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Transcript

Rectal Is Not a Last Resort · Pelvic PT Rising

• 0:02
  Speaker 1: In the last 10 years, our field has gone from an unknown specialty to a household name.
• 0:09
  Speaker 1: This brings unprecedented opportunities, but we need to rise up to meet them and give our patients the care that they deserve.
• 0:17
  Speaker 1: In order to help others get better, we need to be better.
• 0:23
  Speaker 1: This podcast will help you to become more confident with your patients, more successful in your practice or business and a leader in pelvic health, and we're going to have some fun along the way.
• 0:36
  Speaker 1: Join us as we rise together.
• 0:39
  Speaker 1: We're Jesse and Nicole Cozine, founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Huddle, and this is Pelvic PT Rising.
• 0:53
  Speaker 2: Hey guys, welcome back to another episode of the Pelvic PT Rising podcast with Jesse and Nicole Cozine.
• 0:58
  Speaker 2: Hey, nicole, all right.
• 1:00
  Speaker 2: Well, we are going to be talking a lot of October in anticipation of opening up your rectal course to the second cohort to go through there, a lot about rectal evaluation and treatment and whether or not you join us for that cohort or not.
• 1:15
  Speaker 2: We hope you get a lot out of this because I know, nicole, rectal treatment is something you think is one of the most important and most overlooked things in pelvic health.
• 1:23
  Speaker 1: I do and you know it's really interesting.
• 1:26
  Speaker 1: We also presented this at the International Pelvic Pain Society a while back and people are coming into pelvic floor therapy with complaints other than primary bowel complaints.
• 1:38
  Speaker 1: But what was the percentage, jess?
• 1:41
  Speaker 2: Oh, it was almost.
• 1:42
  Speaker 2: Yeah, 73% of people who came in for other things had a pretty significant, serious bowel issue that they weren't coming to pelvic rehab for, but that was obviously impacting their case and in 69% of those cases it was actually constipation, which should surprise exactly no one.
• 2:01
  Speaker 1: Right and so, but the thing that we're going to talk about today is that, even if somebody doesn't have a bowel complaint, even if somebody doesn't have a primary bowel diagnosis, why is it important to consider rectal treatment as part of your pelvic floor therapy?
• 2:18
  Speaker 2: So we're going to dive into that and why rectal should not be a last resort.
• 2:22
  Speaker 2: If you guys are interested in joining I know so many of you guys have already done this.
• 2:25
  Speaker 2: But if you go to pelvicptrisingcom slash rectal, there is a wait list for that cohort.
• 2:31
  Speaker 2: You'll get $50 off.
• 2:32
  Speaker 2: You'll get a live Q&A with Nicole.
• 2:34
  Speaker 2: If you were part of the first cohort you will also have the chance to sit in on that live Q&A, although we will prioritize the questions from those in the second cohort.
• 2:42
  Speaker 2: So make sure you head to pelvicptrisingcom slash rectal if this is interesting to you.
• 2:47
  Speaker 2: So, nicole, one thing I heard you say that was a little bit when we were doing this the first time in your course.
• 2:54
  Speaker 2: I mean rectal evaluation and treatment is looking at it's literally half of the pelvic floor.
• 3:01
  Speaker 1: It is and I think that if you simply state it like that, it's kind of shocking that we don't all assess it in our patients.
• 3:12
  Speaker 1: But we have the urogenital triangle and then we have the anal triangle, and the urogenital triangles is superficial pelvic floor muscles, it's some of the urethral pelvic floor muscles, and the anal triangle is most of the levator anion.
• 3:27
  Speaker 1: And so when you think about just because if someone has two access points, just because you can feel some of the anal triangle musculature through the vaginal opening, doesn't mean that you can feel it the best way there.
• 3:43
  Speaker 1: And it's a lot of times if you actually do a transrectal assessment, then you are actually getting more accurate pelvic floor muscle information from that assessment.
• 4:00
  Speaker 2: So let me tease out something there.
• 4:01
  Speaker 2: So you, as a skilled pelvic therapist, could do a vaginal exam and feel as best you could with those muscles.
• 4:10
  Speaker 2: Then you would do a rectal assessment and you might feel something completely different.
• 4:17
  Speaker 1: The answer to that is absolutely yes.
• 4:19
  Speaker 1: There have been more times.
• 4:20
  Speaker 1: So there's two times where I'm tricked quite a bit in pelvic floor therapy, and that is not doing a standing assessment, which is all about which I'd have a whole course on that, and not doing rectal.
• 4:32
  Speaker 1: I cannot tell you how many times I have been able to assess something in a different way or found something or reproduce somebody's symptoms directly by doing a rectal assessment that I, if I would have just assumed that, oh, I'm feeling everything good enough through a transvaginal assessment, I would have gotten completely bamboozled.
• 4:57
  Speaker 1: And I cannot tell you how many times I've been surprised when I started to do this more frequently and I started to just do this on every patient that we would talk about with this and that they would say, yeah, sure, let's do it.
• 5:10
  Speaker 1: And I cannot tell you how many times I found something different or I was just surprised by what I was finding.
• 5:18
  Speaker 1: It is a different way of assessing the pelvic floor and specifically levator ani.
• 5:23
  Speaker 2: And so that brings up a good point then.
• 5:25
  Speaker 2: So of your patients and I know you see a wide variety of different people, from pregnancy, postpartum, to pelvic pain, to orthopedic pelvic girdle issues, whatever it is, what percentage of those on a whole half pun?
• 5:42
  Speaker 1: very much intended, oh my.
• 5:45
  Speaker 2: Would.
• 5:45
  Speaker 2: Yeah, if you guys had the over under on five minutes in, it actually was over.
• 5:50
  Speaker 2: I think I deserve a medal for that.
• 5:52
  Speaker 2: Really, we're talking a whole rectal thing and I don't get a pun in until after five minutes into the podcast.
• 5:57
  Speaker 2: That's not bad, pretty good.
• 5:59
  Speaker 2: So what percentage of people would you say that you do a rectal evaluation and treatment on?
• 6:05
  Speaker 1: I would say on the whole, 75 to 80% of patients get a rectal exam and I would say that is heavily weighted towards the front end of their therapy and that's where I feel like a lot of us miss things as well.
• 6:26
  Speaker 2: Yeah, you can't leave rectal till the back end.
• 6:28
  Speaker 1: Okay, you guys, this is my life and it's really terrible sometimes and I can't handle it.
• 6:35
  Speaker 1: He's like actually cracking up.
• 6:38
  Speaker 2: When you said front end, I mean you knew it had to be coming Guys.
• 6:43
  Speaker 2: So 75 to 80% though.
• 6:44
  Speaker 2: So that's again not as a last resort, not late in their treatment after everything else has failed, but this is early on, right.
• 6:52
  Speaker 2: This is in the first.
• 6:52
  Speaker 2: What?
• 6:53
  Speaker 2: How many visits?
• 6:54
  Speaker 1: I do it.
• 6:55
  Speaker 1: You know you guys have the different phases.
• 6:57
  Speaker 1: I usually do it in the figure it out phase because you're literally figuring it all out.
• 7:02
  Speaker 1: That's where you're finding the why, that's where you are doing all of your investigation.
• 7:09
  Speaker 1: And to me, if you're not doing this assessment, you're also guessing in a lot of that way and you can't guess.
• 7:18
  Speaker 1: We just cannot guess.
• 7:20
  Speaker 1: And so I just feel like it's so important and we're doing it in that figured out phase, which for me is in the first, like three to five visits of meeting somebody.
• 7:30
  Speaker 2: And one of the reasons that you created this course is because, I mean, we see a lot of out of town patients, patients who have been to other places and come for a second opinion, or because they're so challenging.
• 7:41
  Speaker 2: And one of the big things that you were noticing is that, almost universally, rectal evaluation treatment had not been either not been done at all or had been a very cursory, not truly addressed.
• 7:55
  Speaker 1: Yeah.
• 7:55
  Speaker 1: So just to back up a half a beat for those of you who may not know hopefully you do, but just in case you don't know, we own a clinic, pelvic Sanity.
• 8:02
  Speaker 1: That is in Orange County, california.
• 8:05
  Speaker 1: We have six therapists.
• 8:07
  Speaker 1: We're rocking it's in person and as part of that, partly because I wrote the book, the IC Solution, we get a lot of requests for patients out of California to come to Pelvic Sanity.
• 8:21
  Speaker 1: So over the course of the almost eight years Pelvic Sanity has been in practice, we've seen patients from literally every continent except for Antarctica.
• 8:31
  Speaker 2: Right, if you guys know anyone from Antarctica, you can actually come to Pelvic Sanity for free, just so we can say it's been every continent on the planet.
• 8:40
  Speaker 1: But it's well over a hundred patients that have actually flown in for either one, two, three or sometimes even a month long program.
• 8:47
  Speaker 1: The other thing that I've done that is also increased my ability to sort of see what other folks are going through, as from a patient standpoint, is that we have a remote consultation program, and so I've talked to not only have I treated a lot of patients from out of town, but I've also talked to hundreds more patients that have been to Pelvic floor therapy that are that, essentially because they're talking to me, they like know it work, they know it can work, they know it's working enough, but then they just can't get over that plateau.
• 9:20
  Speaker 1: Or some they're just wanting to make sure, some they're not missing anything, and in my line of questioning for them, most of the time I'm finding that there is been a either rectal exam has not been completed or it has only once and it was never revisited again.
• 9:41
  Speaker 1: So that's sort of the genesis of where the rectal course came.
• 9:45
  Speaker 1: I kept getting frustrated that I'm like gosh, what in the world?
• 9:49
  Speaker 1: Like I just wish for all my remote consultation folks.
• 9:51
  Speaker 1: I'm like man, I just really want to.
• 9:52
  Speaker 1: I really want to assess those people.
• 9:54
  Speaker 1: That's what they need, and I was.
• 9:56
  Speaker 1: I was giving that advice back to them, and one of the things on their action plan to go back was you know, ask your pelvic floor therapist, could you please do a rectal exam?
• 10:06
  Speaker 1: Or ask them, why hasn't one been done?
• 10:08
  Speaker 1: Is there a reason for that?
• 10:10
  Speaker 1: Knowing that like they should say no, we can do it right.
• 10:14
  Speaker 1: And so I would actually have a lot of follow-up visits after that as well, and those people would be like, oh yeah, why hasn't my therapist done that?
• 10:23
  Speaker 1: And I'm like I don't know.
• 10:24
  Speaker 1: Ask them.
• 10:25
  Speaker 1: And a lot of times people would say when I in my follow-up with the remote consultation, they would say, oh well, they didn't think that I it either wasn't important, or they were like oh, I didn't think you wanted to do that.
• 10:38
  Speaker 1: And so you know, I usually wait till the end to do that in case.
• 10:41
  Speaker 1: And so it was just one of those things where I was like I just need to put out a course for this because we need to all stop.
• 10:49
  Speaker 2: Yeah, and be talking about it on the podcast and hopefully have you guys do a little bit of, as Nicole would say, assess to address.
• 10:55
  Speaker 2: But what percentage of your patients are you comfortable doing rectal with?
• 11:00
  Speaker 2: And so when we talk about it as the last resort, we see that a lot.
• 11:04
  Speaker 2: I feel like there's three ways that that manifests as a last resort.
• 11:08
  Speaker 2: One is that you're just not doing it right, and we'll go into the reasons why that might be, but you're just not doing rectal.
• 11:13
  Speaker 2: The second is you might be doing rectal when there's no other choice.
• 11:17
  Speaker 2: So male patients are patients with only one access point or super obvious things, right, crazy constipation, whatever.
• 11:26
  Speaker 2: That is where they actually come in with a very significant bowel thing.
• 11:28
  Speaker 2: Or the third is where it's a Hail Mary at the very end of your treatment stuff, where you've gone through everything else you can do and you haven't gotten kind of like what you were just saying, to call about those out of town patients.
• 11:41
  Speaker 1: Oh well, I guess we'll do that now we've exhausted all other literally every other option, and that is just doing such a disservice to patients, and so it's one of the reasons why I wanted to Challenge everybody with the course and, honestly, this podcast to think about when, in the plan of care, you presenting this Option for patients and it truly is an option for treatment, and so it's like it's one of those things and I really just want Everybody to assess when they're doing it and if they're doing it towards the latter portion of the plan of care, like, move that up in your potential options for assessing, and if you don't take anything else away from this podcast, take away that is that I want you to be thinking about.
• 12:25
  Speaker 1: It's literally half the pelvic floor.
• 12:27
  Speaker 1: The anal opening is a great way to assess in a very different way the posterior part of the public floor in the anal triangle.
• 12:34
  Speaker 1: It's an easier way to access the tailbone, which is literally attachment point to almost all the public floor muscles and it's such a huge end point for the spine and any low back dysfunction and stuff like.
• 12:46
  Speaker 1: It is so important to be able to assess that area in an accurate way, and it's just not as accurate to try to palpate those tissues and those structures transvaginally.
• 13:00
  Speaker 1: And so if you have the ability to do a more thorough assessment, then you should.
• 13:06
  Speaker 2: Yes, so let's go into Nicole.
• 13:08
  Speaker 2: I think we came up with three reasons why it is a last resort for people, and one is what you just said is they don't think it's that important.
• 13:16
  Speaker 2: I can get all the same things Intervaginally, so why would we do rectal?
• 13:22
  Speaker 1: okay question and then also the answer is that it is actually that important and you can't knock it until you try it.
• 13:29
  Speaker 1: Like I just said in the beginning of the podcast, I cannot tell you how many times I've been surprised when everything quote feels fine transvaginally, you go trans rectally and it's a mess and so so that would be anybody who ever says, oh, their pelvic floor was fine, even though they had symptoms.
• 13:47
  Speaker 2: Probably is not done erectile as I know.
• 13:49
  Speaker 1: It's like nails on a chalkboard to me.
• 13:51
  Speaker 1: I that phrase.
• 13:53
  Speaker 1: I hate it.
• 13:54
  Speaker 1: In fact I don't let my therapist say that a couple things.
• 13:58
  Speaker 1: We don't say a public standing, we don't say my schedules falling apart, and we don't say their public floor seemed fine.
• 14:04
  Speaker 1: It's like was it fine?
• 14:06
  Speaker 1: And what does fine mean?
• 14:08
  Speaker 1: And if you're saying that there's no problem and then it's completely normal, then that also includes erectile assessment, because it can't be, it's like so rare that it's like quote unquote, fine.
• 14:21
  Speaker 1: When they're in there for public floor problem, like it's bad enough so that their public floor, the thing that your body is preserving From an autonomic standpoint, to work, because it involves like things that we need to live, being pooping, sex procreation, like those things are prioritized in our body and when something is a rye in one of those regions or one of those areas, something's very wrong.
• 14:49
  Speaker 1: And which is why far folks that have these public floor dysfunctions are so destabilized, sometimes emotionally as well, because it is, it's a very, very core of our being and Gosh, it's just like when we're only assessing half of it, it's doing their patients such a disservice.
• 15:09
  Speaker 2: So it is that important Hopefully we can debunk that reason why it's a last resort.
• 15:14
  Speaker 2: For a lot of you, though, it hasn't been taught, or I think this is really important.
• 15:18
  Speaker 2: We talked about this with Jake Bartholomew, who had taught for the Hermitahualis series early on, was one of the first male instructors there.
• 15:24
  Speaker 2: But the way that things are often taught and you actually, nicole, had an advantage in this, in the way that you were trained, also in having a mentor who was able to help, but you went through a lot of the early courses very quickly.
• 15:38
  Speaker 2: I think a lot of people out there who are listening go through pelvic floor one where we pretend that the rectum doesn't exist, basically right and then go back and they treat, and they treat for six months, for a year, for several years, and then maybe they go back for their rectal course.
• 15:57
  Speaker 2: Well, now it feels like, a, it's not that important, because if it was, they would have taught it in the first course, obviously and B, that it's really an add-on, like you could take it or leave it, or maybe for just male patients or maybe for just bowel things.
• 16:12
  Speaker 2: I think it's almost training that, because now they've gone for several years sometimes and haven't had that skill set.
• 16:19
  Speaker 2: So of course it feels like, well, okay, cool, it's like this role.
• 16:22
  Speaker 2: It's like, oh, I have another little tool by Toolkit.
• 16:25
  Speaker 2: That's something that's integral to actual treatment for most of your patients.
• 16:29
  Speaker 1: Yeah, absolutely.
• 16:30
  Speaker 1: I feel like you know this is.
• 16:32
  Speaker 1: It just happens to be that that's the way that the courses were originally structured.
• 16:37
  Speaker 1: There are other places that I've heard don't structure it that way, which is very interesting, and if I were to do something like this all over again, I would certainly teach both access points to assessment at the beginning, so that someone doesn't come to that conclusion that just because we're prioritizing this over here in number one and then this level two over here is this and I'm not saying that that's an easy decision, because it's very hard to create those courses in that way with so much information to someone that's brand new to internal treatment.
• 17:11
  Speaker 1: So I'm not saying that that's an easy task.
• 17:13
  Speaker 1: But in some of the principles that I would do if I were making this course, it would be this principle that it is half the pelvic floor that you do need to prioritize this type of assessment, both trans-rectally and trans-vaginally, for those who have that.
• 17:31
  Speaker 2: And then the third reason is that you think the patient will think that it's weird.
• 17:35
  Speaker 1: Right.
• 17:35
  Speaker 1: So that's another reason why you might feel like it's the last resort is that you think, as a therapist, the patient thinks it's weird, so it's this.
• 17:42
  Speaker 1: Well, I don't really want to bring it up because I'm worried what they're going to think or about me if I bring it up and so it's just then.
• 17:50
  Speaker 1: Everybody is just acting really weird about it.
• 17:53
  Speaker 2: By the way, just guys, the patient guys, you guys have already crossed over the level of weird, right, I love that.
• 17:58
  Speaker 2: That's where people are drawing the line.
• 18:00
  Speaker 2: Just as a outside observer, it's like, oh, putting my finger in your vagina to cure your bladder pain is normal, but if I thought about putting my finger in your rectum to cure your bladder pain, that's weird.
• 18:12
  Speaker 2: Jesse, this is like we're already in the zone of weird guys.
• 18:16
  Speaker 2: I'm in a patient gown.
• 18:18
  Speaker 1: I don't think what we do is weird at all.
• 18:20
  Speaker 2: Right, but from a patient perspective, right.
• 18:23
  Speaker 2: And you don't think that there's a difference between rectal and vaginal weirdness levels.
• 18:27
  Speaker 1: Well, that's the thing.
• 18:28
  Speaker 1: I feel like it by default.
• 18:30
  Speaker 1: By acting like we're going to choose this access point and not the other access point for someone that has both, we are saying something about that.
• 18:40
  Speaker 1: We're saying something about let's try this first, because, insert, even if you're not saying it, you're saying it Right.
• 18:47
  Speaker 1: And so a lot of times when I am, this is something I go over in the Rectal Course.
• 18:51
  Speaker 1: But when I'm going over the pelvic floor education part as part of my evaluation, if the person has two access points, we're talking about the access points.
• 19:01
  Speaker 1: If the person only has one access point, we're actually talking about that.
• 19:06
  Speaker 1: There can be two in certain anatomy.
• 19:08
  Speaker 1: So I have the same pelvic floor education spiel to everybody, because one of my things is I want to make sure that everyone's educated about everything that is possible.
• 19:18
  Speaker 1: And then for the person in front of me, then I will modify that and say, like, so for you we have two access points, for you we might have one, but by presenting it at the very beginning, then, even if we're not going to do it that first day, then we at least have planted the seed that like oh, this actually is a choice that we're making together as patient practitioner alliance that we're doing and deciding together which it would be the best access point to assess fully the pelvic floor.
• 19:50
  Speaker 1: My argument is that it's both regardless if we come to that agreement together, but we're presenting it in the same way that I feel like it should have been presented to us.
• 20:00
  Speaker 1: That's what I'm doing.
• 20:02
  Speaker 1: I'm presenting it to the patient the same way that I feel like it should have been presented to us when we were learning.
• 20:07
  Speaker 1: And it's that important and it's that just fundamental to what we're doing.
• 20:11
  Speaker 1: And it's just simply which way are we going to access the pelvic floor?
• 20:17
  Speaker 2: So your takeaway or your assessment for this week is just ask yourself what percentage of your patients have you done a rectal evaluation and treatment with.
• 20:26
  Speaker 2: Are you up at that?
• 20:28
  Speaker 2: 75, 80%?
• 20:29
  Speaker 2: Is it 25%?
• 20:31
  Speaker 2: Is it none?
• 20:31
  Speaker 2: Just see where you guys are at this week and think about what that's going to look like.
• 20:36
  Speaker 1: And I would also ask you that if you've done it once and you've deemed it quote, unquote fine and your patient still has symptoms, please consider that if you have two access points and you're treating primarily transvaginally and something is shifted with their symptoms, something can also have shifted with the posterior aspect of the pelvic floor.
• 20:59
  Speaker 1: So this is why I also want you guys to be thinking about it's not just one check and done, it's not just a let me cross that off of my list and I check it once and it's fine.
• 21:09
  Speaker 1: It should be.
• 21:10
  Speaker 1: It should be a constant going back to with your test, retest, assess, to address all of the things that, as your patients going through their plan of care, it should be revisited as a point that can also change.
• 21:25
  Speaker 1: How many times have we seen a change in the pelvic floor that we see a change in the hip recruitment pattern or the lumbar pelvic junction as a change in recruitment pattern, and then we have to tweak something there and we go back and we check the pelvic floor vaginally and then we go back and then I'm all I'm asking is that the rectal assessment is also in that mix of assess, reassess, test, retest, so that we are making sure that we're doing a thorough evaluation throughout the plan of care for all of our patients.
• 21:55
  Speaker 2: And if that doesn't feel easy or intuitive or something that you know how to do.
• 21:59
  Speaker 2: That is, nicole, what the entire rectal course is about.
• 22:02
  Speaker 2: I thought one of the really cool things in the way that you organized it and I'm going to let you brag on this for a second because this is such a cool way to do this.
• 22:10
  Speaker 2: But if your argument is that we should be doing rectal for almost any diagnosis in patient who's open to it, then I love how you go through and actually talk about it in all of these different diagnoses for vulvodynia, for incontinence, for you know, it's not just confined to, oh, tailbone pain and chronic, terrible constipation.
• 22:32
  Speaker 1: Right.
• 22:32
  Speaker 1: So I think one of the things that I was thinking about when I was creating this was all of those things like what are the reasons why people aren't doing it?
• 22:42
  Speaker 1: And if you're thinking it's not that important or you haven't been taught that way, or you think the patient thinks it's weird, or all any of the things that we just said, the whole course is helping all of those aspects and then giving you the fundamentals with anatomy, physiology, pelvic floor For each diagnosis, why somebody might benefit from a rectal assessment.
• 23:09
  Speaker 1: So, to give you one example, we go through vaginismus and why you might choose to add a rectal assessment.
• 23:18
  Speaker 1: For that we give the anatomical reason.
• 23:21
  Speaker 1: We give other reasons that are specific to vaginismus, where sometimes people are really fearful of putting something into the vagina.
• 23:29
  Speaker 1: But there are some patients that are not fearful of putting something into their rectum, and so there's a lot of ways that we can look at somebody with vaginismus and look at them through the lens of wood.
• 23:43
  Speaker 1: Trans rectal help in this situation?
• 23:46
  Speaker 1: If so, how?
• 23:47
  Speaker 1: And by teaching it that way to you guys, then you have some of the language then to bring it up to your patients, and that's the beauty, I think, of the rectal course is we go through each one of those diagnoses.
• 24:02
  Speaker 1: We go through some bowel-specific diagnoses, but we also go through a huge variety of non-bowel-specific diagnoses Vaginosis, vulvodania, interstitial cystitis, prolapse and continence all the things that you wouldn't necessarily think to do a trans rectal assessment first, for we go through the reasons why you would be potentially considering a rectal assessment for those diagnoses.
• 24:27
  Speaker 1: So that's really where I feel like it's awesome and I think it's super valuable and we've heard feedback that way and I'm done talking about it.
• 24:36
  Speaker 2: Yes, this is making us comfortable but, guys, super practical as always, and I hope that this has given you something to think about in terms of are you treating rectal as it's a last resort?
• 24:48
  Speaker 2: If so, what does that mean for your clinical practice?
• 24:51
  Speaker 2: What does that necessarily mean for the way that patients are interpreting that?
• 24:55
  Speaker 2: So if you guys have thoughts or questions, please reach out.
• 24:58
  Speaker 2: Let us know.
• 24:59
  Speaker 2: If you guys are jazzed for being part of that second cohort of this rectal course, make sure to head to pelvicptrisingcom.
• 25:06
  Speaker 2: Slash rectal, get on the wait list.
• 25:07
  Speaker 2: You'll get first priority, $50 off, a live Q&A, all of the good things, being able to go through with it with a awesome group of people in this cohort and, as always, let's keep this conversation going and let's continue to rise.