Ep. 1: Chris DeRienzo, MD, Author of “Tiny Medicine.” Topic: Empathy in Healthcare
Kathy: Hi everyone, and welcome to the Smarter Healthcare Podcast. I’m so glad you are joining us for our very first episode! My goal in creating the Smarter Healthcare Podcast is to share with you the stories of those people in healthcare who are on the front lines of innovation and transformation. My hope is to inspire you with the promise of what’s on the horizon in the healthcare industry and to also learn what practical steps we can take today. It will be a fun – and hopefully informative! - journey – I’m so happy you’re taking it with me. Let me share with you a bit about myself at the outset. I started my career more than 20 years ago in TV broadcasting, before moving into public relations, marketing, and writing. For the past 7 years I’ve been working in healthcare technology for Dimensional Insight, an analytics company in the Boston area. Three years ago, I decided to go back to school to get my MBA in health sector management at Boston University. I’m not quite done with my degree yet, but I do see the light at the end of the tunnel. I have a husband, three daughters, and a year-old puppy at home. So my life is very full, but very rich. My first guest on the show seems to have an even busier life than I do! Dr. Chris DeRienzo is a physician, author, husband, dad, and triathlete. Chris is also the author of the book “Tiny Medicine,” in which he talks about the lessons he learned as a neonatologist. In addition to talking about some of the lessons from the book, Chris and I discuss how empathy is still critical in healthcare and how he’s a believer in the promise of new technologies to enhance provider empathy rather than detract from it. We had a great conversation, and I’m proud to share it here with you. Here’s my discussion with Chris.
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Kathy: Hi Chris.
Chris: Hi Kathy.
Kathy: Welcome to episode one of the Smarter Healthcare podcast. No pressure.
Chris: I’m really excited to be here, and can’t believe you chose me as your first guest.
Kathy: Well thank you very much. I read your book Tiny Medicine and I have to say on the second page you had me choked up a little bit – you were describing being with a very premature infant and that process of, realizing that the child wasn’t going to make it, and being with the parents, and it must be a very emotional type of job to work in the NICU.
Chris: No doubt. I think anywhere that you practice in healthcare, as a physician, as a nurse, as a member of a broad support team, you’re drawn to healthcare for that sort of human-to-human connection. My wife is an oncology nurse, and so she’s drawn to a different kind of connection with older folks who have these long life stories. For me it was just engaging with babies and their parents in the NICU is incredibly rewarding, incredibly challenging as you noted in that particular kind of instance, but to me there’s just nothing else quite like it.
Kathy: Another part of the book that I really enjoyed was just seeing your progression as a provider. You kind of started out, seemed like you didn’t quite know where you wanted to be and then you found your place in medicine, which I thought it was nice to see that because you often think of your providers as knowing that they want to be in this one area but I was reading through that and I was like, oh this is like a nice human story. Can you tell me a little about that – finding your place?
Chris: That’s exactly right – part of my goal in writing the book, I had all these stories that I just really wanted to tell, and I don’t feel like folks who live outside of the clinical world of medicine get to see us as clinicians as humans. We’re taught to wear this professional veneer the majority of the time, in part because it helps engage in some incredibly challenging conversations, but also in part, it’s a profession, right? And so I thought it would be interesting to tell some of the stories that show behind that white coat are just people. And for me it was less about not knowing where my way was going to be in medicine and more what I thought it was going to be changed like five different times. When I started in med school I thought I was going to be an adult cardiologist. I just, I loved the heart, I thought it was going to be really cool. I got into medical school, I did my first rotation, internal medicine, and I just said, I can’t do it. I can’t do the kind of clinical practice that would have been required. I remember being on service and I said I just need to engage with kids. And then I started in pediatrics, and within the universe of pediatrics you go into the NICU and it’s like your job to protect these kids. Every baby who’s born in the NICU, the whole team’s focus is try to get this kiddo as big as he or she needs to be to get home healthy and safe. And so I was just thoroughly drawn to both the need to care for these tiny babies, as a team, and the book talks to some of the stories in the NICU that sort of show that to me. And so for me I’ve never felt more engaged in a team dedicated to a core purpose than when working clinically in the NICU. It’s a really special place.
Kathy: And I think that for parents who have their kids in the NICU, I know that a while ago I spoke to another healthcare provider, she and I were talking about technology, and she was talking about the readmissions in their newborn unit, and she said to me, she’s like, you know for us, it’s this number, but for a family, to have to come back to the hospital, it’s a life-changing event. And the NICU, is, it’s a life-changing event for these families.
Chris: Absolutely. If you look at the history of NICU quality improvement, it goes back almost 40 years to the Vermont-Oxford Network. And I think one of the things that has made that movement so exceptionally successful, in neonatal intensive care, is it is almost impossible to only focus on a number. Because as a practicing clinician, if you’re a nurse practitioner, if you’re a PA, if you’re a doc, if you’re an RT, if you’re a nurse, whatever, you can see the kid in your head who had sepsis, surgical NEC, you name it, you can see that kid and so when you’re trying to drive an improvement effort around eliminating necrotizing enterocolitis, which is a big long word, but you see the kid who had it you say, oh my gosh, we have to prevent that. Because you’re right, it fundamentally deflects the trajectory in a person’s life and their entire family’s life in a way that, wouldn’t it be great if we could prevent it.
Kathy: Now another part of the book that I really enjoyed was when you talked about standing tall on the quarter deck. Can you tell us a little bit about what that means and why it’s so important for all of us in healthcare to stand tall?
Chris: Absolutely. That quote came from a terrific mentor of mine, a man named Doctor Ron Goldberg. He was the medical director, division chief, and the fellowship director at Duke when I did my fellowship there. And when I started fellowship in the NICU at Duke, at least at the time, I’m not sure if it’s the same today, the attendings went home at night. And so as a first-year fellow right out the gate after a couple of, sort of, monitoring shifts, you were the senior-most physician responsible for 67 acutely ill Level IV intensive care nursery babies. And that is an enormous weight. And a level of chaos that was falling on my shoulders as the leader of that team that I had never had to bear before, and it was really clear in the first six months that it was too much. That I wasn’t yet ready to step up in a way that unit needed me to lead. I had to learn how to do that. And, so Doctor Goldberg pulled me aside about a week after one particularly challenging shift, he asked me, “Chris, have you ever seen this movie, ‘Master and Commander?’” And I said, “Doctor Goldberg, I have no idea what you’re talking about.” And so he said, “In the midst of the book, or the movie, which is about the Napoleonic Wars, the captain of this British ship is taking bombardments left and right from his French enemy. And there are cannonballs flying everywhere, and there are holes in the sides of the ship. All these kinds of things. Chaos is reigning. And things settle down for a moment, and the captain rounds a bend and he’s coming down the starboard side of the ship and he sees this young officer still huddled behind a rampart. And so he grabs him by the collar of his dress code, lifts him in the air, and says, ‘Son, we stand tall on the quarterdeck. All of us.’” And at that point Ron looked at me and he said, “Chris, you’re the leader of this team. They’re expecting you to stand up – and that doesn’t mean you always have to know what to do. But it means that you need to stand tall and you’re not doing that.” And that was absolutely a pivotal changing point for me, in NICU fellowship and frankly in my life. I had had leadership roles before, I’d been fortunate to get to serve in a number of leadership roles, but that mantle of ultimate life and death responsibility for that many babies, and the need to both lead and partner and coordinate, was just a whole another level. So from the time that Ron sat down with me, my experience in the NICU really started to change, and I got what that meant. And it really to my core changed who I am as a leader and who I am as a person.
Kathy: That seems like a good lesson for all of us to learn, even if we’re not in the NICU, even if we don’t have those life or death decisions every day, but we all need to stand tall, we all need to take that leadership role when we have to.
Chris: Without question Kathy. And, I think the way that that applies to folks listening to the podcast, people who work in healthcare, people who engage with healthcare, we live in an incredibly dynamic time in the American health system. There’s going to be a decade worth of transformational changes that will make the last decade pale in comparison. That’s just reality. We’re nearly 20 percent of GDP, spending continues to rise. We’re at a point where transformation is happening, and further transformation is inevitable. And that means it can be scary to lead. It’s scary to look at a complex, semi-chaotic problem, like healthcare transformation can be, and not know exactly what to do next. And I think the lesson that I draw from this part of the book is when you’re leading a team, their first expectation of you as a leader is not that you know exactly what to do next, but that you stand up and you take the responsibility of figuring out where do we go from here?
Kathy: And you also talk about doing a little bit better tomorrow, which I really liked. You know it’s that – you don’t have to get from – know exactly how to get from here to there, but it’s just that you have to do a little bit better tomorrow.
Chris: That’s exactly right. To me it’s very analogous to what it’s like to have a 24-weeker born in the NICU. When you’re 500 grams at birth, and you’re born 16 weeks early, it’s a pretty long way down the field to imagine being 40 weeks and 5 pounds at a minimum. Getting from A to Q is a leap that seems impossible to make, but it’s not. And the way these babies make that leap is 20 grams a day, 20 grams a day, 20 grams a day, lose 3 grams, 20 grams a day, 20 grams a day, it’s a little bit, step-by-step, focusing on in the words of Catherine McCauley, being good today, but better tomorrow. That’s the story of how NICU babies get to graduate, I think it’s the story in leadership that – we can’t jump from where we are to this vision of perfection. There are exceptionally rare circumstances, I think, where that’s the way change happens. My experience suggests that the vast majority of the time people get to tremendous outcomes by focusing on getting a little bit better tomorrow, and a little bit better the next day, and a little bit better the next day, and all of a sudden, six months go by and you’ve gone from 400 grams to 2500 grams, you’re ready to go home, and that’s really exciting.
Kathy: Now you also talk about your fallibility as a doctor (yeah), you make mistakes, and that’s something that I don’t think we’re very used to hearing from doctors. Why do you think it’s important to talk about that?
Chris: I think it’s important as a healthcare system that we acknowledge we are fallible. I think for far too long in American healthcare it was verboten to talk about errors and mistakes, and as a result healthcare has lagged decades behind industries that have assumed human fallibility and built processes to support the humans involved in them for making mistakes that reach people and cause harm. The classic example is, right, the nuclear power industry, the airline industry, and so on and so forth. And so in healthcare, it’s only when we begin admitting that we are humans and we will make a mistake, even the best provider, one in 10,000 times, one in 100,000 times – we will make a mistake. When you talk about something like medication doses, a big hospital can go through hundreds of thousands of medication doses in a month, and so one out of hundreds of thousands would be 12 people harmed a year, right? So when we acknowledge that we’re going to be human, and even the best human is going to make an error, that offers us an opportunity that other industries have taken advantage of for years, that says, OK, assuming this person is going to make a mistake, what other slices of swiss cheese, to use the reason model of error, can we build to keep that mistake from falling through all of the holes, reaching the person and causing harm. So my work in the quality world has really demonstrated to me that that is a much better way to think about how we approach driving quality in healthcare, and frankly it acknowledges that as providers, we have to be responsible for our own excellence, we have to strive to be better and better and better every day, and we have to acknowledge that there’s an asymptote there – we’re never going to reach perfection, and so through tools like FMEA or root-cause analysis, we can design better processes, so that interchange any provider into that person’s shoe, and if they make a mistake we can keep it as much as possible from reaching people and causing harm.
Kathy: And you’re an advocate of the Just Culture Model. (Chris: Absolutely.) Can you talk a little bit about that?
Chris: You bet. So Just Culture I think is the right way to approach humans involved in any kind of circumstance where an error is made. The basics of Just Culture say that if the human isn’t acting out of malice, so they’re not intentionally causing an error to hurt somebody, if they’re not substance impaired, you know by alcohol or drugs or whatever, and it’s not a repetitive incident where the person has made the error many times, has been coached many times, that the solution to that mistake is not blame the person, it’s blame the process, and support the human. And so when you follow that kind of algorithm and you look at the kinds of mistakes that we make in healthcare, the interchangeability test is most of the time positive. In other words, if you put a different nurse in that bedroom on that day, is there a chance that he would have grabbed the same medication accidentally that this other nurse grabbed, and if so, then we are the problem. We, the administrative leadership, we have created a process that sets it up to make it too easy for someone to fail. We need to change the process to make it as easy as possible for that person to succeed, and then build in safeguards that account for the fact that even with the best process we’re going to wind up with a mistake at some point and build a layer that keeps that from reaching the patient and causing harm. So under a Just Culture method, very rarely is the answer blame the person. The vast majority of the time it’s blame and fix the process.
Kathy: Right. Now let’s talk a little bit about technology. (Chris: All right.) So my sister recently had a baby. (Chris: Congratulations.) I was in the hospital with her and one thing that I noticed was that every provider who came in always they wheeled in that computer and they would start asking questions and be typing in the computer and some of them would say I’m sorry that I’m typing, I’d like to be bedside with you but I have to do all this stuff before I can do any of that. Do you think that the technology has been taking away from the humanity of our providers at all? Or where do you see that balance between, you know, we know that we need this technology, but we also want to preserve some of that humanity of our caregivers, so what’s the right balance?
Chris: No question Kathy. We not only need to preserve it, we need to scale it. We need to return humanity to the practice of medicine and nursing and therapy and so on. And I think, Steve Jobs, when he was interviewed in Rolling Stone in the 90s had this spectacular quote. He said, “Technology is nothing. It’s people who we have faith in. And if we give them the tools, then people can do wonderful things with them.” And so I think that the story of healthcare technology, and specifically EMR technology that you’re describing over the last twenty years, has really been one of sucking humanity out of our practice. And there are a lot of reasons for that and I’m not one to cast blame in one direction or another, but at the end of the day, we designed, we, humans, designed EMRs to work the way that they do. And what that also means is that we as humans have an opportunity to fix it. And so the process you described doesn’t surprise me in part because that’s exactly the way it used to work on paper. I’d walk into the room with my list, you know when I was a med student, at 4:30 in the morning and I’d be taking notes, and all we’ve done is replace a paper process with an electronic process, and most of the time we haven’t taken advantage of the kinds of changes technology could support in the way that we engage with patients. So my fervent hope in an AI-enabled world is that we’ll be able to leverage opportunities to use technology to drive the return of humanity to our practice. And there are many many ways that could happen but because AI functions the same way that I think as a clinician, in other words deep learning works by being exposed to lots and lots and lots of label data and then seeing patterns emerge, right, there are applications across the healthcare world to tasks that we ask humans to provide today, that can become automated and thereby return time to your human providers’ days to engage with what they should be doing, which is human to human time with their people.
Kathy: So what do you think are some of the most exciting applications of AI?
Chris: There are a number. To me, the biggest opportunities that I see within AI in healthcare have to do with moving upstream of an event, and automating processes that don’t need to be done by humans to scale more human time. And so what do I mean by that? Be it in the acute or in the chronic world, AI is being used today to look at patterns, pattern recognition is AI manifest. And looking in patterns of someone’s clinical history, their claims history, their prescription history, their lab history – we can find patterns that suggest this bad thing is going to happen, we need to do something now. Similar in the inpatient world, combining all of this data that you have to hunt and peck in records for today, on vitals, on labs, on meds, you name it, can serve predictions to people that say hey you need to pay attention to DeRienzo, because we don’t know what’s going to happen but his pattern suggests six hours from now there’s going to be badness. This is what we’ve done clinically as physicians for centuries. We’ve combined patterns of signs and symptoms and looked at different trajectories that we’ve seen over hundreds of patients and said OK I think this is what’s going to happen next, so here’s what we do to intervene. Now that we have the opportunity to serve into AI-enabled interventions, the same capacity, but scaled thousands upon millions of times. That is super-exciting to me. And at the same time, if you look at what happened in the banking world, when ATMs were introduced…I don’t know, have you seen the graph? Eric Schmidt used to put it up all the time at Google, but it’s a graph of the number of ATMs in the country from 1960-2010, so just at kind of the precipice of the internet banking revolution, so 50 years. And of course that number was like vertically up and to the right. What do you think happened to the number of tellers in the U.S.? (Kathy: Went down.) You would think. It actually went up. (Kathy: Interesting.) Not only did it go up, but think about what they were asked to do. So the reason it went up – when you automate the most basic rote tasks of banking, you have fewer tellers per branch. But the tellers who are working there are doing more complex things and spending more time engaging with humans. So what happens? The marginal cost of opening a branch plummeted. So banks opened way more branches. And you can look it up online right now it’s almost linearly in parallel to the scale increase in ATMs, again right up until 2010 and then there was another revolution that happened. The same thing can happen in healthcare. There are processes today that we’ve asked people who have gone to thirty years of education and training to do that we don’t need humans to be doing. We can use AI to automate those things and allow doctors and nurses and therapists and NAs to practice at the tops of their license. That is exciting, because that directly scales humanity and healthcare.
Kathy: Now is there any concern in that pattern recognition of relying too much on the machine?
Chris: Oh, without question. Just in the recent past there have been a number of articles questioning potential bias in AI models, and are we doing the wrong thing? I think that at least for the foreseeable future, it will be rare, or it should be rare, to fully delegate decision-making in healthcare to AI. Where I think AI is much better positioned to serve is as augmented intelligence. In which case, if I can serve a pattern to you as a provider that says hey there’s something you need to pay attention to, that is an information point that you didn’t have yesterday. It still requires you to interpret and take action on it, and so the decision lies with you, so I think to some degree that level of concern is mitigated by stopping short of thoroughly automating an action. That said, there are absolutely some actions that I think could become totally automated, and should become totally automated, clinically and administratively, and when we cross that threshold we have to be exceptionally mindful that we’re not setting ourselves up for a pre-biased outcome.
Kathy: There’s been a lot of talk about provider burnout. That a lot of providers are spending, you know, they’ll say they spend hours at the end of their day typing in things in the EMR, they feel depressed, there are high rates of suicide. Do you think that technology can actually help with provider burnout at all? I know that in many cases the technology has been blamed for it. But are there ways that it can help mitigate some of that?
Chris: I do. And I think we’re touching on exactly why. I don’t think the technology is inherently evil. And I don’t think that anyone developed any of the kinds of solutions we complain about today with evil intent. What I do think that we’ve done is we’ve taken a generation of physicians and worked them through a paper to electronic transformation that without question is asking more of their time. I remember the notes that I used to write in the NICU that required five circles in two sentences. And so from the beginning there was always going to be an increased ask on providers for the downstream benefit of capturing data in a way that enables us to find things we couldn’t find before. As much as I think technology has contributed to provider burnout, which without question it has, I also think that we can use the same technology to dial back our asks of providers. We just have to approach it with intentionality. I think that in a universe where Core Principle One is how are we impacting humans? We develop different kinds of technology, we develop different approaches to deploying that technology, we bring the end users into the process much, much earlier on, and we solve for human factors at the front end instead of the back end. I completely made this mistake myself once at Mission, it was a partnership with the spectacular data science team and I’d asked them can you build a machine learning readmissions model that can beat LACE? And they beyond my wildest dreams surpassed that. So we had this righteous model, it handily beat LACE, which is sort of the very basic standard, gold standard model, so I said the care managers are going to love this. And so it was like February of that particular year, we brought it to the care managers, and we made one serious mistake and that was we didn’t bring the care managers in when we started the development process. And so we didn’t realize how much it was going to change their workflows. How much it was going to change their software? How was it going to change their brainware? Right? So it took a full nine months of working with that team both on the technology side to ensure that we had the uptime that they needed in order to rely on this tool in their day-to-day work and to understand how their current process needed to change as well as expose them to this whole new world of opportunity they didn’t even know existed, which also meant a new kind of work, and potentially even new people doing it. And so it took nine months, Kathy, to work through this process and I had tremendous partnership from the Vice President of Care managing admission at the time, the data science team, all the informatics teams, you name it, they were all in and stayed all in, even though it’s on me, I screwed up and didn’t get them involved at the time they should have been, and so what happened? By the time we got all the processes redesigned, and we figured out how to double screen in a way that wasn’t going to dramatically impact the days of the care managers, and facilitated a process around it, we had three of the best readmissions months on record at Mission Hospital. It was tremendous. That’s the kind of power in leveraging technology and the improvements in process that can happen when you focus on the people involved.
Kathy: And you talked about that importance of bringing the clinicians in and understanding how it impacts their work flows. (Chris: You bet.) I mean, is there concern that we are exposing our providers though to too much technology or too much new change? Because they already have all this other stuff they need to learn, they need to know the latest medical advances, is this almost overwhelming to them?
Chris: Oh, it’s absolutely overwhelming. If it’s considered in layers. The way that I’ve found most successful to walk through this kind of change with teams of providers, in-patient ambulatory, primary care stuff, you name it, you can’t just layer new thing upon new thing upon new thing, you have to start taking things away. And so for example when a brilliant physician, Doctor Shannon Dowler came on at Mission as my ambulatory chief quality officer, she looked at the way we were trying to drive clinical transformation in the ambulatory and appropriately said, this is insane. You guys are asking us to do 14 new things. Instead why don’t we take this one thing we were doing, drive all of the care process model work here, and now we can take away all of this other stuff, and wouldn’t you know it, once we started doing that, the adherence rate went through the roof. And she got 30 new care process models through the process in two years, with incredible support of course from PI and informatics, and analytics and education and nursing and pharmacy, you name it. But just that simple flip from we’re adding this new page or we’re giving you this new thing to look at, to instead of going to 14 different places, this is now the one place that you can go. That’s the way we need to think about change management. And when we flipped our thinking to that approach, now, as a provider, you’re saving me time. And that’s time that is either returned to see more patients, or it means I get home to see my kid’s soccer game, or it means I get to have dinner with my family, three times….or whatever it is – that is really meaningful to people.
Kathy: Seems like it comes back to that whole people, process, technology. (Chris: Absolutely.) It’s not just the technology part, but you need to work on the people and the process as well.
Chris: Without a doubt. I think that when the CIO at Mission and I started working closely together we realized that prior to that partnership IT was at risk of building really shiny pretty things that nobody used, and we on the clinical side were at risk of asking for solutions that we really didn’t need and/or knew how they worked. And so when we brought this partnership together, his name is John Brown, terrific guy, we realized that I needed to stop asking for things and start saying here’s where I need to go, and they needed to devote their dev resources towards this is what our clinical operational quality teams need to drive change. And when we reached that partnership the people, the process, the technology all aligns, and over the course of two and a half years in total we did something like eighty of those care process models. I think it was 85 over 3 years, and 70 over two years. And completely transformed the way that the health system was caring for people. We did the math once and even just on the ambulatory side we could have filled Wembley Stadium twice over with the number of people who had had a new breast cancer screening or a new colorectal cancer screening or whose diabetes was in control. Ed Sheeran, of course, filled Wembley Stadium four times over, but we thought that twice over was pretty solid. (Kathy: Not bad.) That’s right. That’s what can happen when you align the people, the process, the technology, with the right core purpose.
Kathy: Now looking ahead what do you think maybe the next five years holds for healthcare?
Chris: Oh man. I think that regardless of where our political winds blow without question there has to be transformation in healthcare cost and outcomes. No question. And independent of Republican or Democrat, states and the federal government need to push off risk, because they need to pay for things like education and roads and infrastructure, and it’s difficult to budget for that when the healthcare line item is just exploding, right? And so I think that the push to risk onto providers’ backs is only going to continue to increase. At the same time employers are stuck between a rock and a hard place, you’ve got the senior benefits managers at big employers looking to their left and seeing the CFO who says our health plan outcomes now dominates our bottom line performance more than our operations do, and on the other side they’ve got this massive team of employees who they know they need to care for better. And whose health they generally both care about and is core to their business operating. Healthcare is too expensive for them. You’ve got plans who are seeing their books of business radically change, and providers who spend billions upon billions of dollars of infrastructure spend for a sick care fee-for-service system now being asked to help manage a well-care health-focus system. And so to me, there’s never been a more exciting time to be in healthcare. Because all of these stars are aligning around payment models that are now making a sustainable approach to driving population health a reality. That realistically has never existed outside of small pockets in this country before. That means that folks who are able to innovate and who are serving that core purpose in their communities for people, now have the chance to do things that historically would not have been fiscally sustainable as an organization to do. That to me is super-exciting and I think over the next five years we’ll see some incredible progress across the country, probably in pockets, probably in demonstration areas, and then scaling nationwide of how that can all play out.
Kathy: I love your optimism. Well, thank you very much Chris, this was a great conversation.
Chris: I really enjoyed being here Kathy, and I hope the audience enjoys it.
Kathy: Thank you.
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Kathy: If you are interested in following Chris, you can find him on Twitter @ChrisDeRienzoMD, or via his website www.drderienzo.com. You can also find his book “Tiny Medicine” on Amazon. As for us at the Smarter Healthcare Podcast, I am on Twitter @ksucich, and the show is on Twitter @smarthcpodcast, as well as online at smarthcpodcast.com. In addition to show notes and streams of our episodes, we will include resources on there from our guests. For example, you can find a link to Chris’ book on there right now. I hope you will continue to tune into the Smarter Healthcare Podcast. Our episodes will be released every other week. Thank you all so much for joining us today.
