Nicole Szell, DO discusses Pelvic Health, disorders and wellness.
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Pelvic Floor Health: Get Comfortable with the Uncomfortable
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Dr. Szell has enjoyed an interest in women’s health as well as Urology from a very early time; she spent several years volunteering, performing research, and later working for the Planned Parenthood Network of the Greater Cleveland area. Women’s health and pelvic floor medicine have been of great interest to her since growing up in Cleveland, Ohio.
Dr. Szell has received several accolades in science and medicine including the MSUCOM non-resident student scholarship for 3 years of medical training. She is a clinical faculty instructor for the Michigan State College of Osteopathic Medicine and a clinical lecturer within the female reproductive course for medical students. Dr. Szell completed a clinical fellowship through the Bladder Health and Reconstructive Urology Institute in Miami Florida. The fellowship includes the areas of voiding dysfunction, female urology, and urologic reconstruction.
Dr. Szell’s clinical interests include female pelvic floor disorders, pelvic organ prolapse, male and female stress incontinence, and male and female sexual dysfunction. She is also interested in general urology including voiding dysfunction, bladder cancer, and kidney stones.
Learn more about Nicole Szell, DO
Nicole M. Szell, DO
Nicole Szell, DO is a board-certified urologist originally from the midwestern area of Cleveland, Ohio. She completed her B.S. in biology and chemistry at Radford University in Radford, VA, and earned her medical degree at the Michigan State College of Osteopathic Medicine in East Lansing, MI. She completed an internship and residency in urological surgery in Detroit, MI through the St. John Providence Health System.Dr. Szell has enjoyed an interest in women’s health as well as Urology from a very early time; she spent several years volunteering, performing research, and later working for the Planned Parenthood Network of the Greater Cleveland area. Women’s health and pelvic floor medicine have been of great interest to her since growing up in Cleveland, Ohio.
Dr. Szell has received several accolades in science and medicine including the MSUCOM non-resident student scholarship for 3 years of medical training. She is a clinical faculty instructor for the Michigan State College of Osteopathic Medicine and a clinical lecturer within the female reproductive course for medical students. Dr. Szell completed a clinical fellowship through the Bladder Health and Reconstructive Urology Institute in Miami Florida. The fellowship includes the areas of voiding dysfunction, female urology, and urologic reconstruction.
Dr. Szell’s clinical interests include female pelvic floor disorders, pelvic organ prolapse, male and female stress incontinence, and male and female sexual dysfunction. She is also interested in general urology including voiding dysfunction, bladder cancer, and kidney stones.
Learn more about Nicole Szell, DO
Transcription:
Introduction: Here's another edition of the BayCare Health System’s podcast series BayCare HealthChat with Melanie Cole.
Melanie Cole: If you experience urinary leakage, pelvic pain or dysfunction, you're not alone. Many women don't want to discuss it with their doctors as they may be too embarrassed to really discuss it, or they think it's a normal part of aging. Welcome to BayCare HealthChat. I'm Melanie Cole and today we're discussing pelvic floor health. Let's get comfortable with discussing the uncomfortable. Joining me is Dr. Nicole Szell, she's Board Certified Urologist at BayCare. Dr. Szell, it's a pleasure to have you join us today. Let's first kind of set the stage. Tell us about the prevalence of pelvic floor disorders. Do you think it's under reported because many people really are hesitant to discuss them? And as someone who's had two babies and is in her fifties, I can tell you coughing and leaking is not that fun.
Dr. Szell: Oh, absolutely. I do feel it's under reported. The statistics are usually anywhere from 30%. I think that's a bit low. It's probably more upwards of 50 to 60%. And if you're going to ask about pelvic floor disorders in general, we're probably going to even go up higher and say at least 65%, if we're going to encompass all of incontinence, all of prolapse and all of pain as well.
Host: Well, it certainly is a pretty broad spectrum of these disorders. Are they a normal part of aging, Dr. Szell? Is that true? Because that's what a lot of people think and they think I can just deal with it. I don't need to see somebody. Are they a normal part of aging? And if they're not, then who's really at risk for them?
Dr. Szell: Well, I think, unfortunately what happens is they start off a little bother, a little annoyance. And for some patients they get worse and worse and worse. And I think the attitude, especially when going through menopause or the change in life is a lot of people say, Oh, this is just a normal part of menopause. It's just a normal part of aging. It's just what I have to deal with. And it becomes a new normal for patients and they learn how to adapt and kind of cope with it. But I think as a physician, I'd like to tell people, you don't have to treat it like that. It doesn't have to be this sort of new normal for you. You know, we can work with things, we can make them better, we can improve quality of life. And that's the important thing, of course, for most patients.
Host: So, you mentioned a few of the disorders and we mentioned a little bit about pelvic pain, dysfunction, obviously incontinence, urinary leakage, idiopathic pain that we don't even know really what it is. Are there some common conditions or factors that lead to some of them? Do we know what causes these kinds of things?
Dr. Szell: Absolutely. So one of the most common themes that you're going to notice throughout this is pregnancy and childbirth. You know, the incidents of incontinence, even just during pregnancy and childbirth increases by anywhere from 40 to 50% in women and after childbirth and after labor, it will kind of go down. But for a lot of women, it stays on, and it worsens and worsens and the more children we have and the more we stress our pelvic floor without trying to combat any of this with exercise or treatment, the worse it gets. Also another common theme that we'll see with a lot of women is surgery. Specifically hysterectomy or any pelvic surgery, anything that's going to interrupt the pelvic floor mechanism is another common theme or common underlying condition. And then another common underlying theme that we'll see is just menopause or perimenopause. The term nowadays, I think is actually called genital urinary syndrome of menopause. That's the proper term that we use that kind of encompasses changes that happen in the body with hormones and in the pelvic floor, as we start to lose a lot of that hormone balance that we've had for most of our lives. So I think these are probably the three of the most common underlying causes that we see.
Host: I think the big question is when do you seek help? Who treats pelvic floor disorders? So I'd like you to discuss the multidisciplinary approach to treating them because there are many health care providers that work with people that have, and we're not only talking about women, right? Men get some of these as well, especially if they've had prostate issues. But when do you feel it's important for women specifically to really seek help? When do we do something about it?
Dr. Szell: Well, I think for most women, I see a huge spectrum of it. I see a lot of women who come to me and say, I didn't even know I had this. Another physician told me, they said, I should see someone. So I'm coming to see you. What do I do? And I think the key that we need to assess from all patients is how much does it bother you? And really what we're looking at here is bothered, because I have so many women who are bothered by it and they seek out help, which is fantastic. And then I have so many women who are not bothered by it and are sort of forced into this - well you need to do something about it. Well, if it's not bothersome and it's not effecting their quality of life, we might be able to go with some more natural or more conservative therapies. And then I think that there are quite a few women who just don't talk about it until somebody else mentions it.
And I feel with a lot of my patients, what ends up happening or what I've heard commonly is that, Oh, I was talking to one of my friends and she just happened to mention to me that she also has this and she was seeing someone. And I think that really opens up the door for a lot of patients, especially women and men, especially men and in Florida. You know, I think the most common thing I hear is, I was golfing with my friend and he mentioned this to me. And so I think a lot of people are kind of collaborating about it, talking about it, which is a good thing. And people sort of tend to realize, Oh, when other people have this problem, now I can come out and talk about it. Now I can go seek help. Now I can try to change things and make life better for myself. So I think everybody's different and everybody's different as far as their comfort level. And it's important for doctors to know that too.
Host: Well I agree, and I think that it's also important for women to feel comfortable enough with their health care providers, whether it's a urologist or a urogynecologist, somebody that they can talk to and let them know that this is going on. Let's discuss some treatments. First, tell us about some of the nonsurgical. We women have been hearing about Kegel or “Key-gul” (however you pronounce it) for so many years and not a lot of women really do it properly. They don't know how to do it. Tell us about some of the treatments that you might try with someone first.
Dr. Szell: Absolutely. And I just wanted to touch on, because you had asked the specific question about multidisciplinary. And I think that is rather important because I think that a lot of doctors can be approached that you're going to be seeing every day from primary care to family medicine, to gynecology, to urology, to general surgery, to colorectal, to GI specialists. All of these are doctors that are going to help in this area. We're not limited at all by the scope of our practice because we can all help. So that's important to know first off, and then the conservative therapies, lifestyle changes. That's first line. That's what we're going to start talking about with patients. So if there are certain foods or things like that, that bother you, I have, for instance, caffeine and alcohol. Caffeine and alcohol act as natural diuretics, they also irritate the bladder. And there are some people who are extremely sensitive to having any alcohol or any caffeine or even chocolate, which has a ton of caffeine in it.
They have a little bit of it and then suddenly their urgency and their frequency to urinate goes up tenfold. And that's pretty common. One of the first things is to talk about trying to avoid some of those stressors or spicy foods or very acidic foods. For some people [these] can irritate the bladder. So avoiding some of those stressors for them. Stopping fluids before they go to bed at nighttime. This is a big one because we will take a big cup of water and put it next to our bed and drink it all night. But if you're actively waking up and drinking, then at some point you're probably going to be waking up in and urinating too. So if that's bothersome, stopping your fluids at least an hour or two before you go to bed can be helpful. We'll talk about specifically Kegels and you are saying it correctly. It's Kegels [key-guls]. They are very infamous and the way to properly do a Kegel at home is when you are urinating.
If you try to squeeze your pelvic floor muscles and you're able to actually stop your urinary stream midstream. If you're able to do that, then you're able to properly do a Kegel. And those are the muscles that you want to isolate. I think a lot of times patients end up clenching more posterior muscles. And so the best test is when you are forming a urinary stream, if you squeeze those muscles, and if you're able to cut off your stream, that's the best way to know that you're doing it correctly. And to practice those on a very regular basis, practice them quickly, practice them slowly, practice sustaining holds. Those are all good ways to practice your Kegels. So very conservative therapy. And whenever you'd like, I'm happy to talk about pelvic floor physical therapy too, because I think that's a fantastic treatment.
Host: Well, it certainly is. And we can touch on it, but you’re a urologist and I'd like to touch on some of the things that you might try. If someone goes to pelvic floor physical therapy and it doesn't work, people hear about mesh slings, they hear about pessaries, medications, they're all over the, you know, the commercials we see. Ladies on the golf course and the medications that they're taking. Tell us where procedures fit into this and when does that discussion take place.
Dr. Szell: So, I think it's important when you come in for the initial patient interview, the best thing for a clinician to figure out is what bothers you most and kind of target it from there. I have a lot of patients who've come in and said, I've been doing Kegels for years. They do nothing for me. I'm not interested in pelvic floor PT because I've had it or I've done it. My Kegels aren't helping. So specifically for leakage of urine, with sneezing, coughing, laughing, the gold standard is, and probably always will be a sling, which is a surgical procedure, which is still FDA approved. And we do normally use mesh. And I know that there's a great deal of controversy on that, but I will tell you that the controversy came from using older mesh. And it also came from using mesh for prolapse specifically and not for stress incontinence. So a sling is still the gold standard, still FDA approved for leakage of urine, with coughing, sneezing, laughing, stress incontinence.
Some of the best treatments that we have for leakage with running for the bathroom, constantly getting up a lot at night, is medication. First line medication, specifically the newer ones. If you watch those commercials with the little bladder holding onto somebody's hand, Myrbetriq is one of the better medications that we have as a tool in our arsenal nowadays for this complaint. And prolapse, we talk about conservative therapy with pessaries, which come in all different shapes and sizes to fit our patients and have to be properly sized. And those help kind of hold up their prolapse. So they have less of that sensation like everything's falling out or falling down. When pessaries are not working, or women are not interested, then we talk about surgical repair of the prolapse, which can be done with a vaginal approach or with an open abdominal approach, which is considered, I think, these days robotically, using the DaVinci robot is considered the gold standard for a lot of our prolapse surgeries. That is the long and short of those treatments.
Host: Well, another treatment that we're hearing about is Botox. Can you tell us where that fits into this picture?
Dr. Szell: So, a lot of our urgency frequency patients and our patients that are constantly running for the bathroom, they've tried cutting out caffeine. They've tried medications. They're not helped by just these conservative therapies. One of the best third line treatments we have is Botox, which Botox is used for all kinds of things medically nowadays, but it's considered a fantastic treatment. It can be done in the office. It takes about 30 to 45 seconds. It does not require full anesthesia or a hospital visit or a hospital stay, which is awesome. And that can be done in the office. And about 30 to 45 seconds with a little bit of local anesthesia only, and patients are really doing well with this and it can be done, you know, as often as every couple months is needed. And I have some patients who get their Botox once a year and some patients who get it every couple months, it's variable, but it's a fantastic treatment. It's easy, it's quick. I think it's very easy to maintain. And for most patients it's extremely comfortable and extremely tolerable.
Host: As we wrap up, Dr. Szell, this is really great information for women to hear because we don't often hear it laid out the way you've done that for us today. Wrap it up with your best advice for people that are suffering from pelvic floor disorders and what you want them to know about not hesitating to discuss it with their health care providers and the importance of exploring all these options that you've told us about today.
Dr. Szell: Absolutely. You have to do whatever you feel comfortable with and just know that you're not alone. I have lots of women come in and every single day they look at me and say, are you sure you've had to deal with this before? And I look at them and I say, I will see exactly 10 to 20 other women just like you with the same complaint all day today, you're not alone. It's common. It happens and we can help. And there are lots and lots of people that can help and we'll figure out how to get you to the right person at the right time. And we will tailor your treatment to you.
Host: Beautifully put, Dr. Szell. Thank you so much for joining us today and sharing your incredible expertise on this pretty sensitive topic. Thank you again. To learn more about BayCare's pelvic health and wellness programs, please visit BayCare.org. That concludes this episode of BayCare HealthChat. Please also remember to subscribe, rate, and review this podcast and all the other BayCare podcasts. I'm Melanie Cole.
Introduction: Here's another edition of the BayCare Health System’s podcast series BayCare HealthChat with Melanie Cole.
Melanie Cole: If you experience urinary leakage, pelvic pain or dysfunction, you're not alone. Many women don't want to discuss it with their doctors as they may be too embarrassed to really discuss it, or they think it's a normal part of aging. Welcome to BayCare HealthChat. I'm Melanie Cole and today we're discussing pelvic floor health. Let's get comfortable with discussing the uncomfortable. Joining me is Dr. Nicole Szell, she's Board Certified Urologist at BayCare. Dr. Szell, it's a pleasure to have you join us today. Let's first kind of set the stage. Tell us about the prevalence of pelvic floor disorders. Do you think it's under reported because many people really are hesitant to discuss them? And as someone who's had two babies and is in her fifties, I can tell you coughing and leaking is not that fun.
Dr. Szell: Oh, absolutely. I do feel it's under reported. The statistics are usually anywhere from 30%. I think that's a bit low. It's probably more upwards of 50 to 60%. And if you're going to ask about pelvic floor disorders in general, we're probably going to even go up higher and say at least 65%, if we're going to encompass all of incontinence, all of prolapse and all of pain as well.
Host: Well, it certainly is a pretty broad spectrum of these disorders. Are they a normal part of aging, Dr. Szell? Is that true? Because that's what a lot of people think and they think I can just deal with it. I don't need to see somebody. Are they a normal part of aging? And if they're not, then who's really at risk for them?
Dr. Szell: Well, I think, unfortunately what happens is they start off a little bother, a little annoyance. And for some patients they get worse and worse and worse. And I think the attitude, especially when going through menopause or the change in life is a lot of people say, Oh, this is just a normal part of menopause. It's just a normal part of aging. It's just what I have to deal with. And it becomes a new normal for patients and they learn how to adapt and kind of cope with it. But I think as a physician, I'd like to tell people, you don't have to treat it like that. It doesn't have to be this sort of new normal for you. You know, we can work with things, we can make them better, we can improve quality of life. And that's the important thing, of course, for most patients.
Host: So, you mentioned a few of the disorders and we mentioned a little bit about pelvic pain, dysfunction, obviously incontinence, urinary leakage, idiopathic pain that we don't even know really what it is. Are there some common conditions or factors that lead to some of them? Do we know what causes these kinds of things?
Dr. Szell: Absolutely. So one of the most common themes that you're going to notice throughout this is pregnancy and childbirth. You know, the incidents of incontinence, even just during pregnancy and childbirth increases by anywhere from 40 to 50% in women and after childbirth and after labor, it will kind of go down. But for a lot of women, it stays on, and it worsens and worsens and the more children we have and the more we stress our pelvic floor without trying to combat any of this with exercise or treatment, the worse it gets. Also another common theme that we'll see with a lot of women is surgery. Specifically hysterectomy or any pelvic surgery, anything that's going to interrupt the pelvic floor mechanism is another common theme or common underlying condition. And then another common underlying theme that we'll see is just menopause or perimenopause. The term nowadays, I think is actually called genital urinary syndrome of menopause. That's the proper term that we use that kind of encompasses changes that happen in the body with hormones and in the pelvic floor, as we start to lose a lot of that hormone balance that we've had for most of our lives. So I think these are probably the three of the most common underlying causes that we see.
Host: I think the big question is when do you seek help? Who treats pelvic floor disorders? So I'd like you to discuss the multidisciplinary approach to treating them because there are many health care providers that work with people that have, and we're not only talking about women, right? Men get some of these as well, especially if they've had prostate issues. But when do you feel it's important for women specifically to really seek help? When do we do something about it?
Dr. Szell: Well, I think for most women, I see a huge spectrum of it. I see a lot of women who come to me and say, I didn't even know I had this. Another physician told me, they said, I should see someone. So I'm coming to see you. What do I do? And I think the key that we need to assess from all patients is how much does it bother you? And really what we're looking at here is bothered, because I have so many women who are bothered by it and they seek out help, which is fantastic. And then I have so many women who are not bothered by it and are sort of forced into this - well you need to do something about it. Well, if it's not bothersome and it's not effecting their quality of life, we might be able to go with some more natural or more conservative therapies. And then I think that there are quite a few women who just don't talk about it until somebody else mentions it.
And I feel with a lot of my patients, what ends up happening or what I've heard commonly is that, Oh, I was talking to one of my friends and she just happened to mention to me that she also has this and she was seeing someone. And I think that really opens up the door for a lot of patients, especially women and men, especially men and in Florida. You know, I think the most common thing I hear is, I was golfing with my friend and he mentioned this to me. And so I think a lot of people are kind of collaborating about it, talking about it, which is a good thing. And people sort of tend to realize, Oh, when other people have this problem, now I can come out and talk about it. Now I can go seek help. Now I can try to change things and make life better for myself. So I think everybody's different and everybody's different as far as their comfort level. And it's important for doctors to know that too.
Host: Well I agree, and I think that it's also important for women to feel comfortable enough with their health care providers, whether it's a urologist or a urogynecologist, somebody that they can talk to and let them know that this is going on. Let's discuss some treatments. First, tell us about some of the nonsurgical. We women have been hearing about Kegel or “Key-gul” (however you pronounce it) for so many years and not a lot of women really do it properly. They don't know how to do it. Tell us about some of the treatments that you might try with someone first.
Dr. Szell: Absolutely. And I just wanted to touch on, because you had asked the specific question about multidisciplinary. And I think that is rather important because I think that a lot of doctors can be approached that you're going to be seeing every day from primary care to family medicine, to gynecology, to urology, to general surgery, to colorectal, to GI specialists. All of these are doctors that are going to help in this area. We're not limited at all by the scope of our practice because we can all help. So that's important to know first off, and then the conservative therapies, lifestyle changes. That's first line. That's what we're going to start talking about with patients. So if there are certain foods or things like that, that bother you, I have, for instance, caffeine and alcohol. Caffeine and alcohol act as natural diuretics, they also irritate the bladder. And there are some people who are extremely sensitive to having any alcohol or any caffeine or even chocolate, which has a ton of caffeine in it.
They have a little bit of it and then suddenly their urgency and their frequency to urinate goes up tenfold. And that's pretty common. One of the first things is to talk about trying to avoid some of those stressors or spicy foods or very acidic foods. For some people [these] can irritate the bladder. So avoiding some of those stressors for them. Stopping fluids before they go to bed at nighttime. This is a big one because we will take a big cup of water and put it next to our bed and drink it all night. But if you're actively waking up and drinking, then at some point you're probably going to be waking up in and urinating too. So if that's bothersome, stopping your fluids at least an hour or two before you go to bed can be helpful. We'll talk about specifically Kegels and you are saying it correctly. It's Kegels [key-guls]. They are very infamous and the way to properly do a Kegel at home is when you are urinating.
If you try to squeeze your pelvic floor muscles and you're able to actually stop your urinary stream midstream. If you're able to do that, then you're able to properly do a Kegel. And those are the muscles that you want to isolate. I think a lot of times patients end up clenching more posterior muscles. And so the best test is when you are forming a urinary stream, if you squeeze those muscles, and if you're able to cut off your stream, that's the best way to know that you're doing it correctly. And to practice those on a very regular basis, practice them quickly, practice them slowly, practice sustaining holds. Those are all good ways to practice your Kegels. So very conservative therapy. And whenever you'd like, I'm happy to talk about pelvic floor physical therapy too, because I think that's a fantastic treatment.
Host: Well, it certainly is. And we can touch on it, but you’re a urologist and I'd like to touch on some of the things that you might try. If someone goes to pelvic floor physical therapy and it doesn't work, people hear about mesh slings, they hear about pessaries, medications, they're all over the, you know, the commercials we see. Ladies on the golf course and the medications that they're taking. Tell us where procedures fit into this and when does that discussion take place.
Dr. Szell: So, I think it's important when you come in for the initial patient interview, the best thing for a clinician to figure out is what bothers you most and kind of target it from there. I have a lot of patients who've come in and said, I've been doing Kegels for years. They do nothing for me. I'm not interested in pelvic floor PT because I've had it or I've done it. My Kegels aren't helping. So specifically for leakage of urine, with sneezing, coughing, laughing, the gold standard is, and probably always will be a sling, which is a surgical procedure, which is still FDA approved. And we do normally use mesh. And I know that there's a great deal of controversy on that, but I will tell you that the controversy came from using older mesh. And it also came from using mesh for prolapse specifically and not for stress incontinence. So a sling is still the gold standard, still FDA approved for leakage of urine, with coughing, sneezing, laughing, stress incontinence.
Some of the best treatments that we have for leakage with running for the bathroom, constantly getting up a lot at night, is medication. First line medication, specifically the newer ones. If you watch those commercials with the little bladder holding onto somebody's hand, Myrbetriq is one of the better medications that we have as a tool in our arsenal nowadays for this complaint. And prolapse, we talk about conservative therapy with pessaries, which come in all different shapes and sizes to fit our patients and have to be properly sized. And those help kind of hold up their prolapse. So they have less of that sensation like everything's falling out or falling down. When pessaries are not working, or women are not interested, then we talk about surgical repair of the prolapse, which can be done with a vaginal approach or with an open abdominal approach, which is considered, I think, these days robotically, using the DaVinci robot is considered the gold standard for a lot of our prolapse surgeries. That is the long and short of those treatments.
Host: Well, another treatment that we're hearing about is Botox. Can you tell us where that fits into this picture?
Dr. Szell: So, a lot of our urgency frequency patients and our patients that are constantly running for the bathroom, they've tried cutting out caffeine. They've tried medications. They're not helped by just these conservative therapies. One of the best third line treatments we have is Botox, which Botox is used for all kinds of things medically nowadays, but it's considered a fantastic treatment. It can be done in the office. It takes about 30 to 45 seconds. It does not require full anesthesia or a hospital visit or a hospital stay, which is awesome. And that can be done in the office. And about 30 to 45 seconds with a little bit of local anesthesia only, and patients are really doing well with this and it can be done, you know, as often as every couple months is needed. And I have some patients who get their Botox once a year and some patients who get it every couple months, it's variable, but it's a fantastic treatment. It's easy, it's quick. I think it's very easy to maintain. And for most patients it's extremely comfortable and extremely tolerable.
Host: As we wrap up, Dr. Szell, this is really great information for women to hear because we don't often hear it laid out the way you've done that for us today. Wrap it up with your best advice for people that are suffering from pelvic floor disorders and what you want them to know about not hesitating to discuss it with their health care providers and the importance of exploring all these options that you've told us about today.
Dr. Szell: Absolutely. You have to do whatever you feel comfortable with and just know that you're not alone. I have lots of women come in and every single day they look at me and say, are you sure you've had to deal with this before? And I look at them and I say, I will see exactly 10 to 20 other women just like you with the same complaint all day today, you're not alone. It's common. It happens and we can help. And there are lots and lots of people that can help and we'll figure out how to get you to the right person at the right time. And we will tailor your treatment to you.
Host: Beautifully put, Dr. Szell. Thank you so much for joining us today and sharing your incredible expertise on this pretty sensitive topic. Thank you again. To learn more about BayCare's pelvic health and wellness programs, please visit BayCare.org. That concludes this episode of BayCare HealthChat. Please also remember to subscribe, rate, and review this podcast and all the other BayCare podcasts. I'm Melanie Cole.