Helping Medical Students Manage Information Overload - Dr. Ted O’Connell, Regional Director of Medical Education at Kaiser Permanente, Northern California

Shiv Gaglani: Hi, I'm Shiv Gaglani and today I'm delighted to welcome Dr. Ted O'Connell to Raise the Line. He's a family medicine physician who has deep experience in medical education as a professor, department leader, textbook author, and residency program director. Among his many accomplishments, he's authored eighteen medical textbooks with Elsevier and serves as editor-in-chief of Elsevier's ClinicalKey MedEd. 

He's putting all that experience to use in his new position as regional director of undergraduate, graduate, and continuing medical education at Kaiser Permanente in Northern California. Dr. O'Connell is also a best-selling author, podcast host, and speaker, and has launched several companies in medical education and communications. 

I'm really looking forward to getting his perspective on how to improve medical education, among other topics, and I'm also a personal fan and user of his products.  As many of the listeners to Raise the Lineknow, I'm actually resuming my third year of med school. So, before we started this podcast, I was talking to him about how I've been starting to use his products to study for the USMLE as I've been going back into rotation. So, Dr. O'Connell, thanks for taking the time to be with us today. 

Dr. Ted O’Connell: Absolutely, Shiv. It's nice to see you again, and I appreciate the invitation to be on your podcast. 

Shiv Gaglani: For sure. So, obviously I know a lot about your background, but what we like to ask all of our guests on Raise the Line is first, in their own words, to give us their career highlights and what got them interested in medicine in the first place. 

Dr. Ted O’Connell: Absolutely. I think this is actually a story of interests manifesting in unexpected ways. When I was in high school, I was really interested in business and entrepreneurship and then had a participation in a service project helping to take care of the unhoused in Los Angeles and that really kind of changed my world view quite a bit and I started to reconsider my career goals. 

As I headed off to college, I kind of put the business idea on the back burner and thought, you know, maybe I want to be a writer and write the great American novel or even screenplays. But then I also got some very good advice to essentially take some math and science classes and have something solid to fall back on in case the writing didn't work out. 

So, as I wove through my college experience, I ended up majoring in psychology and also participating in the pre-med program and realized towards the third and fourth years of college that I really wanted to go to medical school. There was some family influence there, certainly interest in the sciences, and really a desire to help others directly. That's how I ended up going into medicine. But then subsequently down the line, started writing, had the kind of business and entrepreneurship interest manifest in terms of some of the online medical education products that I've helped launch. So, it's interesting just to think about how things kind of come through in unexpected ways. 

Shiv Gaglani: For sure, yeah, the zigzagging of careers is very interesting. We're definitely going to dive into your educational experience and background, but first, let's go into your clinical. Can you talk to us a bit about your present clinical state? You chose family medicine. What do you find most satisfying about the clinical work? 

Dr. Ted O’Connell: Yeah, you know, I love being a physician, and even in this new role overseeing the medical education programs for Kaiser Permanente Northern California, I've maintained that clinical practice and still do both inpatient and outpatient. It’s part of my professional identity, it's part of what I like to do. I also think if I am the leader of our organization for medical education, it's important to still be a physician and be able to have that credibility. 

In terms of your question about why family medicine, there are actually a lot of factors that went into that. The ongoing relationship with patients over time, the ability to develop that deeper relationship...I really enjoyed seeing the full age spectrum that family medicine offers. I like working with my hands as well. There's a certain procedural component that you can build into a career in family medicine. As I was thinking about careers, I was also having a hard time with the idea of giving up parts of what I had learned in medical school to focus really narrowly. It was just something that I didn't feel like I wanted to give that up, and I wanted to stay broader. 

Because family medicine is a broad field, there's real opportunity to flex your career and go in different directions over time and almost reinvent yourself, and I kind of liked that component of it. And then I really like the people that are in that field. When I did my rotations, I felt like I had kind of found my tribe.

Shiv Gaglani: Yes, absolutely. I think that's a common way to pick specialties is, you know, who are you like, who are your mentors? And certainly there are other people I know and who I have come to respect who choose the family medicine career. People like David Price from the American Board of Medical Specialties and Atul Nakhasi, who was one of my friends from medical school, who was on the Raise the Line podcast and actually wound up doing a lot of homeless care during COVID in L.A. So, maybe he has similar kind of background there. 

Dr. Ted O’Connell: Yeah, you're absolutely right. There is that kind of common theme about how people find their specialty. 

Shiv Gaglani: Yeah. So, moving to the education side, we're both fans of Jim Merritt, who kept in touch with me since when we were just starting Osmosis and he also has been working with you for a number of years with your books. Can you talk to us a bit about your experience as an educator and then specifically how you got involved with Elsevier and maybe some of the projects or books you've worked on at Elsevier that have been most satisfying? 

Dr. Ted O’Connell: Absolutely, and I'm glad you gave Jim Merritt a shout out. I'll mention his connection to Elsevier and me in a moment. In terms of the educational side of my career, you know, it's interesting, I didn't really think of myself as an educator early on. But then now looking back on it, you can kind of see the dots and how they all connect. When I was towards the end of my college career, I actually returned to my high school and was essentially looking for a summer job, and for two summers, I was a summer schoolteacher there teaching science courses. I think that's kind of the first nugget of interest in education that happened. I really enjoyed that.

I then realized as I progressed in medical school that as I was learning, I had something to offer to those who were a year or two below me. As a fourth year, I really embraced that opportunity to help kind of take the third years who are new on their clinical rotations under my wing and try to teach them what I could and kind of smooth their pathway out a little bit. I got involved in the doctoring program at UCLA that allowed me to teach courses for the first years in their doctoring curriculum. As I progressed in residency, it was kind of the same theme...the opportunity to teach the medical students and the more junior residents. 

Over time, I realized that I wanted to build medical education into my career and got some very nice mentorship from my residency faculty. By the time I finished up residency, decided I wanted to land in a faculty position and make medical education a real part of my professional career. Along the way, I started writing both journal articles and some clinical materials and some board review and ended up meeting Jack Pfenninger, who's also known as John Pfenninger. He's the one of the two authors of Procedures for Primary Care, which is kind of the bible for procedural care in primary care medicine, and he invited me to help do some writing and editing of his textbook. 

Then a few years later, I had an idea for a clinical textbook that I wanted to write. I reached out to Jack and said, “Hey, you're an author. Do you know anybody that you could put me in contact with?” And in his very kind way, he not only gave me an email address, what he actually did was write a nice introductory email to Elsevier and Jim Merritt kind of vouching for me. That led to the Instant Workup series of books. Then, working directly with Jim and Elsevier, I was offered the opportunity to become an editor of Procedures for Primary Care and then took over some of the products that Elsevier has-- the USMLE Secret series and the USMLE Crush series, and then we launched a Crush Step 1 -- that didn't exist, and it's now an almost two-decade relationship with Elsevier that's been, I think, just a really great one.

Shiv Gaglani: Yeah, absolutely. So, what are some of the things you're most proud of? Because obviously you've authored a lot of titles, you've educated a lot of students over those two decades and even before then. But, like, what stands out as some of the things you're most proud of at this point? 

Dr. Ted O’Connell: Well, really, my intent with being involved in these products is twofold. One, was to develop some clinical resources that would make clinicians' lives a little bit easier and hopefully lead to higher quality patient care; and the other was to develop USMLE products because, you know, those standardized exams can be a real hurdle for a lot of students. 

It can be tough to synthesize all of the medical material that you need to learn in medical school and really my hope -- similarly to what I was trying to do as a teacher and kind of smooth people's pathway -- is to help everyone get through medical school with a little bit more ease than the current system allows.

Ultimately, I think if you're providing people with a really solid medical foundation, that's ultimately going to lead to more wellness in their professional careers and hopefully better patient outcomes. That's really what I've been going for.

Shiv Gaglani: Yes. I can relate to a lot of that. Not only do we want to improve the experience of students during a very hard but formative period of their life, but most importantly, the outcome of medical education is patient outcomes. That's ultimately what we're doing. So, that's been definitely a great source of meaning for us at Osmosis, I'm sure for you as well. 

Let's talk specifically about Clinical Key Med Ed. Do you want to just give us an overview and what's your role as editor-in-chief?

Dr. Ted O’Connell: Absolutely. Clinical Key Med Ed is actually an entire platform of medical education products that Elsevier has. My role in there has been to be the editor-in-chief of the USMLE Step 1 and Step 2 question banks. The things that I think make this question bank particularly powerful is, first, it's supported by foundational textbooks. Elsevier's got Netter's Anatomy, Nelson's Textbook of Pediatrics, Cecil's Essentials of Medicine, Robin's Pathophysiology...kind of all the books that everybody knows. Those are foundational to this question bank and directly linked within the system to each question so that after you take the key learning point from your question, if you want to take a deeper dive into any particular topic,that platform allows that really direct linkage there. 

The other thing that we did that I think is fairly novel is around quality control and the review of the questions that went into this question bank. What we did was actually created a three-tier process.Each question is reviewed by an editor and then by a senior editor and then by me as the editor-in-chief. So, you know, things change and errors, I'm sure, can happen. But we've really done a solid job of ensuring that these are truly high-quality questions and learning points that exist in this question bank.

Shiv Gaglani: Yeah, certainly. I've started playing around with it because, I'll be taking the USMLE exams in the coming years and certainly will be relying on it, so I appreciate all the work you guys have put into that. Outside of the Elsevier educational work, I wanted to give you an opportunity to comment on any of the other kind of educational work you've done outside of Elsevier and Kaiser Permanente before we get into your role at Kaiser. 

Dr. Ted O’Connell: Sure. I think the one that I'm most engaged and most proud of currently is MedPrep2Go. What we're doing is crowdsourcing questions and putting them out in audio format and making them free, which I think is actually a key thing. The intent here is just like any of the other medical education that I've done. It’s to ease people's path and make sure that you're building a solid medical foundation and having a reasonable approach to the standardized exams. But I really wanted to help support student wellness, and my thinking here is that if you have an audio product, you can listen to that while you're working out, commuting, doing chores, cooking dinner, whatever, so that you're kind of maximizing your time and hopefully creating a little bit more time in your day so that you can visit with friends and family and pursue your hobbies and interests and maintain that balance as you go through medical school.

Then the other piece is to put it out there free of charge to help support students. Medical debt is a real issue in this country, and I get it that this is just a small piece, but I think if a lot of us are taking that perspective of what can we do to lessen that debt load, that also hopefully will help lead to student wellness. 

Shiv Gaglani: Yes, absolutely. We had Jim Dahle, the White Coat Investor, on the podcast and that's definitely an area that we've talked about at length, which is why making medical education more efficient can help things go from a four-year medical program to a three-year medical program. You could save a whole year of time in tuition or replace tuition with earning potential. So, there's all these kind of ramifications. 

That's actually a good segue into your work at Kaiser because that starts from undergraduate to graduate to CME -- so, you see the whole spectrum. Talk to us a bit about the role of Kaiser Permanente -- which, by the way, I'll say is known as one of the most innovative systems in the entire U.S. given the cost and the outcomes -- so maybe you can talk a bit about that context too.

Dr. Ted O’Connell: Absolutely, and Kaiser Permanente is known as an innovative leader, is known for its integrated health system, its focus on quality, outcomes, population care.  I think because we're known for those things, our educational footprint isn't always known or recognized outside of our organization, and that's one of the things that I'm really trying to do in this new role is to make sure external organizations see the footprint that we have and the outstanding residency training programs. 

So, in our system, just in Northern California -- and I want to emphasize we have training programs in Southern California, Mid-Atlantic, Pacific Northwest -- but in Northern California alone, we have 800 medical students who come through our facilities each year for their third and fourth years to get their clinical rotations, as well as many pipeline programs that we have that reach down into community colleges, high schools, et cetera, to help develop the health care workforce in our communities.

We have eighteen residents and nineteen fellowship programs in Northern California. That includes 375 of our own sponsored residents. Plus we also get 1,100 residents per year from surrounding residency programs at UC San Francisco, Stanford, UC Davis, et cetera. So, there are a lot of trainees coming through our system to get exposure to patient volume and expertise in our system. 

There's a lot of research as well going on, both within the training programs and outside of the training programs. Each of our residency and fellowship programs is supported by a research project manager that then plugs into the biostatistical consulting unit at our division of research. Just last year in 2022, we had 320 resident-led research projects that happened, so it’s a really large research footprint.

We have over 5,000 CME events annually at Kaiser Permanente in Northern California, and that's, again, just emphasizing that's just Northern California. Southern California has nineteen residency programs of their own and I believe sixteen fellowships. So, it's a really big educational footprint that I don't think is always recognized because it's our system that gets a lot of the attention.

Shiv Gaglani: Yes, that's an incredible scale. We've been privileged to be able to work with people like Mark Schuster, the Dean of the Kaiser Permanente School of Medicine, as well. I've just been really impressed with the kind of ground-up approach that people at Kaiser take and try vertically integrating and removing a lot of the inefficiencies that a lot of siloed systems seem to have. So, zooming out to all the education work, let's talk about medical education as a whole. What are some of the positive changes you've seen in the medical education landscape in the last couple of years, and then what are some of the biggest concerns you have about where we're going, or opportunities? 

Dr. Ted O’Connell: Absolutely. There's been both of those, a lot of positive changes as well as concerns and challenges that medical education is facing. In terms of positives, I would point to more students who are traditionally underrepresented in medicine going into careers in medicine, and we still have a lot of work to do in networking and programmatic development to continue to make that happen. But seeing that has been outstanding. We also need to build systems on the other side of it to make sure that those learners are supported as they go through their medical education or medical school and residency training. 

We're seeing more medical schools initiate early clinical experiences in the first and second year. You know, it used to be very traditional where first and second year were classroom work and then you'd be launched into your clinical experiences in the third year. But I think building that in early just has a lot of benefits for medical education and really creates a why for why you're learning this stuff from the textbooks and videos and wherever else you're getting your information.

In terms of concerns, I think the pandemic very definitely for those two, two and a half years had an impact on students' clinical experiences for that cohort going through, and that's created some challenges and hurdles for that particular cohort in terms of just getting back up to speed from a clinical standpoint.

Burnout is a process that really probably begins in undergrad and the pre-med experience and then on through medical school. There are just higher rates of burnout all the way along the line that I think need to be addressed. There are some medical schools that I think rely a bit too much on shadowing experiences in the clinical realm as opposed to actually getting in there and being more like a junior resident. So, that is something I think probably needs to be addressed. 

Probably the biggest challenge is just the doubling time of medical knowledge that exists and the challenge in managing that. In 1950, the doubling time of medical knowledge was fifty years, and by 2010, it was down to three and a half years and is now estimated to be somewhere around seventy-three days. So, just trying to manage all that incoming knowledge. What that actually means is that whatever somebody learns in their first three years of medical school, ten years from now, that's going to be only 6% of the knowledge that they need to have. Trying to fathom how you keep up with that doubling time is just a challenge for all of us in medicine and speaks to the need for lifelong learning, too...making sure that you have access to really good CME and other medical education sources. 

Shiv Gaglani: Definitely and those are great stats to share. I'm glad you brought that up because when I started med school, which was not long ago, it was 2011, the saying was “50% of what you learn in med school will be out of date in five years. The problem is you just don't know which 50%.” Clearly, if we talk about five years ago, there was no COVID-19 and obviously that became a major issue the last few years. 

So, this is something I'm just kind of asking all of our guests about because AI is so in the news and so top of mind and I've been experimenting with it a lot. The age of AI has begun, with ChatGPT really bringing it to consciousness. There's been a lot of AI over the years. We've had people on the podcast like Eric Topol and Dr. Dave Albert, who you may know, talk about AI in medicine and there are tons of FDA approved AI tools for detection of different ailments -- ECGs, radiology, dermatology, et cetera. But this is different where it's about knowledge generation, knowledge creation. You can use these tools to create quizzes, multiple choice questions, to create videos, to diagnose, potentially. A lot of that's happening. There are examples of people plugging in lab results in a patient case and getting a differential diagnosis. Companies like Glass Health, et cetera. So, I'm just curious, what's your take on generative AI and are you starting to use it? Are you pro? Are you con? What do you think? 

Dr. Ted O’Connell: Well, I think, some of our tech leaders are starting to urge some caution around AI, and I think that's certainly in the background that we need to think about unintended consequences and how it potentially can alter society. But I'm pro overall, with that note of caution. When you think about clinical medicine, the opportunities are virtually boundless.

Recently there was a discussion of the ability to have the AI listen in the background and help generate clinical notes, and as you mentioned, the ability to potentially diagnose cancers earlier and assist in mammography. You could take any particular part of medicine, I think, drill down and see how AI potentially has a benefit there.

The other question is, how does AI fit into medical education? I'm still kind of pondering that because it's a double-edged sword. It has the ability, I think, to really help synthesize data and allow a learner to focus in a particular area. But it also has the potential to just massively increase the amount of information coming at a learner, and I think it will be very important for learners to understand what their learning style is so they can harness AI to help them really drill down into how their brains work the best. But I think we all know we're really just scratching the surface here and seeing the tip of the iceberg in terms of what AI might be.

So, it's going to be something I will continue to explore and try to figure out how it works into medical education. 

Shiv Gaglani: Yeah, absolutely. And continuing on that theme, one debate that flares up every couple of years in earnest -- but it's kind of in the background all the time -- is the importance of summative assessments, right? So as we know, I think the majority of colleges in the U.S. don't even require the SAT or ACT anymore. Eight years ago I wrote an article for the Healthcare blog called The Real Problem with Board Exams and How to Solve It, where I was advocating that the USMLE -- among other summative assessments -- plays two important roles. One is, the demand for certain residency spots outweighs the supply, and so you have to have some sort of national objective exam to help program directors figure out that -- and you're a program director, so you can comment on that much better than I can. 

The second and probably more important one is, it's a forcing function for people to sit down and learn, right? They actually just have to learn. They can't just kind of go through and pass classes and not really emerge with a working knowledge. The analogy I used was vocabulary. Why do we teach children vocabulary in school? It's because even though we have great dictionaries and word processors and tools like that, if they don't know any vocabulary, their ability to read or write is just so slow. They won't even know how they're using words because they don't know the connotations, et cetera.

I think it's very similar to why you have to sit down and actually have a working knowledge. But that was ten years ago. Now with AI and diagnosing better -- being able to pull the right clinical trial guidelines, pull the right scientific paper to try a new drug -- the role of a doctor has changed. The role of a nurse is changing. Both of us have done so much USMLE test prep. I'm just curious, what do you think of these exams? Step 1 went pass/fail. Step 2 is more important now? What’s your commentary on that?

Dr. Ted O’Connell: Wow, Shiv, we could probably do a whole hour on this topic alone, but I'll try to hit some of the key points. I totally agree about the forcing function of an exam like the USMLE. I think it's important that we acknowledge that those exams can be biased, that individuals' access to education programming starting with kindergarten can have an impact on how they're able to perform on an exam like that. Because of the cost of the exam and the cost of some of the preparation materials, there's variability in terms of individuals' access to materials to prepare for that. All of that does create inequities in our system that we absolutely need to address. 

In terms of the exam itself, over these last two decades, the exam has moved away from memorization and more towards clinical vignettes and synthesizing information and being able to take medical knowledge and apply it to clinical scenarios. So, I think that's heading in the right direction. But as medicine changes and AI gets involved and we're now in an era where it's more important to know how to find where the information is than to have it all in your brain, the exam's going to need to change.  Besides the forcing function that you mentioned, it is a licensure exam, and similarly to somebody who's trying to get board certified in a particular specialty, there's a certain quality control that I think is behind the intent. 

I don't want to minimize that this is big business and the USMLE brings in a lot of revenue on the backs of medical students. Like, none of that is lost on me. There is a quality control component in our society, and there's a reason why residency programs are accredited, and medical schools are accredited, and this is kind of the way to accredit individuals. At the same time, I think the exam kind of needs to be rethought for these next ten, twenty years where medicine's rapidly changing.

Shiv Gaglani: Yes, that's a very nuanced reply. I appreciate that and hopefully we can get you back on the podcast and talk more about this or work on a paper or something together about it because I think it is a fundamental question in every level of training -- not just medical -- but college, pre-college, they’re all going through this existential crisis of what's the point of education in this age or how do you optimize it. 

So, I know we're taking you over time, so I only have two other questions for you. The first is, you directly and indirectly helped so many current and future physicians. What's your advice to our audience about meeting the challenges of the present moment and approaching their careers in health care?

Dr. Ted O’Connell: I think I have a couple of pieces of advice there, Shiv. One is to seek mentorship early. You know, medicine is a nuanced field. I don't think anybody inherently just knows how to go in and be successful in that, and mentorship can really help facilitate that path. It's important for everyone. I think it's particularly important for those who are underrepresented in medicine because they don't have the same representation in the medical field. So, trying to seek alignment in the mentorship is super important. 

It is a tricky process, just starting with the whole pre-med program and how do you get into medical school and then how do you navigate and how do you learn best and how do you pick a specialty. There's so many potential pitfalls and potholes that I think having that mentorship and starting early can really help facilitate the process. 

The other really big thing that I think can help students address the challenges is really considering how you learn best. We all have different learning styles. There are a lot of resources out there that fit different learning styles and sometimes what works for you in college doesn't work as well in medical school. Then, even if it works well in medical school, suddenly in residency you're mostly a full-time physician and have less time to learn. So, just consider how you learn well and what your strategy for learning is going to be so that you can build that knowledge base to help you care for patients. It’s just very important to be intentional about all of that.

Shiv Gaglani: Yes, that's extremely wise. Those pieces of feedback are things I hope our audience really dives in on from this conversation. My last question, is there anything else in this short conversation that I didn't cover that you want to leave our audience with about you, about Kaiser, your background, medical education...whatever you'd like?

Dr. Ted O’Connell: I think we've had a pretty broad-ranging conversation here, Shiv. There aren't any real gaps that I think need to be filled. In thinking about medical education as well and where some gaps exist that I think Osmosis should address -- or I should help address that just really need to be filled in -- one is personal finance for medical students, residents, and physicians. It's just something that, unless you're taking business courses or doing it intentionally, doesn't really get taught along the way. And embedded in that, I will also add topics around the business of medicine. I think learners in medicine would do well to make sure that they're acquiring some understanding about how medicine actually works and how revenue streams come in and just all the kind of basics of business and medicine I think would be good.

Dermatologic principles for colored skin are one that's been top of mind for me recently. It just has not been represented well traditionally in the medical literature and is now getting some additional attention, but something that needs to be taught better in our medical institutions. 

Then finally, climate change and its impact on health. It affects wellness and health and something that we probably need to address a little bit better as a medical education community.

Shiv Gaglani: I think all three of those are excellent examples. And you're right, I think it comes down to the schools hopefully teaching these better or at least incorporating them. Just three quick comments on those. On climate change, you probably know Dr. Mark Triola at NYU, who's been a long collaborator like Kaiser Permanente has. His wife did a knowledge drop with us on Climate Change, because climate change in health care is a very interesting topic that we can spend a couple hours discussing. 

Second, we're obviously part of the Elsevier family together, and we know Complete Anatomy, I think, has done a great job of introducing diverse skin types in their models. Most recently in the woman's model as well. But then I think you may know Art Papier with VisualDx, who was also a Raise the Line guest. I think they have a really great offering in terms of diverse skin colors and skin types. Obviously, we can all do better, but I think they're leading in this. 

The third is, I mentioned The White Coat Investor. I highly recommend people get interested in personal finance because of the large commitment they're making when they pursue a career in health care, especially medicine. Median debt is $200,000 when you graduate. That's a mortgage. How do you pay that off? How do you live like a resident, is what he often talks about. So, we've done several videos on that. 

But most importantly, medicine is changing so quickly. The reason we have this podcast is five years from now, not just AI, but the value-based medicine is now, what...5%, 10% of health care dollars versus fee for service? Twenty years ago, that was not the case. So, things are changing so quickly. Kaiser set the framework for a lot of other health systems to become integrated delivery networks. I think taking an interest in this list and the podcast, reaching out to people like you on LinkedIn -- which I would encourage all of our listeners to do -- finding the right mentors, I think, can really help educate them, but more importantly, like bring in some smart, passionate, mission-driven people to help you fix the problems that we're discussing here.

Dr. Ted O’Connell: Yes, and thank you for pointing out resources around each of those three areas. They exist right within Osmosis and your podcast and Elsevier, and they're out there in the world as well. But I think that intentional pointing your listeners to where they can find that is just outstanding.

Shiv Gaglani: Thank you. And, Dr. O'Connell, I'd like to thank you not only for taking the last thirty to forty minutes with us, but more importantly, for the work that you've done over the past several decades to educate countless current and future health care professionals, including myself. So, thanks for all that you've done to raise the line. 

Dr. Ted O’Connell: Oh, it's my pleasure.I appreciate the invitation to be on your excellent podcast, and I wish you all the best in these next two years of medical school for you. 

Shiv Gaglani: Thanks so much, and with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to raise the line and strengthen our healthcare system.We're all in this together. Take care.