Medically Speaking #16

Good evening, everybody. Welcome to Medically Speaking. I think this is our fifth program, and again, we're excited to be here with our friends at Lander University and the Chamber of Commerce. My name is Ken Coffey. I'm the Foundation Director for Self Regional. I'm going to introduce one of our welcoming speakers, Mr. David Trent, who is the Chairman of the greenwood chamber of commerce board who's then going to turn it over to dr wharton and then we'll get to dr logan and then our speakers so thank you all for being here and we've got a little reception upstairs afterwards so if you want to don't be bashful about questions tonight and also we'll try to make these microphones available to you so when you ask your questions we can hear because we're videotaping this for our self-regional podcast series that we do so David all yours bud. Good evening on behalf of the Greenwood Chamber of Commerce is my honor to welcome you to medically speaking event my name is Ken said is David Trent I have the privilege of serving as the Chamber Board Chair a very special thank you to the college students that are joining us here tonight. You represent the future of health care and we're inspired by your dedication to making a difference. We're also delighted to welcome professors, community members, and our esteemed guests who have gathered here this evening. We are excited, the Chamber is excited to continue our valued partnership with Self Regional Health Care Foundation and Lander University. To some it may seem like a strange partnership, a Chamber of Commerce, a hospital foundation, and an educational institution. Kind of reminds me of the old joke about a neurosurgeon, a plumber, and a mechanic walking into a bar. I'll spare you that one for now. A thriving health care system creates jobs which stimulate our local economy and also contributes significantly to attracting and retaining business and industry. A local university in our backyard produces a pool of skilled talent, supports entrepreneurship, students gain valuable experience in our business community secures a pipeline of well- prepared talent. This collaboration exemplifies how partnerships like ours drive progress and build a brighter future for Greenwood and beyond. Again, thank you for being with you here with us tonight as we explore the evolution of spine care in Greenwood. It's now my pleasure to introduce Halisa Wharton, the Dean of Landers Nursing Program. Thank you. Hello everyone. On behalf of the Lander administration, especially Dr. Richard Costantino and his cabinet and our Lander family, we welcome you to Lander tonight. We hope that you are comfortable. We appreciate you taking time out of your evening to come to think this is like our second or third year of the medically speaking event I look forward to this opportunity especially for our nursing students to be able to learn from the physicians that they will soon be working with so again thank you all thank you to the community thank you to all of our sponsors and we welcome you here to Landon University I invite to podium dr. Matt Logan well hey y'all similar to what Halisa was just saying you guys are awesome listen we love our lander we consider them our lander nursing students when they come through and do their clinicals with us when you get into your up or upper level classes and we love having our lander students and Piedmont Tech students and really any students at all that want to spend some time with us. So we're certainly glad to have you guys join us. So many thanks to the Greenwood Chamber for partnering with us, as well as Lander to help put on this event. And many thanks to Lander, Dr. Cosentino, for letting us use this auditorium and for allowing us to share some of the work that we do in health care right here in Greenwood. I really think this partnership between Lander and South Regional is really special. I truly think in Greenwood, they're two of the most influential institutions that are in the county. I really think in this whole area of South Carolina, frankly, and the relationship between the two has just grown better and better every year. And so we're certainly glad to continue to foster that. Tonight we have a special program. We're going to be talking about the evolution of spine care in Greenwood. It's really more than just spine care that our neurosurgeons do. They really take care of the breadth of neurosurgical issues. If you think about a community the size of Greenwood, to have some of the specialty care that we're able to offer right here at home for folks that live in this area is really phenomenal. I don't think you realize that until you actually maybe go away and see how some other communities are sized and the amount, the types of care that you can get in some other similar size communities. When I say similar size, I really mean like the number of people that live in a community. We itself regionally service about 250 to 300,000 people, and that's Greenwood and then the surrounding counties. If you look at other areas, you wouldn't have three board certified neurosurgeons serving a population that size. It's really special. It's very unique. We have a special little pearl here in Greenwood that I think many around the state maybe don't know about or certainly maybe don't appreciate. But anyway, I just wanted to say that. We have three phenomenal neurosurgeons with us here tonight. We have Dr. Jay Cole. Jay has joined us from Kentucky. He is a graduate of Wake Forest University and completed his medical degree at the University of Kentucky and stayed on there and did a neurosurgery and spine fellowship at the University of Kentucky. He's a board-certified member of the American Association of Neurological Surgeons. We also have with us Dr. Mike Kilburn and Dr. Lau. They've been friends for years. They both went to undergraduate at University of Saskatchewan and also medical school up there in Canada. And Dr. Kilburn went on to do a fellowship at the University of Alabama in Tuscaloosa, as well as Dr. Lau did a fellowship in neuro-oncology at MD Anderson. I mean, you've got some highly trained physicians here that are going to be talking with you tonight about some of the really amazing work that they do. And so without further ado, I'll turn it over to our neurosurgical colleagues and let them tell you about some of the cool stuff that they're working on. Thank you. Now on? Yeah? Okay. Well, I was hoping for some further ado. So, I mean, neurological surgery, I mean, is a specialty born out of the idea that we're going to identify pathology and implement a strategy to assist a patient with a problem related to the nervous system. So it spans spine care, it spans peripheral nerve care. In some instances, it spans intracranial pathology as well. So it's a reasonably specialized thing. And to reiterate some of the points that Dr. Logan made, we're lucky in the sense that we have a great community around us that support us. And we all realize that and work for the community. So moving along, we're asked to discuss neurological surgery here in our community. And so I was recruited here five years ago when Samir and Mike's former partner fell ill. And I interviewed in a number of different places before I made the decision to come here. And the decision to come here was really predicated on finding a collegial relationship and in a hospital system that was supportive. And that was one of the things that drew me to SELF. It's a very team-based place, and that spans nursing and my other colleagues who are physicians and other providers. so here's a screenshot of us looking I don't know screen shoddy all right slide I don't know who's got this like controller is that you get okay maybe I should grab that so these guys asked me to do a little a little talk we don't have any disclosures we don't we don't make money from industry so I think we can give you unfettered opinions about what we think in terms of products and so on you know basically there's there's there's two distinct stories in terms of neurosurgical care itself one is is is acquiring the correct people and that's that's been something that Mike started more than 20 years ago he came and then he added Samir and then he added dr. McLaughlin who is the neurosurgeon who fell ill that who I ultimately replaced and then they've added me and I felt lucky to be here and then married to that idea of trying to acquire the correct people to do the correct things we we have always partnered with the hospital to provide us with cutting-edge technology which really elevates the hospital beyond a city of 30,000 people so like I said Mike arrived in 1999 Samir joined him in 2004 they trained together so they're they were fast friends and and were friends all through their their residencies and maintain their friendship for that entire time Greg McLaughlin joined them and completed his residency I think the same place happens so there's this longitudinal history of the the the trans-canadian pipeline down to the Greenwood South Carolina of fearful Canadians hating the winner and then and And then I arrived in 2020. So a couple things about us, and I think important things to understand, is that we want to do safe care. We want our patients to be cared for like they're our family members. And I often am asked that, what would you do? What would you do if it was your wife or your dad or your mom? And I think if you can answer that question honestly, then you're going to certainly engender trust. And we always, I think, all work from that framework. We want to push the boundaries of what a regional hospital can do in a rural setting. So even though we have a 300,000 catchment area in terms of populace, we're in a smaller place. But that being said, we get a lot of consultations coming from Anderson and a lot of consultations coming from as far away as North Carolina and Charlotte. So we have built a practice that was built upon the idea of trying to adapt new technologies to allow us to do one and two. And then the other part of our philosophy is to espouse challenging cases. So we take on a lot of revision work, and then by its nature, you know, you can understand that having to wade back in wherever someone else has been in the world of surgery is sometimes a challenge because you weren't there the first time. And sometimes you were there the first time, but you have to address pathology because we're all in a state of continual evolution and sometimes, unfortunately, devolution. We're sort of slowly falling apart and things can happen that transpire that need additional work. And then the other thing I think that we've been very specific about in terms of building the practice, and this is really on the shoulders of Mike and Samir, and it started well before I came, is to have a team of people around us, meaning we have physician's assistants and nurse practitioners, we have nurse navigators, we have our colleagues who are nurses, we have physical therapists and occupational therapists, we have our colleagues in anesthesia and pain management. And together, we're charting a path, a course for the patients to see optimal outcomes. So in the context of the evolution of neurosurgical care in this city, we have to think about what was going to allow this place to find success in terms of what cases are we going to take on that are going to serve the community best and then really espouse the ideas of the philosophy I laid out. And navigation is the thing in terms of neurosurgical care, which is an important aspect of that. And what navigation means is imaging, because the neurologic examination is a blunt tool. It's a tool that certainly we use it every day, but the sensitivity and specificity of the findings on a neurologic examination leaves something to be desired. So we need to be able to hone in on pathology. And that allows us to sort of focus on the patient's issue and ensure that it's addressed at the time of an intervention. And it also allows us to deal with difficulties of placing implants to assist people in terms of having an optimal outcome. So, you know, neuroimaging had a very lengthy and longitudinal period of what we call the dark ages. This is one of the most brutal things that thankfully is never done nowadays. But this is a pneumoencephalogram table. So the way that we used to image intracranial pathology is they would do a lumbar puncture, which is where they put a needle into the spinal sac and drain all the spinal fluid out, inject air into your head, and then put you on this torture device, flip you around, rotate you around, and take some x-rays. And there's air inside the head. I can't imagine the headache that would come from that. But I would gander that it's absolutely brutal. So thankfully, we've moved beyond that. And my colleagues made a big pitch to the hospital at a reasonably high cost many years ago. And they purchased a brain suite, which was the first iteration of sort of neuro-navigation that's been purchased by Self. It served us very well for a long time. And thousands of cases were done here with great safety and a great traffic record. But like every other piece of technology, it sundowns. So some of the things that we noticed that were becoming challenging were navigation of drills because now we can navigate actually where the bit is going in a way that we don't have to watch where it's going. And then some of the fixations we do in terms of the bigger revision work, we were needing better imaging. So the newest iteration of that is an O-arm, and we have two now. So basically, this is an intraoperative imaging system that allows us to sort of take a CT scan of a patient on a table, register the patient, and then we can implement any number of tools and know exactly where those things are. The beauty of it is that it allows us to expand the profile of the cases that we can take on. It also allows us to sort of cannulate places that we would have to visualize directly by opening a patient up with a very long incision percutaneously. So we can make small incisions that are a centimeter long, place a drill in there and blindly drill, blindly deliver a screw and stabilize a person who suffered some trauma. So from the dark ages, now you see that now this is a person who has had an anterior and a posterior cervical fixation and a reconstruction of their neck. I mean, this is something that you couldn't do in the era of Newman cephalography with any degree of safety. So other things that we do that are sort of on the cusp of cutting edge are fixing some of the most distal portions of the places that we see pathology, one of them being sacroiliac joint dysfunction. So where your sacral bone, which is the bone that's at the lowest portion of your spine, and your hip meet, there's a very large joint, and it can be very painful for patients, especially if they've had prior surgery. What my colleague, Dr. Lau, has found is that a large percentage of patients that were deemed failures previously were actually patients who were suffering from sacroiliac joint dysfunction. And that's an operation that he can do in 20 minutes and the patient goes home the next day. And it's had a tremendous impact in terms of our community, in terms of safety, in terms of improving patients' quality of life. Other things we're doing are minimally invasive fusions and minimally invasive access surgical implants. So this is a case that I did where I put in two cages and six screws through two one-and-a-half-inch incisions, and the patients went home, you know, the next day from surgery. Other things we're doing include minimally invasive craniotomies. So whereas we used to have expansile incisions in the shape of a reverse question mark to have access to a whole side of the head, And now we can really tailor with imaging the ability to perform a smaller craniotomy, a smaller incision, and to resect a tumor via a little tubular retractor system. So we don't have to do as much by way of dissection, and it saves the patient time and grief. Other things we're doing include stereotactic radiosurgery. And Mike's taken this on as a champion with our colleagues in neuro-oncology. and what it involves is the delivery of high doses of radiation to very focal targets, and a patient can come in and have a metastasis from a systemic cancer and have that treated effectively in about 25 minutes and go home the same day. So from the beginning to the current state of affairs, there's really two things. It's acquiring the correct staff. It's building the correct team of nurses. So we look to you all as the future, and then coupling our efforts with our colleagues in administration, Dr. Logue, to allow us to provide that high-quality care. So at this point, I think we're going to open the floor to questions and see if there's anybody who has any other questions. We have a microphone because this is being taped. I would invite the questions to be posed to the mic so that we have both the question and the answer. Anybody? yeah so i i mean i think everybody in this room can say yeah they've seen gray's anatomy um but so something i never hear anybody talking about is steady hands when it comes to being a neurosurgeon or in general a surgeon how steady do you actually need to have your hands like i feel like people put this like you have to have perfectly still hands out there i don't i don't think you need perfectly steady hands i mean i think that you know you're you're going to operate from a position of of comfort i mean i think we all um face fatigue and we all brace ourselves we use two hands when we're working in really high priced real estate um but but i mean the key to having steady hands is is to not drink 15 cups of coffee before doing a complicated craniotomy and then the other key part of it is to is to just be relaxed and relaxation is something that comes with with repetition just like anything else but we i mean we all we all occupy our hands i mean mike is an avid pickleball player and and uh i play guitar and and samir likes to cook and so we all have things that we do with our hands every day beyond our beyond our vocation so you don't have to be made of marble but you obviously can't have parkinson's either i i've never actually had that question asked i mean that's really interesting that you bring it up um so you need to have somewhat steady hands in all aspects of medicine in in nursing as well i mean you're going to have to take care of patients, take out sutures, start IVs, stuff like that. So it's, I mean, I think, I think you need that no matter what you're doing, really. Yeah. Hey, so I see on TikTok a lot that, that was, that's really loud. I don't know how far I should have it i see on tiktok a lot that uh surgeons will talk about certain music they listen to while they're in the operating room or sometimes podcasts is there anything that y'all listen to while you're operating to maybe think make things go by quicker because i have to imagine some of those surgeries must take hours upon hours uh the tragically hip uh queen um queen's a good one Rush, from Canada, so I listen to a lot of Canadian bands. Samira likes the 80s. I think Jay likes bluegrass, yeah. So we have… Yeah, loud, yeah. And it depends on who else is in the room. Our scrub techs and circulating nurses have their own particular taste for music, too. So, yeah. Thank you. what is it that you guys look for when you're building like your team and like for nursing what is it that you look for that once that makes you want to pick that nurse or scrub tech or whoever is in the room with you i think jay said it i think he did a good job in his presentation, you want to have a team player, someone who is dependable, reliable, and is fastidious in terms of their attention to detail. That's really, really important. You could be the nicest person in the world, but if you're not sort of paying attention to little details, that's where you can really go astray with patient care. So I think that's really, really important. We have an excellent OR team. Our lead nurse in our room is truly excellent. Probably the best person we've ever worked with. And, you know, the stuff that we do is only part of it. I mean, there's a whole team of people. Like when a patient comes into the hospital they might meet us in the office one of the surgeons but they're cared for by dozens and dozens of people most of them nursing staff i mean i think i think an important thing to understand is that you know when samir and mike and i round on patients we i typically will see my patients once or twice every day and and that can be as brief as five minutes or it could be, you know, as long as, as the discussion mandates, but our colleagues and nurses are really the face of, of our care. And so I think compassion is one of those things, um, that we, we really value as a, as a, as a team member, because, you know, you, you all are with them, a patient for their entire shift. And, and, um, you're the, they're advocate for us. If a patient's having trouble then you reach out to us and we we formulate a plan together I mean I think that that's the sort of the normative way that this transpires so you have to you have to value yourself first but you also have to you know deliver you know care in a way that that that makes the patient feel feel loved because it it really is an extension of us thank you so I actually have two questions please one is what may y'all want to get into neurology and spinal care and what goals do y'all have in the future for this field okay I'm sorry I I didn't hear what you said. Could you repeat it, please? Yes, I said, what made y'all want to decide to work in neurology and spinal care, and what goals do you have in the future with your career in those fields? So I can speak for myself and Dr. Kilburn a little bit, because Dr. Kilburn and I did medical school together. We interned together. We did our residencies together. We did all our exams together. So we've known each other. We're brothers from another mother. I think neurosurgery in particular attracts a certain type of individual, somebody who likes to pay attention to detail, enjoys the challenge of learning neuroanatomy and neurophysiology, and enjoys spending time doing hard procedures. And it's something that you have to really enjoy and I feel very comfortable to say that I really enjoy it. And I really like going to work every day. I like getting up in the morning and going to work. And for me, personally, when I came here, there was just Mike and I and we had six employees. We have ten providers right now for neurosurgery, which includes two physiatrists, nurse practitioners and PAs. And we have, I think, about 30 employees overall. And so there is, for me personally, and I'm only speaking this on my end, is it's the enjoyment of trying to build something that you feel proud of. And so I think, for me personally, we've gone from doing surgeries that were very basic to essentially doing university-level surgery. from stereotactic radiosurgery, which, you know, the hospital has state-of-the-art equipment, for spinal surgeries, doing thoracolumbar re-exploration surgeries, and doing craniotomies that we know that we should be able to do here. You know, it was good enough that the MUSC thought we should be part of their allied staff. So I think that's what I like. And, you know, I can sometimes be very annoying to administration because I'm always trying to grow more because that's something that I enjoy. So I'd like to see my program grow bigger. I'd like to see this. So that's where, if you ask me what I'm sort of striving for, is before I retire, I'd like to see us have a bigger, better program that attracts people from beyond our service area. So right now, as it stands, I think Jay did an excellent presentation, We are getting patients from beyond our service area. That's a challenge, but spine care in particular, patients will travel large distances to have surgery if they feel that they're going to have a good surgery and they're going to be well looked after. So it's paramount for us to do the best we can. So that's what I'm personally striving to strive for. It's a bit of a challenge. It's not easy to do, but I enjoy doing it. um I'm losing my hair because of it but it goes you know so but but um I think neurosurgery to be in health care is a privilege for no matter what you do and you know people are relying on you when they're the most vulnerable so whether that's the patient on the floor and you're the nurse or a nursing assistant whether you're the physician assistant or the nurse practitioner. And they're even more vulnerable when they're in the operating room. They are totally helpless. You have a responsibility to try to help them. So I think if you think about that every day, there are days where, like any job, it's annoying. You get upset. You have a problem with, I had a problem before I came in here with an insurance company. And I was a bit animated when I was talking to them and so that's those are things that drive you crazy but but you have to look at it overall the overall picture it's a privilege so for me I really like my job I enjoy doing it I want to build something bigger and better for the community so that's my response to that so I have a question what is individually or together your most interesting case that you've had I think some of the some of the neoplastic cases that we deal with are probably some of the most interesting from a technical standpoint some of the most interesting patients that you have are because of the patient too. Some of the patients are really interesting. The circumstances and the stories and that kind of thing. You have a lot of surgeries over your career and they all kind of start to blend into one over the years. But I would probably say a big tumor, something that um, was challenging to take out, um, in a, in a, in a patient that, you know, like Samir was saying, you know, really needs your help, that, that would be an interesting case, so. All right, I'm going to give you a very interesting case. Um, I served in the army before I, before I became a civilian neurosurgeon, and I was a neurosurgeon in the army, and I had a patient who came in to see me, and he was a Vietnam-era veteran, but he never made it to Vietnam. He was on a boat that was sailing from Hawaii. He got hurt on the boat, and he got a severe head injury. He had an open head injury, and he's in the middle of the South Pacific. And there was a general surgeon who sort of patched him up. So he had an open head injury, so brain was exposed. This general surgeon took him to the little operating room on the boat, and he presented to see me some 40 years later. And he complained. He said, Dr. Cole, I have this spot behind where I had this operation some years ago, and it drains once in a while. I said, it drains once in a while. So we got a CAT scan, and he had an implant, a metallic implant. So I thought that perhaps he had an indolent infection. Now, the interesting thing about this case, so I said, well, sir, we should probably explore this, remove this old implant, wash it out, and if it needs to be reconstructed, we can do that in a delayed manner. So we just come to the operating theater, open this incision up, and I'm gonna give you two guesses what I found was the implant. Any ideas? So it turns out the general surgeon had taken some tin snips and he had cut a beer can Had the beer can I guess semi sterilized sewn this over the defect in this guy's skull and Then closed up the scalp and sent him on his merry way. He never made it to Vietnam He got shipped back to Hawaii and then shipped back stateside made his recovery and actually went on to live a successful full life but ultimately I removed part of a Schlitz beer can from this guy's head some 40 years later now that is an interesting case so if that makes it into your differential of foreign bodies in a guy's head that would be that's a once in a lifetime case yeah I think there's so many you know cases that are so interesting I before I moved here I was got a call from one of the military bases. I think it was Fort Bragg. And I got a call from them. And one of my colleagues, who's a cardiothoracic surgeon, was in Afghanistan at the time. And they had a, uh, informant that, um, had, uh, uh, an injury and, um, and they patched me through and they had to do emergency surgery and he's never done a craniotomy or opened a patient's head because it was a subdural. And so, um, they, they got me to, um, talk to him while he's in the operating room, and they were able to patch some kind of an image to me, and I was at the hospital and directed them on how to do a craniotomy and get the subdural evacuated because the patient was dying. So you just don't know what's going to happen, and interesting things like that can happen anywhere, but that's the advantage of this. It's what's interesting about a job like this is that you're always amazed at what can happen. So that's an example of something that's very interesting, which I actually wasn't actually doing the surgery, but I was directing a cardiothoracic surgeon on an emergency case in the field on an informant that worked for the US government. So there's a lot of interesting things that can happen in our career. So we see a lot of really interesting things, both here in the office, you know, the operating room, but then even something like this that happened to me was very interesting. You guys are going to see an evolution in your careers that are going to blow your minds. Like, what we've seen in our 25-year careers has been staggering, but with information technology advancing as quickly as it is and imaging and the treatment of new or new treatments for old diseases, I think your careers are going to be absolutely fascinating. You can kind of do whatever you want to do, but whatever area in healthcare that you decide to pursue, I think you're going to have a really, really interesting career ahead of you. And I think the introduction of AI is going to change a lot of things from how we diagnose patients, how we follow patients. One of the things that, you know, so in the Southeast, I've started, I'm the first practice, I'm sort of the test case for our group. We're the first practice to have AI integrated on certain cases that we do where the rod is prefabricated and sent from Memphis. It used to come from Paris. But they opened it, and they give the exact, or roughly the exact bend and placement of the rod that goes into the system. And it ships overnight. But that's not really the fascinating part. The AI integrates with our EPIC programming. And what it's doing is it's looking at my images preoperatively and postoperatively. And what it's doing is it's also looking at my note and trying to find whether or not how the patient's doing and looking to see if, I guess, the outcomes are as well, but also how the anatomy looks. And eventually, when you generate enough cases, it can start giving you predictive analysis of what you're doing. So, for example, if I fuse two levels, but 75% of the time I'm taking a patient back to do another level, the AI is going to be telling me that this particular patient may benefit from an extra level of surgery. So, you know, these are innovative and new things, and that's something that's very unique. Like, in the whole Southeast, you know, SELF has, you know, started that program. And so I think there's a lot of opportunities for things to change. I mean, the way we used to put screws in before was blind, really. I mean, you had to do feeling and making sure you were in the right spot. Now, as Jay said, we can put a screw in without actually looking down at the patient. You're looking at a screen, and you're putting a screw in where you've got anatomical structures that could have devastating results if you have an error. So you have nerve roots, you have the aorta, you have the thecal sac, and you can get spinal fluid leaks, you can have paralysis. But we're able to put these things in without even looking. We're just looking at screens. And so that's really something. And Dr. Kilburn and I, we did pneumocephalograms too. when we first, or our staff did, where they would put ventriculostomies in and put air in. So we've gone from that to what we're doing now. And with AI, I think it's unbelievable. And I think you guys are going to see big evolution in healthcare in the next decade or two. What is your, like, biggest piece of advice for when you have to deal with, like, stress on your job, like loss or distress in general? Exercise. Sorry, pretty general question. Pickleball is a great way to go. No, I mean, have great relationships, have interests outside of health care. get a dog. Enjoy your practice, whatever you decide to do. Understand that you don't give the patient the disease. You do your very best to try and help them with it. And most patients are very appreciative of that. And they want your help and they understand when things don't go exactly right. But most of the time, most patients ultimately do fine. But have some other interests besides health care. Yeah. I think, too, as a health care professional, patients can be very difficult. Your colleagues can be very difficult. The insurance company can be very difficult. I don't have any sympathy for those guys. But I do think you have a couple choices. Stress also at work is because I find people react. And reactions are usually instantaneous and spontaneous. And they're usually filled with anger. And so you get upset. You have a choice of reacting or responding. And I think to be a good healthcare provider, to be a good nurse, to be a good physician, is you have to respond, which means you have to stop, listen, and try to understand the other person's point of view. You don't know what that patient's going through. You don't know what your colleague's going through. There's things that every human being goes through every day. I think if you start stopping and sort of responding to people rather than reacting, that carries good in your job, but it also carries out in your personal life. So I think that's a good way to reduce stress. And then find things that you like to do, like painting or running or whatever. So I think all of those things matter. But I find at work, that's the big issue I find, is I feel people just react to everything. Maybe it's the TikTok generation. I don't know. We always have to flip and react to something, but I don't think that, I think that's really where people have problems. That includes myself. I think the other piece of it is that, you know, we deal with real sadness. I mean, I think we all get pretty close to some of our, specifically our oncologic patients, our patients with cancer. And that's a carousel that some people get on and get off of, and some people never get off of. And it's very validating for you to express your sadness. It's okay to be upset. I mean, I've cried with patients before, and that doesn't make me feel weak. It just makes me feel like a human being. And embracing the fact that we deal with hard things is not something to be embarrassed by. I think we have time for one more question, if there is one. Thank you all for being here tonight. Thank you for the questions. Gentlemen, and thank you for taking time out of your busy schedules to put this together for us and be part of our Medically Speaking series. Your expertise and your compassion came out here in full force tonight, and we thank you for that. We've got refreshments upstairs for you all, and while you're here, we're going to do a little photo op up on the stage with a couple of the folks from Lander and the hospital, and then we'll be right up there after you. So thank you all again. Our next program is February 6th, and it's about weight loss and some of the issues around that.