Exploring Trends & Opportunities in Oral Healthcare - Ann Battrell, CEO of the American Dental Hygienists Association and Laura Skarnulis, CEO of the Dental Assisting National Board and the DALE Foundation

Shiv Gaglani: Hi, I'm Shiv Gaglani, and today I'm delighted to welcome two leaders in oral health care to Raise the Line: Laura Skarnulis, CEO of the Dental Assisting National Board and the DALE Foundation, and Ann Battrell, CEO of the American Dental Hygienists Association. I first met Laura actually when she used to work at the American Board of Medical Specialties, the ABMS, which is one of our close collaborators and has been for many, many years. We share many connections, including people like Dr. Lois Nora, who's a personal friend and mentor of mine. Today, I'm looking forward to hearing about their organizations and current trends in oral health care, and getting their insights on the state of the oral healthcare workforce. So, Laura and Ann thanks so much for taking the time to be with us today.

Ann Battrell: Happy to be here.

Laura Skarnulis: Thank you so much, great to be here.

Shiv Gaglani: So what we do for audiences, to set the stage, is to first ask a general question about kind of how you got started in your careers, and what got you interested in healthcare, and then specifically oral health care? So maybe, Laura, can you start us off?

Laura Skarnulis: Sure, I'm happy to do so. So I've been at DANB, the Dental Assisting National Board, and the DALE Foundation now for just over a year. I came here in August of 2021 after, as you mentioned, I was at ABMS, the American Board of Medical Specialties, for about eight and a half years. Both organizations serve as certification organizations for healthcare professionals. My interest in healthcare and my interest in working with organizations that have a purpose stems back to probably twenty-plus years ago. I started my career in public accounting and went into corporate and then I ended up taking a different path and went into organizations that were really making impacts in communities and I found that by connecting my work to an organization's mission and giving back to their communities, or the patients that they serve, is something that's really important to me, and where I can really thrive and do better work, I feel personally. 

Really over the last year or so, DANB and the DALE Foundation, we've implemented many initiatives where we are affording the opportunity for people to increase access to care, or as a professional, increased certifications and other educational opportunities for those professionals to continue to advance their own careers.

Shiv Gaglani: Yeah, and absolutely…that's something we've related on for many years is the scale of the impact and being very mission-driven with what you worked on at ABMS and now clearly what you do at DANB and DALE. So, Ann, how about you? Can you give us a bit of your career highlights and what led you to lead the American Dental Hygienists Association?

Ann Battrell: Sure. A lot of my journey in oral health and healthcare in general started because I came from rural America, rural Illinois, where the dental cavities rate was very, very high. We had one dentist for the entire town, and he happened to rent from my dad. So, I was able to get that entry-level position and as a high school kid I began the journey of learning oral healthcare. The dentist's wife -- ironically, her name was also Ann -- she became my very first mentor. I thought what she did as a dental hygienist was so cool. She was the lifeblood of the entire practice and I just loved her so I learned and learned and learned from her as much as I could. 

When I was just seventeen years old, I had graduated from high school early, so I decided to apply to dental hygiene school. I applied early and I got into Northwestern University and I said goodbye to rural America and came into downtown Chicago. The student membership in the American Dental Hygienists Association was something that our faculty always stressed how important that was for us. I had no idea what that meant. I was a seventeen-year-old kid, but I knew how important the organization was and so my professional ethics required me to support it. Little did I know that thirty years later, I would return to run the organization as CEO. It was a great opportunity. 

In my first two years at Northwestern, they didn't have the baccalaureate option, but in my very final year before I became a hygienist they started a baccalaureate program and they asked me and four of my classmates to come into the program kind of as guinea pigs. They tried every single thing they could, threw a lot of different opportunities at us, and asked for our feedback all along the way. So, I became very much a lifelong learner, which is really important to me even in the role that I play at the ADHA today. 

I practiced for a while. I taught dental hygiene for a while. I did some corporate work for a while. So, I had a varied career, which I'm going to talk a little bit about, Shiv, throughout our podcast today…about how important the variety is in your career as Laura has already talked about. I obtained my Master's degree in dental hygiene from the University of Missouri, Kansas City just a few years ago and I was also a guinea pig in that program. I did all of that online when online was first becoming the popular norm. I got very involved in online education and found that it works. 

On the ADHA side, I became president of the association in 1996-1997 and then, after that stint, I was asked to join the staff as a manager of dental hygiene education just a few years later, and then became the CEO about, believe it or not, twenty years ago.

Shiv Gaglani: Wow, that's incredible. I love how your story began with a very personal kind of interaction with a dental hygienist who kind of worked out of your father's office, to now leading this large organization. My personal story and connection to the dental field -- as Laura really well knows from all my times visiting Chicago -- is that my sister and brother-in-law, Dr. Anushka Gaglani and Dr. Abhishek Nagaraj, are dentists who have half a dozen dental practices in the Chicago area. I've gotten to know many of their staff, including dental hygienists and dental assistants over the years. 

Now for our audience, can you give them a sense of your organization’s membership and missions, as well as the kind of the growth rates? Let's start with you Ann, and go into the growth rates of the dental hygienist career then transition over to Laura to talk about dental assisting.

Ann Battrell: The profession of dental hygiene pretty much grew exponentially over the years until COVID hit, and when COVID hit, we saw a great number of hygienists -- about 8% of the population -- literally left the profession. That might have been the cohort of people who were pretty close to retirement anyway, and had made the decision that this was time to go. There was a lot of concern about the availability of PPE, just as there would be for dental assistants. We're back now to about 4.9% of the profession still hasn't returned, but we hope that that continues as more and more hygienists and assistants feel confident of the safety of their dental practice, because many of them are moms and dads and they're worried about taking things home to their kids or to their parents who they may have in their homes as well. 

There are about 15,000 members of ADHA right now and that includes student members. Our mission really speaks to them. It's supporting the career paths of dental hygienists, no matter what career path they may choose. But we've gone through so many changes, that it's really important -- particularly with governmental agencies Shiv -- that dental hygiene speaks with one voice. ADHA is that voice to say where the profession stands on a number of issues, especially healthcare issues today, which are numerous. We work to help our state associations pass legislation that allows dental hygienists to practice to the top of their scope of practice, not at the bottom, but at the top just like dental assistants. Let these educated healthcare professionals do what they're educated, certified, and trained to do. So, that's a big role of ADHA is to help our state association advocate for the top of the scope of practice.

Shiv Gaglani: That's really helpful. Before we even started the podcast, we talked about the theme of scope of practice, which is not just occurring in dentistry but also in medicine and nursing and many other fields. So, let's transition over to Laura. Can you talk a bit about both DANB and the DALE Foundation, the missions and any salient points that you'd like our audience to know about them?

Laura Skarnulis: Yeah, absolutely. One of the defining differences is that we are not a membership organization. We are the national certifying body for dental assistants and we also administer exams for dental assistants that may become certified or are using these exams to become certified or might be using our exams to meet state requirements or to just maybe get some portability in areas where they want to maybe go into various different areas within their career or across the country. 

One thing I think is important to point out -- building upon what Ann said -- the last several years have had such an impact on the profession as a whole. Dental assistants as well have been leaving the profession, some retiring. There are about 380,000 dental assistants practicing, or at least there were prior to the pandemic. We had about 37,000 of those certified, and there are reasons for why there's not as many certified as there are dental assistants. The main reason is that one, it is not required. States have so many different dental practices acts and there's nothing uniform about it unlike medicine, where you have state licensure, and then you have certification. 

This was an eye opener for me. I thought, of course you would get certified because that's your highest standard of quality, and we have a lot of work to do in that regard. But it is recognized as such a portable national professional credential for dental assistants that we have, and there's a lot of interest and I think momentum to move in that direction. 

However, we did have people leave the profession because when they come into the profession, the compensation is not necessarily where you would expect it to be for individuals that are highly qualified, highly educated, coming through these training programs. Work is being done on that as well. Many of our dental assistants go on to become hygienists. Many of our dental assistants go on and start looking at going to dental school. So, it can be an entryway into the dental profession for many people who don't have it in their family or don’t have it on their radar that they want to come into dentistry.

To build upon what Ann was saying, through COVID, one area where we did see growth was in our learners. Our DALE Foundation offers educational offerings for not only dental assistants, but oral healthcare professionals as a whole and the educational offerings grew exponentially through COVID. We're still digging into the reasons why for this, but what we're seeing is that because our educational opportunities are either training materials, exam preparation materials, continuing ed, or we have some new certifications that we launched. 

So, are people expanding their knowledge base? Are they going in and learning more to advance? To make shifts? We don't quite know yet, but we saw such growth and people had time. As Ann said, being a lifelong learner is what's required in an oral healthcare profession but it is hard to find time for that. We also recognize that during COVID, when some of these practices were not open, people did take advantage of that opportunity to grow and to learn. 

I do want to just take a minute, though, to talk about the organization and the mission, but really what does a dental assistant do? I didn't have a lot of knowledge of what the dental assistant does in the practice and the integral part that they play and the member they are of the oral healthcare team. It's a very dynamic role with a lot of variety. They often are responsible for patient communication, greeting and seating the patients, and tending to their needs during an appointment. 

But here's a really important piece of it: the communication of the post-care instructions for everything that comes after the appointment. It has been shown that when you have a dental assistant that is part of that team, that the patients actually adhere to those instructions. I don't know if it's because it's more relaxed -- it's not the dentist talking to them -- but they can relate to the dental assistant and I think that they feel more comfortable. 

Also, they sterilize the room, the instruments for treatments, they take dental radiographs, and then they assist dentists with many procedures. Many of the organizations are doing some studies on efficiencies to see how much more efficient dental practices are that have dental assistants who are, to Ann's point, practicing at the top of their scope and their abilities and their competencies because some can perform some expanded functions, whether it be restorative or preventive care. 

But that's additional education and training. Really having them as part of the team and valuing them as part of the team is such a great opportunity for individuals to be in the profession. We've done some surveys recently and we have some data that will be coming out in the fall showing that many find it to be a rewarding and fulfilling profession that meets their lifestyle needs. Some of these professions that you go into in oral healthcare -- not just oral healthcare but in any healthcare role -- you might not have as much…I don't want to say "control" of your schedule, but it's not necessarily late nights, every weekend, working on Sunday. There's the opportunity to make some sort of flexible schedule as well. So, great opportunities within it and we're working with a variety of stakeholders within the oral healthcare community to see what we can do to make sure that we can get even more dental assistants prepared and ready to be in the workforce.

Shiv Gaglani: I love that. There are certain key topics you mentioned there that I'd love to pull on, one of which is this career laddering that's evident in the dental profession or oral healthcare profession. Certainly, the nursing profession has a lot of this, where there are clear pathways for people to go from associate's degrees to bachelor's degrees, all the way through doctors and nurse practitioner degrees, and we see that DNPs often started out as an associate's degree. So, it's really good to hear that that sort of career laddering occurs with dental assistants, dental hygienists, and dentists.

We talked about scope of practice a bit, or you both mentioned that. Our audience primarily is familiar with medical and nursing. In the PA profession, as an example, there's surgical PAs, and there's further kind of segmentation of that field itself. Laura, you alluded to this a bit, but I'm curious if either of you can comment on sort of the stratification of the various careers in oral healthcare and more of the scope of practice where people can operate so we can basically make sure the right skill set is matched to the right part of the patient journey. As you mentioned, Laura, the fact that dental assistants are being trained and being assessed on their ability to communicate post-discharge instructions to patients…that's essential because the average time a dentist is able to spend on the patient has been decreasing over the years, same with physicians. So, can either of you comment a bit about the stratification of more careers in oral healthcare, as well as any career laddering considerations?

Ann Battrell: I like to use a different symbol than a ladder, because a ladder says "I'm at the top or you're at the bottom.” I like to think of career options as a web. People can go laterally, they can make all different kinds of choices today that never had been there before. Especially when we see, Shiv, this medical-dental integration occurring more and more frequently. So, think about why on earth does it seem like in our healthcare system, the mouth -- no pun intended -- was extracted from the rest of the body when we know in fact that most diseases have some type of sign or symptom first in the mouth? 

The diversification is going to happen at least in hygiene and I think it's going to happen in assisting as well. One of the options is dental therapy which is been described as akin to a nurse practitioner -- kind of in between that dental hygienist and a dentist -- where the scope is different. The scope allows some of the more dental procedures that aren't as expansive as the other end of the services that dentists provide. We've seen that first take place in many states like Vermont. It first happened in Minnesota. We're seeing other states pass legislation that's called direct access. What that means is a state would allow a dental hygienist to provide services directly to the public and sometimes they do have a designation that would signal to lawmakers and regulatory agencies that a hygienist has received this additional education in order to be a direct access provider. 

My master's degree was on a group of hygienists in Oregon called Limited Access Providers or LAPs. I chose to study them to get the information into the scientific literature about what they do and what kind of services they provide. So, the diversification that happened in medicine many years ago is now happening in the dental space. You're seeing more hygienists be employed in hospitals, in pediatricians' offices, in long-term care facilities. That is a trend that's not going to stop. It's just going to continue to grow.

Shiv Gaglani: Yeah, fascinating. Thank you for adding that. Go ahead, Laura.

Laura Skarnulis: I was just going to build upon that. Ann and I talked about this a bit when we were together in July, about the opportunity to improve the access to care by getting hygienists and dental assistants into the community. I think the ADA has a great example of this. The American Dental Association has a Community Health Coordinator program that they've done. They are often hygienists or dental assistants, and they are trained to help people access dental services and care. They built bridges from the community to dental clinics by removing the barriers to care such as transportation, health literacy, and language. Dental assistants can serve as case managers in these types of situations and we know that case managers are a highly effective model in medicine. And with these care homes, they're integrating both dental and medical care. Often in these situations, these individuals work in the same communities in which they live, so they're seen as that link and that they're linking their communities to these opportunities together. 

I spent years at United Way before I even came to the ABMS, and United Way Metro Chicago has a health initiative with three pillars of impact areas: it's financial, education, and health. They go into communities with other organizations and build wraparound services to increase not only the access to care, but the education about preventative care and getting that to them. 

I think there's an example of a program that we work with talking about how building in the various members of the dental team is so integral to making sure that that's a high-performing team and that's through Temple's post-baccalaureate program. They have a post-bacc program for students that are looking to get into dental school and they actually require those post-bacc students to become NELDA certified. That’s the National Entry Level Dental Assisting certification. It's education and training for somebody to come into the field at the entry-level and their future dental students earn that certification but then may actually serve as dental assistants in their dental school at Temple providing to the community. The dental assistants or the future dental students are working in the clinic and then giving back to the community improving access to care. For me, it's a win-win all the way around. 

But really the integration of medical and oral healthcare is becoming much, much closer. We're talking with various organizations about how we can increase the access to information and education and what transcends all of it that we need to know together to improve the profession and ensure that people are qualified to work. I like a lot what Ann said about this being a web because when you broaden your perspectives and broaden your knowledge base, that provides you so many more opportunities to take your career in different directions that you might not have even thought possible.

Shiv Gaglani: All those are really great points, especially the social determinants of health and dental assistants as case managers and dental hygienists, as well as how we can also get the students who may be in programs like dentistry programs also training up as dental assistants. I know in the medical context, we have a lot of partners who require that students become a scribe or EMS or EMT, which gives them a lot of empathy and lets them work in care coordination much better. 

I love the fact that the link between oral healthcare and general healthcare is so strong. We've had guests like Dr. Sachin Jain, the CEO of Scan Group and Health Plan, who did a lot around how do we bring preventative medical care -- hypertension screening, diabetes screening -- to the dental office. Certainly, dental assistants and dental hygienists are integral parts of that. 

I'm also aware of your guys' time, so just a couple of more questions here. The first is, we talk a lot about the shortages we have, especially post-COVID with moral injury and burnout of physicians and nurses. There are other camps that talk about not so much a shortage but more a distribution problem of where these people are located, and you mentioned you come from rural Illinois. Certainly there are a lot of rural and home healthcare trends going on right now, virtual care as well. Can you talk to us a bit about dental assisting, dental hygienists and maybe dentistry too in terms of a shortages, or is it a distribution problem? Do we need tens of thousands or hundreds of thousands more people to be trained? Any commentary on that would be great.

Laura Skarnulis: I'll jump in on this one, because I will tell you that we had a meeting with members of ADA councils last week and the prevailing sentiment is we need dental assistants and we needed them yesterday. Dental assistants are in high demand and for the reasons we've stated earlier, the profession is going through I would say a shift. As people look at dental assisting possibly as an entryway into the profession and moving into other directions, there's more openings for a variety of reasons. But we certainly know that there is a shortage and it has been for years. I think it ebbs and flows, but I can tell you what we're doing to work on it.

We're building a curriculum and framework to train dental assistants starting in high school, and we are going to be starting awareness in middle schools for dental assisting. We are piloting this framework in two different states -- North Dakota as well as in Michigan. North Dakota happened because of need, and Michigan happened because of capacity. We're learning from those opportunities, and then we will be bringing that to scale in early 2023, and we're very excited about that. We also think that that framework could be utilized by dental practices and they can take pieces that they want to train their dental assistants on that come into their offices and provide quality care. 

We also brought together stakeholders in early July -- and Ann was part of that…thank you for your participation and engagement -- we had about twenty organizations talking about the future of oral healthcare. In particular, we were very interested in the future workforce of dental assistants. We identified some initiatives, and one of them was to form a workforce coalition with organizations throughout the room and others that weren't able to be there, and really put efforts forward to come up with tangible solutions to increase accessibility to the programs. We want to look at our requirements to modernize them to reach dental assistants across the country and make sure that we have the right representation from all groups -- rural, all segments of the population -- that are being served and that are in the profession.

Shiv Gaglani: That's awesome. Thanks for sharing all that and it's great to hear that there's so much coordination behind the scenes between all these different levels of groups. It's very complicated. I knew this from ABMS with all thirty-two member boards and the state federation's medical boards. There's no reason that it wouldn't be as complicated, or more complicated, in the oral healthcare sphere. 

You mentioned curriculum, and I know Ann, you taught dental hygienists and you've gone through several layers of education. Osmosis is a teaching company at its heart. If you could snap your fingers and teach any stakeholder -- whether it's the general public, middle schoolers who may be interested in careers in dental hygiene or dental assisting, whatever stakeholders you have in mind -- what would you teach them and why? Like, if Osmosis could develop a video or a course what would it be on?

Ann Battrell: I think oral health literacy…how important your oral health is to your overall health. It’s something that the general consumer is relatively not too knowledgeable about. A couple of years ago, we did a collaborative project around getting consumers to understand --particularly in children and low-income families -- that brushing twice a day with a fluoridated toothpaste was an important factor for their children's oral health. A large number of caretakers -- parents or grandparents or whomever -- had no idea that if you just help your child develop the habit of brushing twice a day, with a fluoridated toothpaste, it could save them years of dental pain and dental care needing to be done. They really didn't know. 

So, we're continually reminded to go back, Shiv, to a basic message. Often, we in the dental space -- Laura would know, and I'll take full responsibility too -- we complicate the message so much. We go to like a college-level of education. When you're talking about oral healthcare, it needs to be like at a fourth or fifth-grade level in order for people to understand what does oral health even look like? How do I know that I'm healthy from an oral health perspective? What about oral cancer? You know, we don't talk a lot about oral cancer. When we see kids vaping now and all of the risky behaviors that kids can have, they don't really know the impact to their overall health. There are so many topic areas that I think we can share with consumers that really would kind of open their eyes about why is my oral health even important? Why should I pay attention to it?

Shiv Gaglani: Those are really, really great points Ann. The same thing happens especially with COVID health misinformation. I'm sure there's plenty of oral health misinformation out there, whether it's intended or not…just confusion around it. So going back to the basics and making sure people have health literacy is key. Laura, I'm curious what your answer to this question is?

Laura Skarnulis: Yes, and I have an answer for it, but Ann I will tell you, you are not responsible for it. It's prevalent in every health care profession and organization I am affiliated with. Shiv, thank you for asking the question. One of the things that I'm seeing is that we could really benefit from education or courses on how to deal with patients of varying abilities. I saw a poster at a recent conference about the special needs patient. If you go into a dental office and you look at the chair and you look at the way the room is set up…there's anxiety, there are mental health issues, there are physical disabilities, there's cognitive disabilities. I think it would be wonderful to - one video isn't going to take care of it all - but a video on not only the empathy, but that deeper understanding that’s needed. Kind of stepping back and recognizing that treating patients with varying abilities takes a certain level of finesse and training and skills that I think people would benefit from.

Ann Battrell: Yeah, and the point Laura's making about mental health, Shiv, is so important. We just did a series of studies with the ADA Health Policy Institute, and mental health of dental professionals was one of the topics that we covered and the high rate of anxiety and depression that really impacted them and their decisions to stay or how they're going to earn a living was a top priority. You saw a lot on the news about the healthcare professionals who were frontline workers and what their mental health status was. People didn't think about, "Hmm, I wonder what the dental professionals' anxiety and depression rates are?” And they were pretty high. So, people who were trying to battle their anxiety and depression were also part of the community that left because it was just too much.

Shiv Gaglani: Yes, absolutely. Those are really good points, and especially the mental health care, the burnout. I know from my own sister and brother-in-law, about staffing as well. If you are a psychiatrist or OBGYN, you're still on the front lines providing patient care and putting yourself at risk for contracting COVID, right? But if you're in the dental profession, the only way you can provide care is if your patient isn't wearing a mask, if you're actually in their mouth, and if you're actually inspecting their teeth and gums, and tongue, etc. So, that's even riskier. Clearly, there were issues there that need to be addressed.

Ann Battrell: And I think the dental practices today that have a few metrics instilled in them will not have workforce shortages. If you are running a dental practice, or in a dental practice, where communication is your top core value, you're going to do well. We learned through a lot of our studies how poor the communication was in dental practices. If you are really making sure that the appropriate PPE is available in your practice, you probably aren't going to have a shortage. If you are up on your knowledge about what is a good compensation for dental assistants and dental hygienists and you pay them well and you express appreciation for them, you are not going to have a workforce shortage. It is so simple, it's scary. Respect them, pay them well, have good communication, keep all of that moving forward, and you're not going to have a problem. But offices that don't…we heard crazy stories of dental hygienists who said "We haven't had any communication from our employer. None."

Shiv Gaglani: Wow.

Ann Battrell: Yeah, none. But then we heard the other side to where when they had team meetings -- the hygienists met, the dental assistants met, they developed office protocols that were based on the CDC recommendations, and they were a team. That team stayed together. But if any one of those parts is missing, the teams tended to fracture.

Laura Skarnulis: I would just add one piece to that. I completely agree with everything that Ann just said, and I would say investing in their education – and this is not self-serving, even though it probably sounds that way -- but when you have organizations that are investing in people learning and growing and continuing in their professional development, that means something to them.

Ann Battrell: Yes.

Shiv Gaglani: Absolutely, treating them with all those hats is important. The last question I'll ask both of you is what advice would you give to our audience about approaching their careers in oral healthcare or healthcare in general?

Laura Skarnulis: First of all, I would consider oral healthcare because there are so many opportunities and pathways and rewarding careers, jobs, and environments in which to work. But most of all, I would say, be your own advocate. Seek out opportunities to learn and grow, expand your knowledge, and by doing so it not only allows you to advance your career, but it can deepen your level of engagement and satisfaction in your work. Having a breadth of knowledge also makes you more well-rounded, in my opinion, and that's really powerful for a healthcare professional, which benefits not only you but then the patients that you serve too.

Ann Battrell: Right, and with everything that Laura said, which I agree with, find that mentor. Find that person that you can lean on for advice. I had them throughout my entire career. And diversify your experience as much as possible. We talk a lot here about getting comfortable with being uncomfortable. You're not gonna grow if you're comfortable all the time. So, throw yourself into those experiences that you might not have ever thought you would thrive in. That is the only way we grow is to get a little bit outside of ourselves and try something new.

Shiv Gaglani: All that is excellent advice. Coincidentally, Ann, just today I was listening to a podcast with our CEO Kumsal Bayazit, who will be on this podcast in a couple of weeks. She said the exact same thing. When she was at a consulting firm in LA, she told one of her first mentors that she was feeling very overwhelmed by the work. That person gave her some lasting advice that she repeated on the podcast, which is 'Be grateful for that discomfort because it means you're learning and growing.”  

Also, understanding that careers are long. Both of your careers have wound around, and now you have this immense scale of impact. Ann, you started off as a dental hygienist and Laura, you started off in accounting. Now you've both led organizations that reach tens of thousands, hundreds of thousands, millions of people in aggregate. 

I'd like to thank you both for taking time to join me on the podcast, and more importantly, for the work that you both do to Raise the Line and strengthen our healthcare system.

Ann Battrell: Great, thank you so much.

Laura Skarnulis: Thank you so much, Shiv. It's been our pleasure.

Shiv Gaglani: 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 collective healthcare system. We're all in this together. Take care.