Medically Speaking #6

Hello everybody, welcome to another edition of Medically Speaking, we're glad to have you joining us today. Today I have two special guests with me, we have an interesting conversation today. I have Dr. Draper, OBGYN doctor, works primarily with Montgomery Center, and then I have Dr. Guerra, one of our neonatologists here in Greenwood. And we're going to talk about a variety of topics today, I thought maybe we'd just start with some introductions. So Joy, why don't you just tell me a little bit about yourself to start with and a little bit of your background. Yeah, so I am an OBGYN and a family medicine doctor. I've spent a lot of my life working in low resource settings, including areas of East Africa. I moved to Greenwood about five years ago now and joined the staff itself in Montgomery Center. I'm primarily dedicated to women's health, obstetrics, and working with our residents and doing teaching as faculty at the Montgomery Center. Awesome, thanks Joy. Dr. Guerra? Alright, I'm originally from Trinidad and Tobago, for those of you who don't know, where I did medical school, then I did my training in the U.S. and moved here. Awesome, and you've been here for a number of years. When did you start here at Greenwood? In 2017. 2017. You came the year before I did, I think. Yes. Yep, awesome. Well, I will tell you all, these two ladies are phenomenal. They both do just a wonderful job. Just a little personal story real quick, my own son was in our NICU here at Self Regional when he was first born and had just excellent care. And our NICU does a great job for a lot of people. And I think some in the community may not even know that we have a neonatal intensive care unit here at Self Regional. So maybe I'll just start with Dr. Guerra for a second and maybe just tell us a little bit about our NICU, the kind of patients that you take care of. Yeah. And, you know, just about that little bit. So we're actually fortunate here in Greenwood because we have a level three NICU, neonatal intensive care unit. And we serve Greenwood and the seven surrounding counties. We are licensed for 18 beds. We can go above that. But we deal with any babies who are 23 weeks and above. Yeah. For various different, I mean, low birth weight, respiratory issues, low blood sugar. We can take care of numerous issues in our NICU. So we're really fortunate. Absolutely. You wouldn't think just on the surface that a hospital maybe the size of Self Regional would have a neonatal ICU with up to 18 beds. Right. Could potentially even handle even more. Yes. So that service really goes to, in my mind anyway, to say that, you know, having a baby at Self Regional is a great place to have a baby. It is a great place to have a baby. That baby has the resources if born or if there's a problem at birth to be handled. And handled immediately right here by our team. Right. Exactly. Yeah. So we're really fortunate. Awesome. I mean, if there are issues that we can't deal with, we will transfer to Greenville. Right. But I mean, on average, we probably transfer one or two babies a year. Sure. So I think we are very fortunate in Greenwood and obviously the seven surrounding counties. Sure. And as someone who practices obstetrics here, I can tell you when I first came, I just assumed that we were a small hospital. And that we would have to send all of our babies out at 36 weeks. Yeah. And then all of a sudden, I realized, no, that we have this fantastic NICU. And you have made such a huge impact on our obstetrics patients. Yeah. And we're just so grateful to have a NICU like we have here. Yeah. Oh, yeah. Absolutely. It's a phenomenal service. And I hear very frequently in the community, gosh, so many people have been impacted by our neonatal ICU. Yeah. So thank you for that great work that you guys do. Yeah. So maybe give me an example of something that you would need to transfer out. So we don't have surgical support, pediatric surgical support. So if there's an issue where the baby would need surgery, we would have to transfer that out. For example, so most of the surgical complications, I transfer out. And those are the main reasons why we transfer. Gotcha. We don't actually have pediatric subspecialties, but like in person, but we have access to them. So usually if it's like a renal kidney issue, I can always call the pediatric renal specialist and I can manage here, but I can have access to them from Greenville. So I think most of the times we transfer is for surgical because we don't have that pediatric surgery, surgeon, sorry. And I think of my own son too, when he was in the neonatal ICU, he had an echocardiogram, which is an ultrasound of the heart. Right. And it was read by a pediatric cardiology specialist that was in Greenville. Right. And that relationship that we have is another form kind of where we use a form of telemedicine, I guess, to help take care of our patients here. So that's… So yeah, so that's a good example as well, because that's probably the second reason why I myself transfer out to MUSC for the cardiac complications. So some of them we can deal with in Greenwood. But if it's again, surgical or something like that. Again, surgical or more severe, then we transfer them to where there's not only a cardiologist, but a cardiothoracic surgeon. Yeah. Great, great. Well, Joy, tell me a little bit about the work that you're doing at the Montgomery Center and, you know, the teaching. I think teaching is a really neat aspect of some of the things we do here. And thanks for what you do. Tell about the Montgomery Center OB service and then OB in general at Greenwood and what services we're able to provide here. Yeah. So I work at the Montgomery Center, which is the physical space where we have the South Regional Healthcare Family Medicine Residency Program. And so I work with other faculty, family medicine faculty, some of whom also do OB. And we have 10 residents a year for a total of 30 residents every year. So they have their first, second and third year. So we work together as a team. We do low-risk and high-risk obstetrics. We have partnered with some OBGYNs in the community. They work. We cross-cover each other for call. And then we work very closely with maternal-fetal medicine in Greenville as well to try to take care of our patients and to cover our patients as needed. We've recently expanded to Edgefield. We might talk about this a little bit later, but talking about maternity deserts. There are maternity deserts that are developing. There are maternity deserts that are developing in the United States. And we have some of those in South Carolina. So part of what South Regional has done is we've moved and have a clinic now in Edgefield, which is south of here. And Dr. Lauren Hearn is one of my partners, and she's covering the clinic there. And we also have our residents there. So our residents work very closely with us. We're all a team. The residents are always supervised by one of the faculty members. So we do everything. We do ultrasounds. We do all the prenatal care. We partner with some free clinics in this area. And then we do our deliveries. So we do regular vaginal deliveries and then cesarean section deliveries and all the postpartum care. And we're supposed to have MFM come into Greenwood, right? That's right. Yeah, we're very excited about that. We have a maternal-fetal medicine specialist coming to work one day a week with us at Montgomery Center. But he will be seeing all of our patients who get OB/GYN services in Greenwood. And we have some fantastic practices that we work with. So he'll be starting, and he'll be doing the higher-level ultrasounds and consultations. The physician that's coming I've actually worked with in East Africa. That's where we first met. And he's had a pretty extensive history working in Greenville as a maternal-fetal medicine doctor. So I think that's really going to add to what we can provide locally for our patients. And for the NICU as well. Because, you know, sometimes we lose a lot of the hype. We lose a lot of the high-risk pregnancies to Greenville or Columbia because that's where their maternal-fetal medicine doctor is. So to have somebody local will increase, you know, the hope is that they would feel comfortable to deliver here. Because those will be issues that we can deal with in the NICU. Some of our patients, especially working through Montgomery Center, we have a lot of patients that have difficulty with access to transportation. So for us, being able to have a maternal-fetal medicine doctor come here, I think it's really going to help just with overall care and making sure these mamas and these babies are getting the best care that they can get. Absolutely. Yeah, I think that's great that we're having that level of specialty here in Greenwood for the community. So, yeah, between the Montgomery Center OB and then the private OB groups in town, then having a maternal-fetal medicine specialist to help with those high-risk patients, and having a NICU here that's capable of managing the majority of problems that come up with early premature births or problems, unanticipated problems that can happen at birth is really awesome. So I really thank you both for the great work you guys do and what y'all are doing for the community. I wanted to touch base and talk with you a little bit next about a DHEC report that came out, was released in April of this year, and there were some things in there that were concerning, I think concerning to the whole state of South Carolina as well as to our community here locally. And it really had to do with birth outcomes and specifically in some of the minority populations that seem to be more affected than other populations. I was hoping maybe we could talk about that a little bit and maybe gather some insights and some things that we can do to improve the situation. Yeah, I think, you know, the report is concerning because it showed that the infant mortality rate in South Carolina had increased at least in 2021 compared to 2020. And I guess the question is, you know, why are we worried about infant mortality, right? And it's because the infant mortality is an indication of our overall, you know, the health of the population. So most programs nationwide and locally, you know, they aim to decrease the infant mortality rate. So back to the DHEC report. It showed that the infant mortality rate had increased and that, you know, within the infant mortality, there were notable disparities. Now, these disparities have existed over the last, I mean, they reported from 2017 to 2021. But what was even more concerning was that gap was increasing. I mean, exactly why? I mean, I think it's multifactorial. But some of this, you know, it's important to know this so that we can figure out what can we do to, I mean, improve our overall infant mortality, but also to decrease that gap. And, you know, some of the causes, when we look at the causes of infant mortality, you know, the main causes in that report were congenital malformations, birth defects, premature birth, low birth rate. And then the third cause was, third cause was childbirth. And then the fourth cause was as a result of complications of pregnancy, maternal complications. So I think knowing the cause is important so we can look at how we can improve our overall infant mortality rate. And then some of the things to decrease the gap or to just look at, you know, why are we having these disparities or how can we improve the gap? I think that's a loaded question. Yeah. Some of the things, I think one is access to care. How can we improve access to care? How can we improve the care that, you know, moms or these moms are receiving? Because, you know, if you improve the maternal outcomes, you're going to improve the infant outcomes. And then, well, how do we decrease? What are some of the strategies we can do to decrease preterm birth? And it all goes back to, you know, improving access and maternal and, you know, prenatal care. And I think overall, if we aim to have, you know, in terms of the malformations or the birth defects and, you know, better screening, how can we make these moms healthier or population healthier, which can indirectly lead to decreased complications in pregnancy and infant mortality? But I think the other thing that was notable from that report was that, yes, our infant mortality rate increased. But when you look at, so an infant is anybody less than one year of age. And you look at, they broke it down into neonatal and post-neonatal causes. And the biggest, the neonatal causes increased, but the biggest increase was really post-neonatal, so after 28 days. The cause, the biggest increase was post-neonatal. And one of the main causes, I mean, moving away from maternal health, was actually sudden infant death syndrome. So SIDS, which is now called sudden unexpected. So I think for me, I mean, yes, we have to look at the overall infant mortality. But that's another thing we have to, as a pediatrician, not only as a neonatologist, focus on. And 2021 was a kind of strange year. You know, it was in the middle of COVID. So not that these babies died because of COVID. Like, you know, they were infected with COVID. But I think it was a time where we didn't really access, you know, care, you know, follow-up, education. So that's another thing I took from the report, me personally. And we saw that. We saw during the COVID epidemic that patients would not come in for prenatal care because they were scared. And if they would come in, they would come in late. And we're still seeing some of that. I don't think it's related to COVID anymore. But with our catchment area in Greenwood, a number of patients will come in late for prenatal care. And that can complicate their total care and how we're working with them and then ultimately the baby. But, you know, looking at maternal morbidity and mortality in the United States, it is so much improved from 100 years ago. So we had this huge decrease in maternal mortality. And, you know, working in Kenya for a number of years, I saw the other side of that, what it looks like to be in a place where you don't have all the surgical options, the antibiotics. But then some years ago, we started seeing a tick up in maternal mortality compared to other very advanced countries. So we began to question why that was happening. And I agree with Dr. Garrett. It's multifactorial. And I can't give all the answers. But one of my big concerns is that patients are having — they're having some issues with coming in for prenatal care. They're coming in later. And a lot of times our patients, I think all of us struggle with this, are having trouble being healthy before they get pregnant. So we're seeing an increase in women who are having challenges with weight, being overweight. And then also when that happens. In the pregnancy, they're at increased risk for high blood pressure, diabetes, complications with labor and delivery, increased surgical deliveries. So I think that's all factoring into some of these things that we're seeing in our area with increased maternal morbidity and mortality. And then that goes over into what you're seeing with increased infant morbidity and mortality. Morbidity, mortality, low birth rate. Gotcha. Joy, I'm just curious. Have you noticed that –? I guess during COVID or even in the last few years, has there been like an increase in pregnant mothers or folks who are pregnant delaying seeking that initial OB appointment? Yes, absolutely. We're seeing women coming in in third trimester without — they don't know their dates very well. So we're getting late ultrasounds. And so we're working with — we say poor dating, meaning we don't exactly know how old the baby is. So that has been very much of an issue that has — we've seen it escalate during COVID, but we're still seeing it now post-COVID. So we always try to encourage — we love to do preconception health care, family medicine, have women come in early before they even get pregnant and, you know, try to get them as healthy as they can be. And then tell them, you know, when you first find out you're pregnant, make an appointment and come in to see your OB/GYN or your family physician. Mm-hmm. I think COVID kind of sets us back a little bit. And I think it's important, like we always talk, you know, sometimes we talk about it with other colleagues. I think right now we just have to restart. We have to get back out there and promote and market and make people feel comfortable to come back to the offices or, you know, the hospital so that they can access care and just restart, you know, all our educational campaigns in terms of prenatal care, the importance of prenatal care. And postnatal, you know, but follow up for the moms and the babies and just really drive and, you know, push that for us to get back where we were before COVID. Right. Something that's made me a little sad in all this too is that I think there has been a level of distrust that now has existed since COVID with the medical system. Mm-hmm. So we'll talk to some patients and, you know, recommend things and they'll hesitate. And I don't believe that's going to happen. I think that's going to happen. I think that's going to happen. I think that's going to happen. I think that's going to happen. I think that's going to happen. I think that's going to happen. I think that's going to happen. I think that's going to happen. I think that's going to happen. I think that's going to happen. Mm-hmm. So we'll talk to some patients and, you know, recommend things and they'll hesitate. And I don't blame folks for that at all, but I agree. I think we need to reset. I think we need to rebuild some trust with our patients. Mm-hmm. I think that would help. I know at the Montgomery Center, we had a program called Centering Pregnancy for a number of years, and that's group prenatal care. And that is one of the recommendations that we have for trying to decrease maternal morbidity. Mm-hmm. Pregnancy and mortality, decrease perinatal morbidity and mortality. It's group prenatal care. And that's been shown to decrease preterm birth. Mm-hmm. And it's also been shown to increase birth weights, which is a great thing. Mm-hmm. So we had women coming together, all about the same due date. Mm-hmm. And they would go through their pregnancy together, and we would have their prenatal visits. We would talk in groups about education. It was wonderful. And then COVID. And we have had trouble since that time restarting the groups, not because they weren't available, but I think people were just — had gotten out of the habit of meeting together in community, in groups. And that's something that we're hoping that we can work towards getting group prenatal care going again, because that really does impact maternal and fetal care. Okay. Mm-hmm. Okay. Mm-hmm. And Dr. Draper touched on the sort of lack of trust. If we go back to the disparities, just — Sure. I just want to touch on this for a second. And what the report showed was that the mortality rate was higher amongst non-Hispanic black infants. And it was almost — the gap is now almost twice as higher compared to the non-Hispanic white infants. And I think some of the — you know, if we want to talk about — Yeah. You know, if we want to talk about causes, which it is multifactorial, but I think some of it has to do with the mistrust that they had before COVID, and then COVID probably made it a little bit worse. Mm-hmm. And then all — you know, COVID affected all the social determinants of health, so access to care, you know, people lost jobs, so loss of income, follow-up, you know, the time where we would take these — you know, the moms would take these things. You know, the moms would take these babies to be seen or get prenatal care. They weren't able to do that. A time where we drive education about SIDS, sudden infant death syndrome, we weren't able to enforce those things. So I wonder — I mean, obviously, like I said, these disparities have existed when you look for the past six, 10 years. But I think in the last couple of years, those — the things that happened, you know, COVID, for example — I mean, I know we're harping on COVID. But that did not help our situation. Sure. The number one cause of maternal mortality now is actually mental health disorders, suicide and drug overdoses. And playing off COVID, we saw the drug use and drug overdoses — Increase. Escalate and increase. And there was a lot of depression. And so now in the United States, that is the number one cause of maternal mortality, which is — it's very rare. It's very sad. It's very hard to deal with that. Again, working in different parts of the world globally, postpartum hemorrhage, obstetric hemorrhage is the number one killer of women globally. But now in the United States, hemorrhage — there's still — hemorrhage is always a risk. But we're doing things like we have all these care bundles and we're working with teams and simulations. So we really are working on trying to recognize hemorrhage early. Sepsis early. So we have really good approaches to that. But when you talk about mental health and depression and drug use, we're not as good at managing that. So that is also part of what is impacting maternal health in the United States, but actually I think in Greenwood in particular as well. So, you know, you mentioned mental health. So is this specifically, do you think, postpartum depression related or some other just underlying mental health? Or just underlying mental health concerns in general? I think it's both. And then just kind of exacerbated. I think it's both. I think the rates of anxiety and depression are going up across the United States. And then, you know, these women are getting pregnant and maybe they're not seeing their doctor. Maybe they're not seeing a counselor. And then they're at much higher risk for postpartum depression and postpartum psychosis actually. Sure. And then people are desperate. They try to treat themselves. And they treat themselves with substances. And they have addiction. And then we're seeing a lot of overdoses. You know, the fentanyl crisis is here in South Carolina too. So we see that too frequently. So what do we do about it? Right. So I feel a responsibility to the community to not only provide high-level care when the time is there, but to also be preventative. And when we see something like this that we recognize as a problem, a problem across South Carolina, we have it right here in our own communities. What are some things that we can do to improve the situation? And I know, Dr. Geer, maybe you can touch on a little bit our health equity task force and some of the work that that group is doing to try to start looking at these issues and really start trying to get to the root and make some difference. So, yeah. So we formed a health equity task force. And what we do is we, you know, we look, we gather the information. So we review the data. And we try to come up with actions. And we try to come up with action plans or evidence-based strategies that we can use here locally in Greenwood and our surrounding counties. So in terms of what we do, for the infant mortality and maternal mortality, I think it's important for us to, well, this is one, you know, get the information out there so that people know what's happening. And we're really secondarily going to try to, how can we improve access, you know, locally in Greenwood and the surrounding counties? How can we improve access for moms and their babies? Well, the moms, really. So we really need to work with our local health professionals. So, you know, obstetrics. And we've already started, like Joy talked about, Dr. Draper, that clinic in Edgefield. So increasing clinics where they can, you know, we can go to the patients. Because a lot of them have transport issues. So how can we set things up where they can access care? We talked about, in the task force, working really hard to try to get a mobile clinic, an obstetrics mobile clinic. We haven't really, you know, sorted out all the details. But how can we get this mobile clinic to go to the areas where we have… Where they don't have the access, I guess, to be able to come to South Regional or in the surrounding counties? One of the other things is we're going to continue to work with our partner with some organizations in South Carolina. So DHEC, our South Carolina chapter of March of Dimes, to try to get education out there in terms of access to prenatal care, the importance of prenatal care. In terms of the post-neonatal, you know, sudden infant death, how do you, you know, care for your babies? It's also important to, you know, because all these things, even access to prenatal care decreases SIDS. But, you know, so routine prenatal care, immunizations, all those things are important. So we can work through the South Carolina chapter of March of Dimes. And then South Regional is actually, we're part of the birth outcomes initiative. And they work towards improving health of moms and babies. So we're trying to use our local and local healthcare professionals and the organizations to try to improve these outcomes of not only moms but the babies. Right. Yeah, when you look at it, when I read what the experts say, they talk about, you know, national approaches, state approaches, community approaches, and then your local hospital approaches. Mobile care, the mobile care vans, I think, has been shown to really work well getting care to women. I've worked on that kind of van before in my previous work in Virginia. And it's amazing, you can just pull the van up to an apartment complex and you see the patients, the patients that don't have transportation. Now they can get prenatal care. So I think going to the patients. Doing things like education, doing group prenatal care. Or if a patient can't do group prenatal care, you know, bring, offer educational seminars to bring people to hear about not just prenatal care but then, you know, the concern of, you know, what you do with your baby afterwards, immunizations, how to prevent sudden infant death. And smoking cessation and drugs also. All those things improve actually. The rate of sudden infant death syndrome is actually higher in households where the parents smoke or drug abuse. So it all goes back to really education and trying to access care. Yeah. And I did, in fellowship, we had to do the mobile clinics as well. And it was a phenomenal experience going out into the communities and really seeing how many people come to the mobile clinics just because they couldn't get to the main hospital. So I think that will be great if we can. Because we already have mobile. We have a mobile van here itself. But just, you know, dedicating one to maternal care would be fantastic. Yeah, I think that would be something wonderful for the residents, too. And our residents are just an incredible group of people. They're so smart and they're so good. And I know that they would love to be a part of that. Because they're very passionate about health care in general, but also maternal health care. And so something like that would be a great project. It would be a great learning experience. That's great. You know, we talked about social determinants health just a little bit. Certainly transportation, to be able to take the care to the patient, that would be, it's a great idea. Do you guys encounter patients that are, like, maybe afraid or concerned about going to the doctor because they're afraid, "Gosh, I don't have insurance," or, "Gosh, I don't have money"? And maybe let's just talk about that for a second. So those patients that may not have resources, like, what are some options for them? So we see a number of patients at the Montgomery Center that have no access to insurance. So if you're a woman and you're a pregnant woman, you can get Medicaid. And we will help you do that. We have very smart people working at Self who can help you get plugged in. And there are people that may not be eligible for Medicaid. And if that is the case, they can get what's called emergency Medicaid. Which will cover their deliveries. And then we work with people at the Montgomery Center so that their health care, their prenatal care can be covered even if they can't afford it. So there are a lot of options. I hate for any woman not to come in because she said, "I can't afford it." We will work with you. And I think we see it most in maybe the Hispanic population. Yes. Where beyond being able to afford it. And they are worried about, you know, having to self pay an insurance. They're really worried about immigration issues as well. So sometimes when I'm asked to do prenatal consults and I interact with these women, they want to sign out AMA and leave. Because they're so worried about, you know, the implications of not having insurance or if they would, you know. And it's really just lack of education. They just don't know and they assume. So I think that would — Yeah. We work very closely with a free clinic called Clinica Gratis. And we have a partnership with them. And so they see many of our wonderful ladies who will go there for initial care and they'll be transferred into the Montgomery Center. And so we take care of them. And it's been a great partnership. Again, it's a part of planning, community planning, working with local free clinics and trying to let people know, hey, we want to see you. We care about you and your baby. Nobody is going to, you know, if you're having immigration issues, we don't judge that. We just want to take care of you. And we have had that partnership for a number of years. And it's working really well. So I think one of the things that we can do is also just market, you know, market and marketing our labor and delivery, you know, floors, the clinics, marketing the NICU. You know, pushing, centering, you know, since just post-COVID, just try to get our numbers back up, letting people, you know, put the information out there so we can — people can know and get back to a place where they're comfortable. Know what we're doing at South Regional, but also help them to be comfortable to come or come to where we are going to — come to South Regional or wherever we will be, you know, so that they can access care. And we're working on expanding our ability. We're expanding our ability to have translation services. And we have translation services available 24/7 through our phone translation service, which I think works very well. We're having more and more physicians that are bilingual in Spanish and English, which is fantastic. And then we're working on also getting bilingual nurses and other translators. So the language barrier should never cause fear. We have an ability to get things translated quickly and to take care of people that way. We're actually working on — it's a patient-focused group, and we're working to have in-person interpreters available whenever we need them, especially for patients during labor or on labor and delivery for whatever reason. It makes a big difference. It does. Yeah. It's sort of kind of impersonal when you're on the phone and you're trying to go through labor. So we're trying to work to have them available in person on the labor and delivery and in the NICU. Because if you have a really sick baby, I find it more personable to be able to talk with the person, you know, in front of you as opposed to on the phone. Do you guys have any other things that you think are important on this topic or anything else that you guys would like any of our listeners to know about? I would just like to give a shout-out to our nurses and staff, both in the NICU, pediatric nursery, and the labor and delivery. These folks have just done a phenomenal job looking at issues with maternal morbidity and mortality. We're working now on all these postpartum hemorrhage protocols, things that we were all doing, but we're really sharpening it up. And we're doing practices and simulations. And it's pretty just amazing how everyone's working together with that. We're also, with our residents, being very cognizant of issues like sepsis. So there's been a — Thank you. There's been a realization that maternal morbidity and mortality is an issue in some parts of this country. And we are actually proactively going after that and trying to make our labor and delivery just as one of the best labor and deliveries I've ever worked in with our nurses who are just tops. Awesome. Perfect. Dr. Guerra, do you have any last thoughts? No, I think I agree. You know, it's just — yes, we have these action plans, but it's really just working towards putting them in motion so that we can really see an improvement. And, again, I think it's — what I would take away is it's so important that these babies aren't necessarily dying in the NICU. It's postnatal, post-neonatal. So really just driving the importance of follow-up with pediatricians. You know, the safe sleep campaign, which we start our education in the NICU. But for the pediatricians and just driving the education, you know, safe sleep, prenatal care, immunization, smoke cessation, drug abuse, you know, decrease trying to help those who have drug addictions. So really just working hard so that we can improve all those things in the community. Yeah. The end goal, healthy community. Healthy people. Healthy moms. Exactly. Yes. You know, healthy people, healthy moms, healthy babies. Great. Yes. I can't thank you guys enough for joining me today. Thank you. For the Medically Speaking episode. Thank you for having us. We really appreciate it. Thank you both for what you all do for the community and the patients you take care of. You all are awesome. Appreciate you. Thanks. Thanks. Thank you.