictor. Age of the egg is the number one predictor of overall fertility and success. As the age of the egg increases, the probability of obtaining a euploid embryo drops significantly. Age of the sperm does not significantly impact aneuploidy rates. Age of the sperm does seem to, limited data, but does seem to contribute to sort of things like actually a lot of the psychiatric illnesses, schizophrenia, bipolar disorder, autism rates seem to go up as the age of the sperm goes up. But specifically, chromosomal abnormalities are generally tied to the age of the egg. In large part, because it's so dependent on the age of the egg, a lot of people, as we had said before, will require multiple IVF cycles. And unfortunately, some can go through many, many rounds and still, unfortunately, never have success. This is a, I just put two examples up. This is from SART.org, which is an organization that partners with the CDC that collects data from the majority of sort of major clinics in the U.S. So we have a, at UCSF, we have a dedicated person who just does SART, who like collates our statistics and submits it to SART every year. And so it oversees a lot of the major clinics in the U.S. And there's a calculator on the website where you can put in age of the egg, height, weight, whether you know the diagnosis or not. Are you using your own eggs? Do you, have you undergone fertility treatment before? Have you been pregnant? And so just as an example, I put in someone, you know, a hypothetical person with a normal BMI and said, I don't know my diagnosis, and then changed it from age 35 to 40. And you can see, it's a little small here, but you can see the probability of live birth at age 35 after one cycle is 41% at age 35. And it drops to 23% at age 40. So this hypothetical 40-year-old after even three IVF cycles still has a higher chance of not having success than having a baby. So this just really highlights the need for proactive sort of family planning at the age during which most of us are in training. So really depending on family goals, and I often, when I meet with people about fertility preservation, I say, you know, ideally how many kids would you like and what is your time frame? Because I also try to adjust sort of realistic expectations of whether that's going to be feasible and or what you're going to need to do in order to try to have a good chance of that. So ideally everyone during their primary productive years would try to conceive as early as possible, but that's not possible for many, many people for a number of reasons. And so really fertility preservation is where, plays the biggest, the most important role there. But as we had said, most people as a trainee cannot afford to do that either financially or time-wise. So again, call to action, and we'll talk more about this in a second about sort of the advocacy work here. I'm going to pass it back to Dr. Morgan here. Thank you so much about this really great overview. Is this better? Okay, that's better for me because I was bending over before. It feels a little more intimate because I wanted to share a story about my experience with infertility, kind of how it started. I think it's a good example of what many women in medicine struggle with silently, sometimes less silently. And I really appreciated Dr. Mocklin going over the details of why this is happening to all of us, the logistics, the medicine behind it is really important. So I came to America as a college student by myself when I was 18. I didn't have a family here. My family was not rich, so they couldn't really help me financially when I was in America. It took me many years to get into medical school. I got into medical school in 2009. I was 28 at the time. I got married to my husband during medical school. We started trying during medical school. And when I got accepted at UCSF, I went for my first year for my PGY here. When I was an intern, I went to the primary care doctor. And the primary care doctor ran some tests, some labs, to evaluate my fertility. And they put infertility as the billable diagnosis associated with those labs. And then I got a $5,000 bill. And I said, wow, this is not for me. I'm 32. I can't pursue this now. I have to wait. While I was a resident, I was chief for research. I was in the research track at UCSF. I really wanted to pursue a life as a physician scientist. I was moonlighting a lot. I was working like 80 hours a week or something like that. And then when I did my geriatric psychiatry fellowship, my salary was still, I don't know, $60,000 or something like that. And I was starting to look at research fellowships, which at this point I was 38. And I'm looking at research fellowships that would pay, for another three years, they would pay $60,000. Okay, maybe $60,000 is a lot, actually, for a research fellowship. I just realized I would not be able to work, you know, to moonlight 40 hours a week and then also to do research 40 hours a week. That was just not going to work. It would not be good for my research. So, you know, I had to have an existential crisis over that, as many of us do when we finish training. So that was mine. And actually, I think when I was a PGY-4 and 5, I went to the LBGYN and they were like, oh no, just keep trying. Yeah, it would have been good if they told me to go. So once I was done at 38, let's say, in my geriatric psychiatry fellowship in 2019, that's when I decided I was not going to pursue research. I just started doing as much work as I can for as much money as I could in order to make money to, you know, do this IVF by myself. I mean, sorry, not by myself, without support from insurance, because insurance didn't cover it. So I paid, probably in the last three years, it's been between $150,000 and $2,100. Not successful. And I think, I guess I just wanted to say that I think my experience is not unique for people that are coming from different backgrounds than the standard background of, you know, born in America, have some socioeconomic status that is helpful in life. And, you know, I was an immigrant. I didn't have money. I had to delay my pregnancies as much as I could in order to get through medical school. And I think a lot of people that come from different backgrounds can relate to that. And even when I was in medical school and when I was in residency, I thought, you know, you should feel lucky that you're here. And also, this is not for you. This is for people who have money. This is for people who have more opportunities, more resources. And when I was choosing fellowships, I think it would have been good to think about, oh, well, do I know which one of these, or when I was choosing residencies, it would have been good to know which one of these residencies covers fertility treatment. I think that would have made a huge difference in terms of my, you know, my choice. Maybe. Maybe not. But I think it similarly, I think, affects a lot of people that come from different backgrounds, including people who, you know, are LGBTQ. And we're going to talk about that next. And I think that's it. Thanks, everybody, for listening. Thank you. Well, thank you, Stefana, for just that very real story of your experiences. So, I, and also, oh, thank you. It's, it's, I'm really grateful to be invited to be part of this panel. So, I want to position myself. So, I am, you know, Chinese American, cisgender man, identify as gay, queer. I'm, you know, able-bodied, financially stable, highly educated, from originally Salt Lake City, Utah. Growing up in a very white, Mormon, conservative community. You know, my family was not Mormon. But I think because all my friends were, I very much kind of picked up on the cultural kind of values and expectations at that time. Which is very much, you know, toward family building and kind of very negative toward LGBTQ people. I'll say that I represent one aspect of the LGBTQ plus experience. Not the whole, you know, rainbow spectrum of experiences. And also wanted to comment on coming from Chinese culture, that there is a lot of expectations for building family. Especially as the eldest son. And expectations to carry on the family name. And when I came out as gay to my family, it was really having children and the perceived, you know, lack of having children. That was one of the hardest parts for my parents and family to accept. So, that just kind of gives a little bit of context to kind of my journey. My partner, yeah, so my partner, we actually met in medical school. And he actually grew up Mormon. Although not in Utah. And, you know, as he describes it, you know, in the Mormon culture, the messages he internalized were that as a gay man, if you're gay, you'll have HIV. You'll have AIDS. You're a pedophile. It's a sin. You can't have children. And those were kind of the message that he had heard. That it just wouldn't be possible to have children. So, but we've been both very much aligned in wanting to have kids. You know, I'm a child psychiatrist. I really enjoy kids. And it's not quite always the case among our friend group. And actually, among our closest friends right now, aside from Stefana, no one else is really trying to have kids right now. And so we are, we do know people who are, who are, you know, gay couples who are. But there are, there's, but I've also found that challenging, just that the cultural context that I'm in right now has been not so much encouraging, you know, family planning and building a family. You know, it is something that I just also thought was not possible during residency or training. And just because of the financial aspect. And also, you know, after I finished my training, then my partner did another fellowship. And then so he was a trainee. And so that kind of, it felt like supporting him during that time also, it just meant that finances were tight. And it also felt like, okay, this is not something we can really explore until after we're both done with our training. So, and, you know, fortunately, so my sister has agreed to be an egg donor for us. She's 33. And so that means even though I don't quite yet feel ready to have kids, but this is really, I think, the ideal time, as we heard from Dr. Maughlin, to be really thinking about this, right, to freeze embryos. And, you know, my partner does have a sister as well. She's 40 now. And so I feel like that was something that might have been a conversation had we thought about it earlier or had we felt like it was accessible earlier. And I think it also, there's a lot of complexity involved, but we've been, we have been thinking about it for a long time. And then we've also been talking to my sister about it for a long time, probably about a year. You know, and she wanted time to think about it. We thought about, we were very open with our communication and talked about how we would handle different scenarios if my partner and I separated, if, you know, if my sister tried to have children and she couldn't. You know, like we just kind of thought about all the different scenarios. And we didn't come up with answers, but it was more that we were willing to talk about these conversations. And we felt confident that should these scenarios arise, that we would be able to handle it together. So, yeah, I want to also say that one, I think one of the factors that helped, that might have factored into my sister's decision, she, at least that she mentioned, is that having grandchildren that were genetically related to my parents might help them like love our kids more. And I don't know that they wouldn't have loved our kids, but I do think that that was something that she thought about, that maybe that would help increase the acceptance of our kids within our family system. And so even after we made the decision to move forward, it still required like so much planning and coordination. And, you know, I'm early career, you know, psychiatrist and my partner was just finishing fellowship. We were both busy. So even though we wanted to do it, it still took probably another half year before we even were able to schedule an appointment with the fertility clinic. So I wanted to also just touch base on that experience. So far, it's been really positive. I would say this fertility clinic does not, we're not in network, our insurance is not in network with them. So it has been a lot of out of pocket cost. Part of the process is also us meeting with a psychologist, which is interesting to be on the other side and to have that experience. The psychologist was really wonderful, I thought, and really brought up some important questions in terms of thinking about how are we going to communicate, you know, how this kid was conceived and their story to the kid, to the family, to other people. And to do so in a developmentally appropriate way. And have this not be a secret, right, that the kidman later finds out. But to be very open from the beginning about it. Even thinking about how to then refer to, you know, my sister. And I was just hearing how there are like new terms, I don't know if we'll use these, but like mant, someone who's like mom, aunt, you know. And I also heard diblings, you know, like siblings who are from the same donor, you know. So I don't know if we'll use these like novel terms, but it was interesting at least to think about how are we actually going to be talking about this, right. And then also my sister is going to have to meet with this psychologist as well. And I think part of that is to be really looking at kind of the reasons for doing this and making sure probably that there's no like coercion or that there's not unrealistic expectations about it. And so, yeah, and then another process is that we need to have a lawyer involved to draft up a legal contract. That it's going to be clear kind of that like the donor is not going to have parental rights, right. And that we have to be very clear from up front about all those things. And then I think it's also brought up some questions about. So if I do want to have kind of children genetically related to me in the future, it's brought up questions about like, you know, race, ethnicity. You know, my partner is white. And so the kids we have with my partner and, you know, sister's donor eggs would be like mixed race. And then for me, I would have to think in the future, would I want my kids to look like each other? Or is it important for me to preserve my own like Asian American, you know, heritage? And I don't know where I land right now, but it's interesting to even think that I actually have that. That that's a consideration that I need to make. And then something else that came up that I thought was interesting that, you know, we are going to need to use a surrogate. And that the gestational carrier that we also have to be make sure we're on the same page about, you know, invasive diagnostic procedures. Also, the morality of terminating a potential pregnancy if there were, let's say, genetic or chromosomal abnormalities. And also, is this gestational carrier or surrogate going to be in a state that will allow for that, right? Knowing just the anti-abortion challenges across the country. And yeah, I think it's, there are books out there actually that are designed for kids that talk about, you know, in a very developmentally appropriate way, how to have these conversations, even with a two-year-old. So those resources are out there. And yeah, and then I think just in terms of like the financial considerations, you know, the quote we got, it was for like all these different steps and getting the genetic testing, it was like $27,000, right? We're still trying to figure out how much our insurance will cover because our insurance technically should cover 50% of IVF. But then I don't know if we actually have to, you know, have this clause of like trying, attempting, you know, attempting for a year, like what is that going to look like? I don't know. So yeah, so that is kind of like on our radar to be figuring that piece out. I do feel we have some privilege now that we're both out of training that we have some more financial stability in order to be making these decisions. And I also think that it would have been really great to be able to have these conversations earlier and potentially have different options. All right, I think that's it for my part. Thank you. Thank you so much for your stories. They were just so compelling, so raw. And I think just overall, so universal to so many people. I know to me, they really, really hit really close to home. So thank you both for sharing so openly. Okay, everyone, I'm Martha. This is Isaac. We're going to talk today about developing a cultural workshop with the cultural AOD at UCSF residency last year and kind of the steps that went through it. A couple things just to kind of set up the stage. As part of the residency at UCSF, we have the opportunity to join AODs or areas of distinction. Think of these like minors. So psychiatry training is our major. That's what we're going through. That's what many of us have gone through. The area of distinction is more of a subset or a specialty or a minor, like we talked about, where we get to focus in topics that we're interested in. UCSF has many different areas of distinction, including cultural psychiatry, which we'll talk about today, LGBTQ+, interventional, public psychiatry, clinical neuroscience, women's mental health. So there are different areas of distinction. As part of the AOD or the area of distinction, the residency program gives us four precious hours where we're able to arrange a workshop once a year on any topic. The beautiful thing about cultural and the word culture or cultural is it can be any topic, right? And we get to talk to residents and faculty because faculty often come about anything that we feel is important in our patients to ourselves, something that's relevant. So in us thinking about, in us, you know, us being residents, thinking about what can we talk about? What feels relevant? You know, the COVID pandemic is still ranging on. Is it ever going to end? Everyone's feeling isolated. At that point, a couple of us were just, you know, venting. A lot of us are venting. Many of us didn't know if we wanted to have kids or did we? Did we not? Clearly, at some point I made a decision for myself to do, to have children. But just overall, didn't feel like we had a space to talk about it. It felt almost wrong to talk about. This was work. This was professional. To be professional is to live your life in a certain way. And there wasn't space for it. We didn't feel like we had mentorship. We felt like it was kind of a closed secret that you only heard about it once people were going through infertility treatments. And we wanted to change that. So through, you know, through thinking about it, talking about it, we said, hey, let's talk about fertility, but here's the thing about being in a small group of venting residents. Is there actually an interest in fertility? This is a huge topic with a lot of potential topics that are difficult to talk about, that can be triggering, that can be hard to engage. There's so many different levels. They can kind of take this whole topic and we only have four precious hours. We only have four hours. So what can we do? How can we fill in these four very precious hours? So really from the beginning, as you know, as the small three of us, because that's how small it was in terms of residents, of course, the amazing Dr. Morgan was shepherding us throughout the entire journey. We had some goals. We wanted the four hours to be very relevant. We wanted them to feel accessible. We wanted as much as we could to be as inclusive, and we wanted to make sure there was actually a need, that the residency actually, we felt it was very relevant, but we wanted that our classmates, our coworkers actually felt like this was a topic worth talking about. And in order to do that, we needed to identify the stakeholders. So we did a needs assessment. Yes. Hello everyone. I'm Isaac. I'm a third year resident. So yeah, you know, in identifying the stakeholders, I just very briefly wanted to mention my own personal narrative. So when I found out about this opportunity, I was really excited to join and very appreciative of the opportunity, especially because I was conceived via infertility treatment. So my mother is a clinical psychologist, and she waited, you know, several years to start trying to have kids due to her career. And she was immensely privileged that her insurance covered infertility treatment. And so she underwent infertility treatment in the late eighties until the mid nineties to conceive both me and my brother. She had her two sons at age 42 and 45. She, when she was, she had experienced multiple miscarriages. She purchased a little QP doll and named the doll Isaac because Sarah and the Bible had children when she was a hundred years old. So that's why she named this doll Isaac. And then eventually I was named after the doll. So that's my story. But yeah, so we we held focus groups with with residents to determine what the residents would like to hear for our, our cultural psychiatry workshop. We learned that people felt alone and they also wanted space to hear stories and narratives regarding this topic, regarding infertility and regarding family building. We talked with residents who current residents who have families who have children. And we had a section of our workshop where they spoke and got to hear their voices heard in the residency. We also had a focus group with women identifying residents to hear their voice. And then we also talked with our LGBTQ plus AOD area of distinction at UCSF. We talked with, with residents in that area of distinction. And from, from our LGBTQ plus colleagues, we heard some ambivalence about this topic and also whether they wanted to have children. They were less interested in the how and the when of having children and more interested in the weather and the why, as far as having whether to have children in the first place. They were interested in our workshop shop, including a family building in its many forms, including extended non-nuclear families, including options for fostering and adoption. So yeah, we just really wanted to make our program as inclusive as possible. And that was really important to everyone on our committee who helped with this. We also developed a pre-survey, which we administered to attendees for the workshop, which we'll talk about more later when we talk about the results of the workshop. Yeah. So overall during these, you know, these small groups were really leveled, had conversations with their co-residents. What we kept hearing is this is a hard topic. This has been a topic that for most of them through med school, we've not given the opportunity to talk about, to hear about, to hear other people's perspectives. And we're feeling alone and we want to talk about it in some way or form. It might be hard, but we're willing, we're willing to do it. And people really emphasize the importance of hearing stories and narratives. So you'll see, well, first of all, I'll show the flyer we had for our workshop. This is our workshop. It was April 27th, 2022, last year. And you can see the title of our workshop, our chosen families. And this is the program we had for the day. And you know, the narratives and stories were super important. We got feedback that the narratives and stories that were shared were some of the most poignant and powerful aspects of the day. I think as we've seen today in the narratives we shared today. So the first part of our workshop, we had a local fertility coach come in and talk about egg freezing, embryo freezing, different fertility options, what IUI and IVF are like. We also had another UCSF OBGYN answer questions from the audience about these topics. And then we also had the resident only panel, as I mentioned, with residents who currently have children talking about their experiences with maternity, paternity leave, et cetera, and what it's been like being a resident with kids. Then we had a series of keynote speakers from senior psychiatry faculty who have been faced with a question about how to have kids, whether to have kids, questions like that. Our speakers came from a diverse set of racial and ethnic backgrounds, diverse set of sexual and gender backgrounds. And we heard about multiple ways that people have chosen to build their families. We heard from one psychiatrist who decided to raise a child with four parents, having four parents raising the child. So it was a lesbian couple and a gay couple who co-parented and raised one child together. We heard about that experience. We heard from one faculty member who decided not to have kids, does not currently have kids. And then we heard from, we also heard about the fostering adoption perspective as well. And, you know, overall I think this really gathered the community together and people reported to us afterwards that they felt less alone. That was ultimately one of the main goals of our workshop. And really for our workshop, it was a start to a conversation, a conversation that is still ongoing and we're about to hear a little bit more about how ongoing this conversation is, but really a start. Really, you know, we don't usually have these spaces in medicine. We usually don't talk about these topics. These topics are usually heavily stigmatized. It's kind of go home, figure it out on your own. Even though we're spending the vast majority of our lives in our work, because our work is important, it's meaningful, but we are complex human beings. We can have multiple different meaningful experiences. And kind of shedding light to these topics, to these questions, and starting those conversations, it was just so important for us to do. After the workshop, we actually surveyed senior faculty members of who felt comfortable being reached out specifically about these topics and we were able to create a flyer of basically these are faculty members, these are attendings who are open and wanting to have these conversations and provided that to our residency, which was also incredibly meaningful. But without further ado, let me bring up Dr. Ruvi Luna to talk about major findings and next steps. Hi, everyone. I'm Ruvi Luna and I will grab that pointer. Oh, it's right here. And it's so nice to see so many of my co-residents here. It's such an honor to be speaking after a wonderful, closer, a little closer, such interesting information, education from Dr. Maglin, the personal narratives from Dr. Morgan and Dr. Zhou, and my co-residents, Martha and Isaac, who have been like honestly siblings to me. I promise that I will wrap up or gear towards wrapping up the session on a more positive note with an optimistic tone. And like I said, I'm Ruvi Luna. I'm a third year resident. But over the last two years of my training, I have actually been quite involved in our residency union in doing advocacy work and organizing residents around advocating for our rights and the benefits that matter the most to us. At UCSF, we have a pretty young union relative to the nurses and other groups of healthcare workers. We are about four to five years old now, and we just negotiated our second contract. Over the course of COVID, it is no surprise that all physicians have experienced burnout from taking care of sicker patients for longer periods of hours. So along with this burnout, we have seen an increase in the number of residency programs that have unionized. And at UCSF, we gathered, and I will show you a photo of our group later on, to take this opportunity to put fertility benefits in our collective bargaining table in 2021 and beginning of 2022. So I'm very proud to say that at UCSF currently, we have 100% membership of union membership in the psychiatry department. Overall, at UCSF, we are at around 73% union membership among residents and 83% union membership around fellows. So I'm here to share some of the major findings of our educational workshop on fertility and family building, but most importantly, I'm going to highlight some of the advocacy work that I took part along with my co-residents in the union to secure fertility benefits for residents across the entire University of California system. And I believe these efforts can be an example for other programs across the country to follow on our footsteps to changing the culture of medical training into a more family-friendly culture. So I'm not going to go into too many of the details of our findings because tomorrow, Dr. Vargas is going to be standing at the poster for like 20 minutes going over all the details of our study. But overall, we had a pretty good turnout from our residency program. A total of 48 residents out of 64 attended the workshop, which for a really heavy call and intense academic program is a pretty good turnout. And the average age of the residents who responded to the survey before the workshop and after the workshop was 33 years old. We had a pretty even distribution of female and male residents in the pre-survey prior to the workshop, and then more females responded the post-workshop survey. And I'm not going to go into the specifics of the post-workshop survey. And among some of the most significant findings were that most residents reported that they and or their partner were currently delaying pregnancy due to their career and financial constraints, or that they hadn't even talked about their family planning decisions or considered fertility preservation. Almost three-quarters found the workshop to be valuable, and they stated that they were interested in learning about other topics related to family building and that this was important to do during training. But what was most reassuring to me from an organizer's point of view was seeing that nearly 50% of the residents expressed some motivation to advocate for family-friendly policies during training, including expanding parental leave or increasing access to fertility preservation in residency. So the main conclusion from our workshop was that implementing a formal curriculum on family building had the potential to provide trainees in psychiatry with the knowledge, the time, the space to think about their own family building decisions, and to foster a more supportive family-friendly culture in a residency program that can ultimately improve the overall educational experience of all residents. But how can we expand these findings from this educational workshop to affect system-level change? The answer is through advocacy and organizing, and this is what I wanted to share, I think, for program leaders in other residencies to learn that it is possible. We must think about this educational awareness efforts in the larger context of medical training, where far too often as residents we just don't have the resources or the time, and with the inflexibility of our programs, it's just impossible to pursue family building when and how we want it. And actually, if you think about it, it's these limitations that exacerbate disparities in the diversity of the healthcare workforce. So, as our union reached the time to bargain our second contract, many of us in the union found this to be an opportunity for us to voice our concerns of how important this meant to us, and we put it on the table early in the year as one of the items that we wanted to bargain on. And fortunately for us, the timing couldn't have been more ideal because thanks to the efforts of other staff at UCSF and faculty members who had started doing advocacy around this topic for years, we came in and we organized. And as residents, we recognized that we have very little power as individuals, but we thought as a group, as a collective group, we actually have a lot more than we can think about. We are good storytellers, we have experiences to share, and we can find and we can identify allies who hear our concerns and who understand us. So, if you look at this ladder, this is the ladder that we actually, it's really small in this screen, but this is the ladder that we use in organizing when thinking of the steps to take to make change. And we came at a fortunate time where this issue had already been placed on the table. So, I gathered with a group of residents from UCLA and UCSF and we looked at this and we thought, well, as a group, we could leverage some of our union political power to identify elected leaders and lobby them and tell them our stories and why this is so important to us and make it really clear to the University of California that this matters to us and that we no longer want to make the choice of choosing between pursuing our careers and building our families. So, next slide, oops, sorry. This is the most exciting one. Let me show you. So, how do you get a group of 10 residents from UCLA and UCSF PGY1 through PGY7 level with the most conflicting call schedules from pediatric cardiology fellows to general surgery residents? We have rheumatology, emergency medicine, and psychiatry together in one room. Well, we found this opportunity to meet with the Lieutenant Governor of California. They turned us away twice because, of course, Eleni Koulanakis is busy working with Gavin Newsom, but we got this opportunity and we persisted and we stayed up very late multiple times working on our stories, the stories that we wanted to share with our leaders. This is the chief of staff, actually, Alexander Reitz, who is in the corner over here. Oh, I am so bad with the, this is Alexander Reitz. She's the chief of staff to the Lieutenant Governor of California, and that's me in action giving the opening statement. And we told her, we told her how much this meant to us for the future of our workforce, for those underrepresented residents who started medicine late, who didn't have the resources, and just how challenging it is to not, for this to not be financially possible for us. And she was receptive. So, so what happened was the Lieutenant Governor, the office called on the UC Office of the President, and they, they pressured them to, to give this to us. A response for proposal was formed in which Dr. Mugglin was actually a part of, and she can tell you more about that experience. It took a, it took a whole year, and we were anxiously waiting for this to come true. But it was through the effort of our collective, collective voices that in March 1st, 2023, so just a little bit over two months ago, we got the good news that all of the residents across the University of California, including UC San Diego, Riverside, LA, Davis, SF, had now access to care at fertility, which is a 30,000 lifetime benefit that we can use not only for infertility treatment, but for any sort of family building decision, including surrogacy, even postpartum care. It's a really comprehensive list that was designed to, for, honestly for making sure that any resident, regardless of their age, gender, orientation, socioeconomic status, could have the resources to, to choose their family when and how they want it. So I will now end there, and I think Dr. Mugglin, if, if, if you would, if you wanted to share with the audience a little bit more about what the response for proposal committee's experience was, you can come in, come here, or from the table. Can you hear me? Yeah, I think from, so from the faculty end, I mean, I've been saying for my entire time at UCSF that I felt like trainees should have coverage, but it was just me saying this, and then nothing really happening so I really think like you have to organize and put pressure on on on the on the UC system in order to have this happen and once there was movement then committee was assembled that I was a part of to figure out what would be the best benefits so we had multiple fertility insurance sort of vendors come and give us over a course of many months their presentations on their fertility insurance plans and we had to decide what would what we thought would be the best option for our trainees so I'm really happy with what we settled on and the fact that it's 30,000 I mean we had a lot of considerations that we wanted to make sure that it was equitable if you wanted to adopt or you wanted to foster or you needed to purchase donor sperm or donor eggs that that 30,000 would or you want to freeze eggs or free sperm that that would all be under that $30,000 plan and the trainees all receive essentially like a debit card and so they don't it was designed so that they don't have to pay anything out of pocket because actually carrot is is a separate sort of fertility provider but many other employers in their area actually utilize carrot as well but a lot of times it's a reimbursement where they have their they have whatever amount that they have but the patient has to has to pay up front and then you collect all your receipts and then submit it for reimbursement through carrot which is great if you have the funds to pay up front so it was really important for us that that was clear too that the trainees would not have to have anything out of pocket from the get-go and if we now have two trainees in the UC system they have a total of $60,000 that they could use between the two of them which is great because a lot of times often insurance companies traditional insurance companies will just say it's 30,000 lifetime max for the for the couple here they each have their own debit cards essentially so really great option and that I hope if you're a UC trainee will take advantage of and if you're not I hope that you will do with what these residents have done and really advocate for for that for your programs oh yes so sort of at the same time concurrently but with different committees that I was not a part of the faculty was getting organized to get faculty coverage so now around the same time the faculty now have coverage as well so actually not just faculty staff in general have coverage the so a lot of my nurses now also have coverage unfortunately the staff plan is not nearly as good so it covers up to two IVF cycles lifetime but at 50% so it ends up being about $10,000 out-of-pocket depending on your plan and your deductible and all of that so most of the time people are still paying $10,000 out-of-pocket per IVF cycle and it does not cover fertility preservation so it's better than not having any coverage but the trainee coverage is actually significantly better at this point you can see this is a you know personal project and I think all of each one of us expressed how how much we enjoyed working on this topic but I don't know if we express how much we worked where we enjoyed working with each other this is one of the dinners we had and it's it's been it's just been a pleasure to have to see each one of you step up and bring all the light that you have inside you and you know reflect it back onto our community now I just wanted to open it up for questions would you come would you mind coming up to the microphone so that our people of attendees on demand can see it sure hi I'm Mara Ackerman I've been attending at NYU in Manhattan thank you for this really important talk I work in the reproductive psychiatry space so thinking about this from a number of different lenses but I'm curious when you talk about these topics being difficult to talk about and also at times frowned upon to talk about and I was wondering about how we change that and you started to talk about with workshop and I think that's a great start but even in recruitment right and often when we're thinking about when being transparent about what benefits are available and it would seem you know in your system now you have this benefit to be able to talk about that can you talk about it is one question I have because I think even discussions around family leave policies and what questions can be asked of applicants you know in terms of family planning they're very sensitive topics should they be you know it's a word of another question why have we made it so that it's so difficult to have these conversations so I guess it's a it's a multi it's a very layered question but sort of like how do we bring this into the fold of conversations for people to feel like they can ask about this and that we make this information accessible so that when people are interviewing and making decisions about residency programs or even about jobs once we're attendings to know if family planning benefits are available I have a couple of thoughts and then I want to open it up to the panel so I think the first reason why the the culture of silence regarding family planning is so prevalent in our in our profession even in in psychiatry is simply because medicine was for men and now women have become a part of the workforce and that's just that's just how it is that's the beginning of it I think more complexly speaking I think there's our society as a whole has started to be more mindful of equity amongst the amongst all the genders and I think it's slowly coming to to medicine as well I think the other thing I was thinking about that you were talking about well what can we tell the interviewees I interview medical students for a residency I cannot ask them anything about you know do you have a partner is this into is it this important to you but I think one place where we could talk about it is so the residents when they meet each other informally they can certainly say hey this is actually a really great thing that just happened without and then you don't you actually can just inform people without having to ask them I mean if you you could say oh we have you you we can talk about the parental leave and all these other things if if they were good sorry so I think that's kind of where I'm gonna leave it I love I love that sass very well-placed I completely agree I think as a society and as you know being part of the inter the interviews for the new app met student applicants now for a couple cycles I am you know I'm it is very nice to see that people are being more aware about these issues and they're being more you know just more real and asking questions about this and I try to do my best to empower these questions because these questions and these topics are very important you know as part of UCSF something we pride ourselves in is trying to recruit and create as a diverse workforce as possible and it's it's one of those things that it's easy to say and it's hard to do and support once they're here and I think these are one of the places where we can support so a lot of what we do you know especially resident to resident is informed this is what we have you don't have to tell me anything about yourself but this is what we have the same way I'm going to tell you this is how we do sick leave here this is how we do parental leave here this is how you know the culture is is it a supportive culture is it a warm is it a more strict kind of keep your business to yourself culture and more and more applicants especially those from you know traditionally financially disadvantaged backgrounds we have to be mindful of these things we don't we don't have the privilege of not being mindful of these things anymore so I think just continuing to kind of normalize those conversations is incredibly incredibly important and normalizing these conversations all the way up as high from the hierarchy as possible like in our workshop we wanted as high we didn't want you know as much as we love them straight out of residency attending we want it attendings high up in the hierarchy because you start normalizing from the top that's how you know it's real and the culture is dramatically changing like for when I was interviewing back you know even a couple years ago back in the day pre-kovat like I wouldn't wear my wedding ring to interviews because I just I didn't want to be seen as someone who was about to just you know be seen in a certain way like I don't even have to say it out loud because that's how the culture was now we can talk about these things a little bit more with more confidence and I think that's a lovely change we need to keep shepherding can I just jump in and say one thing I forgot to say so when I became a faculty member so like three years ago or sorry yeah when I became faculty three years ago and I was going through the IVF process it was Kovat and I thought about should I should I share the fact that I'm going through IVF with the residents and then pretty clearly became pretty fast it became clear that I should tell them because you know I was pretty stressed out and it was already Kovat and it was really nice for the for me to not not have to hide it and to say you know I'm I'm going to going right now to get a transvaginal ultrasound I mean I didn't say that but yeah so it was really it was really great and I think I kind of just I wanted to normalize that for for the residents because I when I was a resident I didn't hear about anybody going through anything and all I just I just heard you know that someone had a baby but I had no idea how that happened how did you schedule this and then and I I think that I just want to empower the residents and ourselves in order to change the culture you just have to talk about stuff and maybe laugh about it maybe not cry too much about it that kind of stuff yeah and organize I also just wanted to add as I was sharing my own journey I was shocked at how many people came forward saying actually I went through this too and people that I would have never suspected and so I think this is happening actually much more commonly than we think but for some reason well as we understand people are not talking about it so I think if we can really open up discussions and and we'll realize actually many people are going through this many of our colleagues are going through this we just didn't know because we weren't because they didn't feel comfortable sharing yet and I'll just that I completely agree with dr. Vargas and dr. Morgan I think we create the culture we are part of the culture it takes a lot of courage to be vulnerable and to share personal stories like what dr. Morgan and what dr. Zoe just did that takes a lot of courage I think setting the example for our medical students this is a conversation that we need to start having much sooner I also think that it is to to a degree at the responsibility of the GME in our union we are working directly with some of the graduate medical education like the Dean for well-being to discuss policies around lactation spaces for example it takes good leaders and it takes a culture of transparency that requires vulnerability to make this become more normal and acceptable but I also think that as psychiatrists we we should also remember and this goes for men male especially male colleagues and female colleagues that this is what our patients go through right like it's such a painful experience for those of our patients who have gone through miscarriages who have who are suffering this is a relatable experience that we should all you know learn more about just from the perspective of caring for other human beings who have uteruses so but I do think it's a collective effort it's it cannot be just one-sided the residents doing the advocacy we need people to lead the way with us receptive leaders and I'm really grateful that at least at UCSF we have we were in a really historic moment that it just all sort of aligned but there's still a lot of work to be done to improve workplace conditions for surgical residents and and organizing is really one way now for me and for many of my co-residents to keep pushing forward with changing the culture so usually in my psychotherapy training and when I go to these talks at APA in the question and answer the common thing the panel often says is seek supervision seek supervision and you know in this case it's really hard to go to your boss and talk about these things that you're personally going through and so that's why we created this workshop in this session so that we could hopefully create some community a comfortable community to talk about these things I Dan Safin I'm the residency program director at one of the Mount Sinai programs in New York City and we're fortunate we have a lot of resources and support for things but I had a question from your purse wanted to hear your perspective on as a PD as supportive as the program is and the well-being and the GME I think I've struggled with over the years as certain classes are not supportive of their peers within their class like I've had some classes that have been really horrible to their peers when they have children and then other classes who've been wonderful and I want I'm always struggling and talking to other PDs about how I can help that dynamic we do trainings we do all this stuff and like I just the milieu of those 13 people per class when they have to cross cover and things sometimes it works really well and sometimes it really ends relationships in a residency so I wanted to gather your thoughts as people who thought about this a lot and advocate in the space because it's heartbreaking as a PD to see that happen within a class and definitely it's not my hope for people in that space this is a big issue that we're actually actively discussing in our we actually just had a conference for our for our Union a few weeks ago it's a huge problem especially even like in the smaller surgical sub specialties where there's only one resident covering for all the people who call out sick I can only speak to my experience in in our residency program and I do think there's this is still a point of tension we have been fortunate I think at least over the last three years I have been here to have had multiple co-residents who paved the way to normalizing you know the necessary coverage that we we have to step up to right I think in an ideal scenario I think the system should be the one to mold to the needs of just human life and and the need for time off I think this is where the culture I think is really really important and possibly a topic to begin exploring intern year when people are just starting residency and they're not as burned out we're unfortunately just not at the place yet in medicine and training where we have access to emergency coverage for call and they can really stretch people thin but what we can do is I think rely on our colleagues and you know just know that if if somebody in my class had to take time off for whatever need they needed whether it's for family building reasons or God forbid you know a medical issue this is this is just all we can do for each other but I do think I in an ideal world we should have an emergency coverage system and and in attending stepping up also not leaving all of this on the backs of the residents to step up for for the load of rest of patients that the residents can't see so it's again the the concept and the theme I think it's this collective effort right to make this possible because we pay it forward to each other I completely agree with what you just said dr. Luna like it's a lot of this is example from the top a lot of it is seeing you know upper class you know classes attendings covering for each other being present for there for for each other while also accepting that it's that's not the ideal situation it's not the situation that we should be content with you know having a bunch of benevolent people being okay taking extra coverage right ideally there would be some sort of backup system or some sort of emergency coverage so that not you know think think surgical classes where it's only three residents two are out for other reasons you have a resident working all the time where situations like that aren't happening you can't you can't create policy for culture it's something that's really hard to do and it's like I said something that comes from the top and it starts from the beginning I do genuinely think that overall we go into medicine because we are healers because we want to help I do think that overall there is no good instincts there but the thing about training is that training is really hard and when you're when I say when your bucket's empty when you were over to young call all the time when you've had bad outcomes it's really hard to pull more out of that it's really really hard to do so so you know and sometimes we see that in in our residency where someone activates jeopardy which is our coverage system because they just they cannot like sometimes you just cannot all right and then you're pulling someone else who's already you know say at 98 that takes them to 99 and we kind of see a domino effect so it's you know training is hard it has been hard for a long time and the question is why does it need to be this hard I think that we need to ask ask ourselves no effort that we advocate as residents is through our Union but we can also you know as we're walking into these attending positions these faculty positions we can say hey we can actually change things we can actually support in other ways just because things were done a certain way beforehand it doesn't mean it has to continue to do that but it is it is a challenging thing that we have so many debates about it is quite challenging it's three o'clock right now thank you everybody for being here and for your attention it's been it's been a really great conversation to have we're gonna stick around for a little bit longer some of us I can stick around for a little bit longer if you have any questions otherwise just to answer how do you change the culture how do you change your class plan plan for them to be out and and help them plan teach them oh okay it's gonna take you three years to get pregnant if you're over 35 let's fit that into your clinical rotation schedule like why why don't we do that this is you know we plan so much for our for our career this is something there should be a part of that planning so when I'll leave you with that thanks everybody

Fertility Preservation

Family Planning

Residency Programs

Infertility Risks

Reproductive Sciences

Advocacy Strategies

Insurance Coverage

Supportive Environments

Mentorship

Policy Reform

Collaborative Advocacy

Systemic Support