Breaking the Color Barrier with Gretchen Wartman

Show Notes

On the heels of National Minority Health Month this past April, we’re joined by Dr. Gretchen Wartman, Vice President for Policy and Program at the National Minority Quality Forum, to discuss what healthy aging looks like for Black and Brown older adults and some of the barriers to healthy aging that PoC older adults face. 

The National Minority Quality Forum (NMQF) combats health disparities among Black and Brown communities and empowers our most vulnerable neighbors to create healthier outcomes through culturally and linguistically appropriate resources. An advocate for over 30 years, Gretchen has committed her career to advancing health policy and restoring equity.

Episode Transcript

Sue Peschin:

Hi everyone. Welcome to This Is Growing Old, the podcast all about the common human experience of aging. My name is Sue Peschin, and I’m the president and CEO here at the Alliance for Aging Research. Joining us today is Gretchen Wartman, vice president for policy and program at the National Minority Quality Forum. An advocate for more than 30 years, Gretchen has committed her career to advancing health policy and restoring equity. Gretchen, thank you so much for joining us today.

Gretchen Wartman:

Thank you. And thank you, Sue, for inviting me. I’m honored to be here.

Sue Peschin:

Terrific. Well, tell us a little bit more about your work with the National Minority Quality Forum.

Gretchen Wartman:

Well, thank you. I have been a member of the National Minority Quality Forum team for 20 years, which means I probably need to confess that I’ve been working in the health policy environment for 50 years. 30 of them have been very specifically focused on federal and state policy, but prior to that I spent about 10 years with the federal government and another 10 in Michigan with the City of Detroit Health Department and with the Greater Detroit Area Health Council. So I raised that here because A, not only am I old and working on issues associated with growing old, but in that 50 years I’ve seen or experienced the discussions that you and I are often having in different forms, through any number of different lenses with a particular aspect of the conversation being defined as the challenge, the problem. And in that 50 years, the conversation has not changed significantly nor have the challenges.

We’ve got more precise data available to us to enable churning of the issue, but moving forward from defining the issue towards resolving the issue is where you and I in the work we do together and others are experiencing what could be called a systemic hiccup, but it says to me that we get into the crux of the problem. And I guess I’ll close this by saying that the National Minority Quality Forum has begun to recognize us, as have many of our partners, that reforming a system that is not designed at its core in its core programming to address issues through an equitable lens is an interesting and very busy experience, but will ultimately fail because the operating system. The values that inform the system are designed to do the exact opposite of what we’re asking it to do, which is to not differentiate.

Not assign differential value to different population cohorts or different therapeutic areas, but to find a way to bring all in and respond to their challenges associated with getting the greatest possible advantage from the science that is available, not just relative to another racial or ethnic group or geographic area. And so that’s where NMQF and I think it’s safe to say that’s what my thinking has evolved too towards in the last 50 years. On some level it makes it a tad more daunting, but on another level it’s actually I don’t want to say comforting, but you realize that you were understanding what was happening, that it’s not you who doesn’t understand how the system works. We do understand how the system works, but what it’s doing is not in the best interest of reducing the risk for the patients who are dependent upon it. And as Dr. Puckrein said to me, who’s the president of NMQF, who are indeed the investors in the system. It’s our dollars that move it forward.

Sue Peschin:

So this next question, I’m wondering if we framed this, given everything that you just said, the way that we should have. The question is what do you think are some of the greatest barriers in health equity that older adults of color currently face? But I’m wondering if it almost needs to be broadened to the structure itself, but please go ahead and tell me what your thoughts are.

…the system has to be willing to answer some questions that it may be uncomfortable asking about the history of abusive research in the United States.

Gretchen Wartman:

The challenges that older adults of color experience, they’re not significantly different from the disadvantages that older adults of backgrounds other than of color experience. And you and I know that those of us who are of color differ from each other in terms of language and ethnicity and culture and our sex and gender orientations, our geographic locations intersect with race and ethnicity and can further confound the conversation and do further confound the conversation, particularly in a system that over the years has attempted to narrow its responses to a single response for a single particular patient profile. The issue of Alzheimer’s disease and the fact that individuals of color and women of color are greater risk for being diagnosed with Alzheimer’s disease than populations that are defined as Caucasian, therefore not of color, who are also not Hispanic.

The fact of that, the information that supports that statement is on the website or is on the websites of patient advocacy groups who advocate on behalf of patients with Alzheimer’s disease. You can go to the NIH website and see the same data, and the data that we use within the National Minority Quality Forum we obtained from CMS, yet attention was not paid to that issue, the differential risk and potentially the differential in disease presentation and efficacy, if you will, of therapeutic interventions throughout the stages of the disease. And that’s America. Actually, it’s global colorism throughout the globe that assigns lesser value to people with more brown melanin than other melanin is ubiquitous. And then that affects one’s ability to access often educational resources or financial resources or others.

But I’m going to go back to the comforting part is when you recognize well, they are aware that this is occurring. So my angst, we hear lots of conversation regarding distrust of the system as though it’s somehow unfounded or emotional rather than an intellectual response. A response to a system that assigns lesson and value to you, which is abusive to some degree, is a logical response. And what appears to be the unwillingness of the system to respond to those voices that have been expressing concern for decades, often through the clinical community, patient advocacy community as it had opportunities to speak, is also not unfounded in certain facts. And it is not necessarily an issue of whether there’s racial or ethnic bias. There is. That is a reality globally. But the fact of the matter is the business model that incentivizes the behavior of researchers, of the federal government, of the commercial sector of states and Medicaid programs is in conflict with equity.

And to try to have equity, meaning equity and access to the science, to the creation of new knowledge so that over time we have therapeutic options that can survive the rigor of an FDA approval process regardless of how it is being made manifest at the moment, and when it is then viewed through the lens of payers for reasonableness and necessity also passes muster. And so all of those levers that have to be pulled to make sure that the different sectors of interest that keep the system going are advantaged by engaging in a conversation about equity is I think the challenge that we’re all addressing at this point. And so I’ll go back to the Alzheimer’s conversation. You and I worked on a particular process at CMS, which was a coverage was evidence determination process. And I think great concern was expressed by CMS, by ISR and others about the lack of diversity in the denominator of that research, which is the case for all research in the United States, with an example that I can speak to if I need to.

That information was used to hinder access to that therapy for populations that are not defined as minority in this country. And so in a sense, the disparities that have placed perhaps a preventable burden for this disease on populations of color were then weaponized to help the payer enable the payer world to meet its objective of mitigating its financial risk and justifying it by the lack of access to the creation of the knowledge of which they’ve been aware for decades. And I’m going to say Dr. Puckrein has recently created an annotated bibliography of I think 3,000 references that he found that have communicated very clearly and sometimes were authored by CMS or what was then HCFA employees document the lack of access to research and the fact that the majority of beneficiaries who were perhaps surveyed A, stated that they’d never been asked to participate in research, and also said that, “If you asked me, I’d probably say yes.”

Sue Peschin:

Right.

Gretchen Wartman:

But the system has to be willing to answer some questions then that it may be uncomfortable asking about the history of abusive research in the United States. And when you elect to not answer a question rather than to answer it honestly, directly, it can tend to reinforce what I will call antipathy towards partnering with those entities and advancing their business objectives, which some people like to call distrust. But it is I’m going to say trust that you will continue to be who you have always been.

Sue Peschin:

One thing I want to ask as sort of a follow up to that, I was in a different discussion yesterday where I brought up the question about there’s so much focus on clinical trials and diversity in clinical trials, but clinical trial lists are going to look for people in a disease state based on guidelines for diagnosis and treatment, which are also based on white people. And people of color oftentimes develop these conditions at earlier ages because of racism and other disparities or social determinants I should say. And so their age of disease onset is earlier in many cases, in issues like heart failure, hypertension, diabetes.

So the age at which physicians are taught to look for conditions like heart valve disease or Alzheimer’s that are often those follow-on conditions happening later in life may be happening more in midlife in people of color, but they’re not looked for. So they’re not in the guidelines necessarily of for diagnosis, and then subsequently, it’s not who folks are going to look for clinical trial recruitment. So I’m wondering about your thoughts of earlier even in the process rather than research, is just even identifying disease populations that it’s baked in there as well and how does that contribute to the whole problem later on with clinical trial recruitment?

Gretchen Wartman:

What you have outlined is what I’ll call that compound complex systems loop that has these multiple inflection points that need to be identified and addressed. By definition, that means that one needs to get upstream in terms of policies, guidelines, graduate medical education to begin that process of bringing historically marginalized populations into the center of the bell in a way that they cannot be ignored. It is not an easy thing to do, but it’s something that must be done for a second reason or another reason, which is that the demographics of the United States are changing. And so populations that could fairly easily be situated outside the center of the bell, which was and has most of our lives has been defined as the general population.

And then African-Americans, Hispanics, Asian, Pacific Islanders, others, this is a gross generalization, were interestingly and concerningly defined as subpopulations of that general population, which was predominantly Caucasian and earlier in this I would say the last century, male. And so finding a linear pathway is a first step towards correcting this issue as an impossibility. And I was just in a meeting where there was just this litany of all the challenges associated with creating equitable access for populations who are historically marginalized, and with blinders on and through any particular therapeutic lens, the litany of challenges is similar. The question becomes well, what do you do first?

And I think you know what you do first, I suppose, is bring an equitable framework construct to the opportunity that’s in front of you at the moment, which also means that we need to have partners with different types of stakeholders who recognize that there is a business advantage to bringing equity into their deliberations, into the development of their products or whatever. The 2020 Census Bureau population projections really projected, if I’m recalling accurately, essentially a collective majority of Americans by I think 2060 that is comprised of these populations that have historically been defined as minority or have always been outside of the bell. The bell keeps getting smaller and smaller. For the I would say business interests we’re reaching who are essential to moving this forward, ignoring that fact, ignoring the population shift is unwise.

Sue Peschin:

Yes.

Gretchen Wartman:

And so I think we have an opportunity here because the financial risk mitigation will always be a priority for business interest, but it’s difficult to mitigate one’s financial risk when one’s products, given the data that are available to us, given the information that is currently available, often are demonstrably less effective in the populations who have been excluded from the denominator of the science. So I don’t know where I ended up in that answer, Sue.

Sue Peschin:

I thought it was a great answer, and I do think that the business case is really important because I do think that the companies that are not on the payer end of business but on the healthcare product end to try to improve healthcare are going to start leveling out in terms of their sales if they are just solely focused on wealthier whites and aren’t looking at the changing trajectory of the population. I think that’s absolutely right. And Dr. Puckrein and I were just at the Association of Black Cardiologists meeting and we talked about this with the heart valve manufacturers, and I think they are increasingly aware that their business is flattening over time because of the coverage with evidence development model in Medicare.

That’s who that model caters to, and you can only get so far. It’s been 10 years, so it’s been pretty profitable over 10 years, but you do hit a wall eventually, and I do think they’re going to have to take a look at it. And if that’s what it takes, the motivation is not to do the right thing necessarily, but just to keep the business going, so be it. But I think it’s an important point to be made and one that you are either going to be on the train or not, and it also happens to be the right thing to do.

Gretchen Wartman:

What’s of particular interest to me also, only as it affects only those aspects, what I’ll call them… I’m going blank on the word… the magnitude of the challenge within that particular social determinant category, only as it compromises access to care, particularly within the patient physician diad or the pharmacy diad. There’s a convenient shorthand that’s being used that enables folks to believe that some people have social determinants of health and others do not. It’s being misused in a way that’s problematic. Everyone has social determinants of health, but not everyone-

Sue Peschin:

Not apparent. Right, yes.

Gretchen Wartman:

… they don’t want to accept it that way.

Sue Peschin:

Some people have positive ones and some people have negative ones.

Gretchen Wartman:

Yes, because they increase one’s access in theory to the benefits of the system. We also tend to group communities of color, African American non-Hispanic, Hispanics of African descent, somehow in that negative social determinants. I’m very interested in assuring that social determinants of health are collected on all patients who present and collected in such a way and entered into electronic health records in such a way that we can conduct the kinds of intersectional analysis we need to get a sense of how the system is behaving for those who may not technically have a financial challenge, but present like those who are assumed to have a financial challenge. How is care being prescribed for them? What are they encountering as they move through the healthcare delivery system?

That will give us a sense of where perhaps guidelines or payment policies need to be shored up, if you will, to assure that all populations, and I mean all populations because Caucasian populations have social determinants of health that challenge, Caucasian non-Hispanic, their access to the system and they’re not all in rural areas. So we use these codes in a rural area or you’re in an urban area. And I would say that absent insurance, the American middle class is one unfortunate diagnosis away from financial ruin. And so the language that we use and the messages that we use need to enable us to bring others into this conversation about health equity and assuring that the investments that they have made protect their families and their children moving forward.

Sue Peschin:

Well, now you’re getting into political conversation, so without getting into it-

Gretchen Wartman:

Oh, did I? I didn’t mean to do that.

Sue Peschin:

… no, I know that’s what you slightly… it’s the groups that are forgotten because they are not the groups that vote vote for you necessarily, and it is true. I agree, because it creates a divisiveness or a feeling of being forgotten. And I appreciate the fact that the National Minority Quality Forum is interested in looking at all because the groups that you forget, communities that you forget will find a refuge somewhere. And if we’re trying to create policy that is good for everyone, we can’t forget certain groups just because they don’t vote your way.

Gretchen Wartman:

That is correct. Dr. Puckrein ran some numbers 15 years ago. What the then leadership of the CDC Health Brain Trust was able to do was to take that information to a hearing and communicate to her peers that a significant percentage of your constituents are disadvantaged by policies that you vote for, and it’s to your political advantage to be able to communicate to them that you are working on their behalf. This is a polarized society and I understand that. I don’t want to sound too naive. And so unfortunately, some assume that if it is good for them, it must by definition be harmful to me because it’s somehow taking from me something that I feel I have worked for and earned and of which they are not deserving. I do believe that it is possible to rethink the American health services research, delivery and financing system in a way that assigns value to everyone. I don’t know what that costs. If we use the business models we currently have, we won’t make it.

Sue Peschin:

Right.

As you said, they’re not only going to flatten, a lot of them are going to flatline. And what we know is flat lining in the United States flat lines overseas as well.

Gretchen Wartman:

It will be too expensive and it will stop conversation in its tracks. But that’s why I say at NMQF, we have a foot on either side of the line. We’re operating within the pragmatic reality of the opportunity we have at the moment to influence that issue, but also asking others to join with us to reimagine health services research, delivery and financing going forward, and making sure that there are data to support that. And then making sure that there are opportunities for all to use those data to help themselves, their constituencies, those who design graduate medical education to realign their thinking through truly population health lens. Now, maybe it sounds a bit trite, but I do believe that absent the initiation of that process, long after you and I are both gone, society will continue to be harmed by a failure to do so because the business sectors upon which we all rely are going to struggle.

As you said, they’re not only going to flatten, a lot of them are going to flatline. And what we know is flat lining in the United States flat lines overseas as well. This is not just an American issue. So I don’t have the answer other than we must begin to have those reimagining conversations and as part of that, assuring that Bell encompasses all. There will always be timing challenges associated with bringing certain I would say maybe therapeutic responses to market, but not operating with intention and defining it as somehow a societal do the right thing, but not a business do the right thing will I believe cause any efforts to fail.

Sue Peschin:

So you’re talking about conversations, and NMQF has its upcoming summit on health disparities in Spring Health Brain Trust, which I think is one of the best conversations happening in Washington, and it happens each year. Tell us a little bit about that and what you all attempt to accomplish through that dialogue.

Gretchen Wartman:

Well, what we attempt to accomplish is to expand an understanding of the issue that attends improvements in healthcare outcomes for marginalized populations. Now, let me say this. The name of our organization is the National Minority Quality Forum to call attention to the fact, and Gary might not say this, but I’ll say it, at the time he selected that name, the system was not paying attention to populations that were defined as minority, which I’m going to say once again, a mental picture of African American comes to mind, but there are other populations that fall within the academy. And several years ago, Dr. Puckrein noted that we had spent maybe our first five or 10 years having sessions where we simply ran through the list of all of the challenges. The diseases and the problems with that disease, percentage differences between African American non-Hispanic and Caucasian non-Hispanic, Asian and Native American.

Those kinds of conversations, which don’t need to stop, but at some point you have to start having the conversation about the solutions. And so I would say what I think we’re growing into I will say with the stakeholders in the National Minority Equality Forum is that comfort level, that support for beginning to articulate solutions. And of course, I’m going blank on the theme of the summit, but it speaks to improving care outcomes for the most vulnerable. Now, one can define most vulnerable in one’s way. I define it as populations who are not valued in research and delivery and finance. You and I have spoken to and spoken about the value assessment processes that are underway in this country. Those value assessments by definition assigned differential value to different population cohorts. They include but they’re not limited to ICER.

I won’t say it’s the gorilla in the room, but it’s the most visible value assessment process in the room. But value assessment occurs throughout the public and commercial insurance industry. In the Immunization Practices Committee that is managed by CDC, their deliberations are value assessment deliberations. It’s the reasonableness and the utility, not safety and efficacy. The work that you and I have done and are continuing to do on coverage with evidence development through CMS, that process is a value assessment process. Now, the tools that they use to determine whether they’re going to assign value to therapies that they’re including in the coverage in this development process mimic those that are used by FDA, but they’re looking for something different. And so they’re building on that.

This is my take on it, now. Tell me if you take it differently. The American general population needs to be aware that these kinds of value assessments occur. We’ve been all raised to think that FDA was the decision. Now, I’m not speaking to what’s happening recently in our society. This is something that we’ve become aware of at the National Minority Quality Forum for decades. The fact that FDA approved something and for the physician community, for the clinical community, that was an interesting piece of information, but did not assure right placement in the treatment guidelines because they then undertake to some degree an assessment of the value to their work of referencing that particular therapy and how they’re going to communicate to clinicians when and where and for whom it should be used.

Sue Peschin:

No, I agree with what you’re saying. The CMS, the Centers for Medicare and Medicaid Services, argues that they do adhere to a different statutory standard with reasonableness and if something is reasonable or necessary-

Gretchen Wartman:

Reasonably necessary.

Sue Peschin:

… versus safe and efficacious, which is what the FDA stands for. The FDA standard is part of that definition, but the rest of it is pretty broad and it’s left up to interpretation on the part of the payer, which is CMS and Medicare falls under that. And so I do think that physicians, patients, the whole community is left to not be sure anymore once the FDA approves something, whether or not it’ll be covered by Medicare. And some of that has occurred as the population has aged. We just have a big number of folks that are entering into the Medicare program every year, and we really haven’t faced that as a country. We haven’t said, “We’ve had this huge population shift, what do we do about it?” It’s all been how do we slash and burn? There are too many people in this program now. And so coverage with evidence development is one of the responses to that, and that’s been unfortunate.

Gretchen Wartman:

The movement of the Baby Boomer cohort has been monitored by our society I think since it was identified, so that was sometime in probably the fifties because there were some of us who were post-World War II babies and then it moved into I think the early sixties. I get that confused. But the ability, the awareness of the Boomer cohort as a significant societal influencer has been with us the whole time. The way marketing changed once we moved into our revenue generation and spending years, the way commercials changed because the culture of those of us who matured in the late sixties and early seventies suddenly was on TV, and that was back when we still only had three channels, I think. And TV stopped.

Sue Peschin:

Right, at night? That I remember.

…devaluing older adults as a critical component of research is a stunning thought process from someone I think, who’s not only a practicing physician
but an academician.

Gretchen Wartman:

And so the economic force of us has always been recognized. I find it very interesting that, and I think it’s in spite of Claude Pepper’s Commission, health services research, delivery and finance did not factor that in, in terms of being proactive maybe in identifying therapeutic responses or circling up the wagons to protect themselves for the years when we would perhaps not be contributing as much as we did, still be here because the health services research, delivery and financing system works because you lived longer. And you often live longer, and then you began to develop certain health challenges that didn’t develop when people tended to die between 35 and 40.

I’m confident if we go through the back through the literature and look at that, we will see that there were those who were writing about. The question is, why was it not embraced by the business model? You’ve got Zeke Emanuel. Well, I’m going to always bring it up because I was at the National Press Club a number of years ago before everybody had to go home when he announced that his father had been ill and his father was denying further care. And so then Dr. Emanuel made his statement there, I don’t know if it was for the first time, that after age X, we should all reject any further health intervention and leave the stage. And I remember sitting there, first of all, I was so stunned, and I don’t think anyone responded to him because it was just a stunning statement from a physician. It was a business statement that he was making.

I don’t accept that, and I definitely don’t accept those kinds of statements from those who will almost always, as you’ve said in other environments, be able to purchase that which they need or have access to it by virtue of their position in society. It’s such a callous and disturbing statement. I don’t know Dr. Emanuel, I’m assuming he won’t call me and ask me how dare I say this, but it’s appalling because it also then will serve to undermine the creation of additional knowledge associated with those who live longer with a condition that informs the creation of new therapeutic options and then hopefully cures. So devaluing older adults as a critical component of research is a stunning thought process from someone I think, who’s not only a practicing physician but an academician.

Sue Peschin:

I was just going to say, and probably amply self-insured. I was at a meeting with him, I think it was with HLC, the Health Leadership Council. One year I was invited as a guest and we ended up in a small group together, and I think he worked as an oncologist for a long time, still may, and he spoke about how he often talked to his patients about the price of therapies as part of the decision-making process, and would they want to have the therapy if they knew how much it cost? And I was thinking about the analogy of when all everybody goes to the airport, the common experience of going to the airport and you’re hungry for lunch and they have tuna sandwiches at the airport, and the tuna sandwich at the airport is like $17.

It’s not the same tuna sandwich that you get at a local corner deli or certainly not what you get at your house, but you’re a captive audience and so you pay $17 for the tuna sandwich. And it’s not as though patients are coming from the perspective of, “Oh, I want the Cadillac treatment knowing that it’s going to cost the health system X amount of money,” you’re just in the pickle that you’re in at the time, whether it’s cancer or heart disease, Alzheimer’s or whatever it is you have and you just want help. And you’re not the one that chooses the price tag in the hospital setting or in the doctor’s office. And it was an interesting dialogue because there was that perception of patients are sitting at the airport saying, “I’ll take a tuna sandwich and a chicken salad sandwich and a fruit cup to boot,” as though we are choosing these things because we just have very rich taste.

Gretchen Wartman:

And his rationale for that was what? Because I have a cancer diagnosis, in his wisdom, he thinks that I need to in that moment assign a value to my life and to perhaps the loss of it or the delay versus the delay of what I’m going to be thinking of as an inevitability in terms of death associated with this diagnosis because of what the treatment costs. And I think what Dr. Emanuel is doing is in his way, shining a light for the American population who may hear his remarks and understand the decision-making processes that are going on ongoing all the time. Regardless of whether it’s a cancer diagnosis or a hypertension diagnosis or heart disease diagnosis, this is part of the thought process and absent of I would say community and voter engagement to understand how this will affect care that’s available for them and then how they can influence it, in my view not understanding how the system works is true health and literacy.

Sue Peschin:

It is so true.

Gretchen Wartman:

And it is possible to educate the American general public, all of us, regarding how the system thinks, how it works in language and concepts they can understand. I think that tuna sandwich analogy is perfect. And indeed, you didn’t choose to be hungry. You’re at the airport. You spend your life at the airport and the food for many, it’s not a choice, it is unaffordable. It is unaffordable, and that’s where we are with healthcare at this point. People aren’t making choices about necessities versus non-necessities in life, they’re making choices across necessities. Those of us who have an opportunity to influence the behavior and the system in such a way that it mitigates some of that burden for patients, families, and communities, I ask to take the opportunity to do so.

Sue Peschin:

Where can people find tools or resources to amplify NMQF’S mission?

Gretchen Wartman:

Our website address is www.NMQF.org. It is undergoing a major retooling, but I think that link still works. If not, your listeners can contact me at I’ll say gwartman, G-W-A-R-T-M-A-N, @nqf.org and I’ll do the best I can to get you to the resources you need-

Sue Peschin:

Perfect. Thank you.

Gretchen Wartman:

… or I’ll [inaudible 00:45:02] questions you may have.

Sue Peschin:

Thank you. Now, we have two closing questions I’m going to ask, which we like to ask all our guests. First, when you were a kid, what did you imagine growing older would be like?

Gretchen Wartman:

I can honestly say I didn’t. I probably thought it meant that I could stay up later, and I was generally reading books because we were a reading family. I can honestly say I didn’t expect to encounter the what I’ll call callous disregard and inaction taken in that context of callous disregard that I’m encountering, but maybe I wasn’t listening. I do recall, I have a sister who’s two and a half years older, which I remind her of constantly, and we were having an argument in our teens about something that was absolutely existential, I don’t know, a book or whatever.

And my father’s stopping us and saying, “Listen, you two need to be nice to each other so that you can take care of each other when you get older.” And I’m even thinking, “What?” And here we are. And so I’m reminded of that as the two of us get older together and our ability to function in certain environments has its differentials, but I think my father tried to tell me something in my teens that I just wasn’t seeing. I think we survived it. So that’s question one. What’s question two.

Sue Peschin:

Okay. Question two is what do you enjoy most about growing older now?

Gretchen Wartman:

Ooh. I think what I enjoy, it’s not a freedom, but the relief from losing the burden of feeling the need to please everyone, to be liked, because it’s so terribly important when you’re younger to be liked. And then once you realize that no matter what you do, some people are just not going to like you. But if you allow that to a greater degree, and it has been that way in my life, to constrain your thinking about where you can go and what you can do, what I’m finding at this stage is that it is a non-issue other than the employer, who’s important to me. Okay?

Sue Peschin:

Yes.

Gretchen Wartman:

You’re my employer, but I’m speaking in every aspect of life. Being comfortable with you, who you are. And I heard older people say this and I had no idea what they were talking about, and you liking you and what you’re doing is the most important thing.

Sue Peschin:

That is so true. Amen. I love it. I don’t think anyone has said that so far, and it is so true. And I am just personally starting to get that because it’s tiring to worry about other people all the time.

Gretchen Wartman:

It is. It’s exhausting.

Sue Peschin:

For sure. Thank you so much, Gretchen. I loved this conversation. I know we totally went off script and did not follow directions, which is my usual way and I think it’s often your usual way too, so I think this went the way it was supposed to go.

Gretchen Wartman:

Okay. But thank you so much for your patience with me. I appreciate it.

Sue Peschin:

Thank you. Thank you, Gretchen.