Pharmageddon

Hello everyone, welcome to today's show of Health Chatter. We're gonna be talking about a word actually that's become kind of in everybody's lingo of late, pharmacogen, which is kind of interesting, but obviously it reflects what's going on in the pharmacy world. We've got a great guest with us and hopefully we'll have a guest that comes on board. within the show itself. So stay tuned for that. I'd like to compliment and highlight our great staff. Maddie Levine-Wolfe, Erin Collins, Deandra Howard do background research for us. That's really second to none. It provides Clarence and I with some ideas and talking points that we hope to bring up with our guests that we have on the show. So thank you to them. Sheridan Nygaard also provides us with research marketing expertise and then our production manager is Matthew Campbell who gets our shows out to you the listening audience in a beautiful format, so Thank you to all of you. You're you're great. I would like to also recognize my co-host Clarence Jones We whether you guys realize that we chat offline quite a bit to keep this this show, Health Chatter, vibrant for all you, the listening audience, and we share great ideas going forward. He's a wonderful conversational expert, and I've appreciated his insight, whoa, these years. So thank you to you, Clarence. I also like to thank Human Partnership, our sponsor for these shows, great community health organization in the state of Minnesota, although I believe that their programmatic insights and programs in general have great implications for just about anyone around the United States. You can check them out at humanpartnership.org and as well you can check us out, heal where you'll see all of our research for our shows attached to the actual podcast when it comes out. So thank you to all. So I'm going to... pass the baton over to Clarence who is going to introduce our guests for today. Stan, thank you as always. We appreciate the introduction and we also appreciate those who are listening to us. And today we have an exciting, I think it's an exciting conversation and topic is one that for me in the work that I do, I'm often asked about and we have some. wonderful opportunities to enter this conversation. I also wanna say that today is January the 11th and tomorrow is Happy National Pharmacists Day on January the 12th. And guess what we're talking about today? We're talking about pharmacy and pharmacists and we have with us again, once again, Dr. Rhonda Marie Joukoulis, who is here, she's president of the Minnesota Board of Pharmacy. She is a graduate of the University of Minnesota. She's from the North side. You know, that's really important if you're from Minneapolis, where she comes from. She's from the North side. She's a world traveler, but also she's a health chatter and a human ally and has been, you know, working with us on a variety of different things. And so I wanted to introduce her and let her tell a little bit about herself. And then I need to start off by asking you a question. So I'm gonna let you say a little bit more about yourself and then I'm gonna ask you a question. And then Stan's gonna ask you some questions, okay. Good morning, thank you so much for having me. It is wonderful to be back on Health Chatter, conversating with everyone here. Again, my name is Dr. Rhonda Marie Chakolos. I am a pharmacist, born and raised, as Clarence pointed out, in North Minneapolis. I still live in North Minneapolis. That's a huge thing. If you're from the North side of Minneapolis, it's, and I went to North High School. So part of my identity is tied to that, but also part of my identity is tied to being a pharmacist, the first BIPOC woman to ever be president of the Minnesota Board of Pharmacy. And well over a hundred years, the Board of Pharmacy is designed to protect the public. And in keeping with my tradition, I do have to say that I will have views and opinions on this program. They are my own and don't represent the entities that I work with or who I'm affiliated with, but I am excited to be here and provide some background. My background is a little unique in that I still do a lot of community engagement work. I am lecturing at the University of Minnesota. I'm involved with clinical trials. So my life in terms of being a pharmacist, I would say I'm living the dream. And so thank you so much for having me today. Thank you. Yeah. Great to have you. Yeah. Yep. So let me- Go ahead, Clarence. Yeah, let me ask this question. Why pharmacy? Let's talk about you. We're gonna let our audience get a little bit of a chance to know you because we're gonna dive deeper into the whole issue around pharmacy because right now in our conversation in the community in this country, there's a lot of concern about pharmacists. about their condition, about pharmacies. But let's talk about you first. Why did you get involved in the pharmacy? And then I'm gonna ask, let's say and do some questions for you, okay? Yeah, I knew very early on if some of the earliest and I will date myself, my parents were probably one of the first people in the neighborhood to get a video camera. And at the time, at the time on these VHS tapes, I charted my pathway out. myself at the age of five. And so there are a couple of things that I said I wanted to be, I said I wanted to be either a doctor, a nurse or a pharmacist, that I wanted to get somebody to do my chores for me. And then I wanted to be, I wanted to be a boss. And so there's times where I go back and reflect on that and say, so what is it that got me from being a doctor? from a doctor, from a nurse to a pharmacist. And I will tell you, I have had, people in my family have very adverse reactions to medications. Like my mother on one occasion almost died from getting a medication that she was allergic to. And, you know, I just also saw a local African-American pharmacist in North Minneapolis who was very engaged in the community. And I was like, I wanna be like that person. I want to be involved. I want to be approachable and I want to be connected to community. But we all know in this country that medication is the mainstay often of therapy. And so I wanted to be part of the solution. I saw what my mom went through. I saw what other people went through and I wanted to solve for that and prevent problems. And so that is part of the reason why I became a pharmacist. Well, thank you. Stan, you had some questions. Yeah, so I remember, you know, Clarence and I have a little bit of gray hair. If we have hair, it's mostly gray. So we have some history here. And I remember distinctly when pharmacists got their degrees, they would get a Bachelor of Science degree. And then at some point, and I don't know what point that was or what led to it. There was, I guess, a requirement that if you're gonna become a pharmacist, you would get a Pharm D degree. So can you talk about that a little bit, kind of how all that came about? Yeah, so first of all, I like to talk about one people. One thing that people don't know about me is that I'm actually, my undergrad is in history. I'm a history major in religious studies. Now I really like it. Because I like history too. Yeah. And so I think that's what kind of makes me a little more well-rounded and grounded in history. So I think about the earliest pharmacists, right? They were more of the apocry type. You know, pharmacists were responsible for like the soda fountains and, you know, our Dr. Pepper and those things that we love. but also being very, very approachable and connected in the community. And I would say pharmacy, much like any other profession, I would say one profession that does it really well and will shut things down are nurses. Nurses have re-professionalized themselves several, several times. And so I would say it was probably in the 90s, where there was the shift from the bachelor of science degree to the doctor of pharmacy degree. And then that became part of the requirements in order to be a credited program. So with that shift, things went from, you know, what you would traditionally have had a four year degree when people were bachelor of science pharmacists to now you had this system that required four years of of pharmacy in addition to some prerequisites. So myself personally, I have a bachelor's degree and a PharmD degree. Some people just take the pathway and jump directly to that PharmD degree after doing those prerequisites. So here's the other thing that's kind of, that I'm I guess a little saddened about. The corner drug store, it's like, it doesn't, exist anymore. And I remember very, very distinctly, you know, with our young children and everything, our pharmacist was almost like a neighborhood healthcare provider. You know, everybody knew him, we could walk in and, you know, pick up some medication if we had to, or just sit and chat. Gone. Absolutely gone. I also have two cousins out in California who are they're retired now, but were pharmacists as well. And they were in that mode, that kind of corner pharmacy. So what happened there? That's a huge question. It's a big question. I think a lot of that is related to what we, the structure and financing of our healthcare system. And so, pharmacy, when you have a business, you have to be profitable, right? So obviously, if you're seeing the closing of businesses, that means they're no longer able to generate a profit. And so there are a lot of market variables that drive that reimbursement structure. A term that sometimes we call pharmacy benefit management companies, it can be the cost of medications, there's just a lot of a lot of variables that probably have contributed to that fact. And it didn't happen overnight, right? I mean, it just, it kind of took a while. Yeah, absolutely. And I think we're seeing, you know, even more of a shift. It used to be where, you know, you probably had a pharmacy in every corner and then now we have our, you know, our reduction in hours and all of these things that have happened. And so that has certainly been a challenge, but it looks like we did have our most distinguished guests join us and so I wanted to take a moment to pause and introduce her. Absolutely. It is a pleasure and honor to have Dr. Lenore Newsome, who is the current president of the National Associations of the Board of Pharmacies. It is a national organization that's been around for about 120 years. She has certainly made history with her presence. And I'm excited to have her here and I will let her say a few words about herself. Good morning, everyone. Morning, good morning. But sometimes our technology doesn't do what we want it to do. It needs medication. Yeah, true. But I'm happy to be serving as president of National Association of Boards of Pharmacy. And my presidential initiative is the mental health and well-being of pharmacists. pharmacy technicians and all pharmacy. But as I have progressed with my chosen subject, I found out that the very things that are needed in pharmacy are needed everywhere. I am meeting people in hotels and airports, and what you do, you just take the time to listen. And if I can, or if I do have any guidance, try to point them in the right direction. But... This is a big thing and this is something that we all have to address. Thank you. So, DeSanne, I'd like to ask both Dr. Chakolas and Dr. Newsome this question. It seems that the public perception of pharmacists is changing, has changed, there have been a lot of conditions. Could you talk a little bit about that? I mean, what's going on? Because it seems like, in fact, recently we've had pharmacists stop working, they're stressed out, I think, which speaks to Dr. Lenora's point. What's going on around pharmacy? I just think we've reached a time of burnout. We've been doing more and more. And once the pandemic came along, once you've been doing a lot and then you're asked to be squeezed a little bit more, but it was like nothing to give. It's like now we're hammering to go back to address those issues, to get everybody back right in center. so that we're in a position to continue to give because of the profession, we are always the ones that give, try to get everybody back to normal, get them well physically and also mentally. And right now that's been hard to do. So we're working on trying to get back to there, if that makes sense to you. Yeah. Dr. Wanda? Yeah, and I will just kind of second that burnout is real. Both of us are still practicing, we're connected with community and you know, you can't pour from an empty cup. And so like the demands and the expectations have significantly increased. So you know, I would say pre pandemic people were less reliant on medications. One thing about the pandemic is that it allowed people to check on their mental health. I saw a surge in mental health medications and ADHD medications, and probably the volume of medications that people take have increased. And then you pair that with the rollout of various vaccines and just the demands of having to multitask and as Dr. Newsom said, just constantly give and squeeze out a little bit more when there's nothing there. And then... you have to turn around and try to be present for family and present for community. And so we're definitely at a point where we're in a crisis and I'm glad we're here to talk about those issues. So I wanna ask this question, Dr. Ronakos, you mentioned this when you first started talking up, you talked about the changing role of pharmacists cause you and Dr. Newsome talk a little bit more about what is this changing role? I mean, we talked about the pandemic, but what's, you know, we used to have, you know, you just said that, you know, the pharmacists used to have the soda fountain. You know, you could just go and talk to them, but it appears that there is a changing role. Can we talk about that? What is that? Um, I can just say, I, I would certainly welcome Dr. Newsome's opinion. She has a outstanding career. Um, she is from Arkansas. She's done a lot of work. Um, I know she could probably provide additional insight, but for me, I can remember when I first started practicing in 2009 and I was like, Whoa, what did I get myself into? Um, but there's just been the expansion of, um, services. So in addition to, you know, when you think about just the prescription, there's things that we're supposed to do when we pass out that prescription. We're supposed to counsel the patient and tell them how to use it and then know you're looking for interactions. And so then fast forward, you start thinking about, as we discussed, a business model and how do you remain profitable when potentially you're losing money on dispensing medications, you add things like other clinical services. So you'll add things like vaccines, or you'll add things where you have the ability to prescribe birth control. And so you have all of these different things, but you don't necessarily have more bodies or more time to do it. Dr. Newsome, do you have anything to add? I think that you're spot on. We are promoting more services, but in the past, we used to have a little bit more time to spend with our patients. And the more things you do, then there's less time to spread around. And I think that we'll begin to see the results of not having that little extra special time, time to answer those little bitty questions that may be not big to us, but big to you, that will make your life. go a lot better. We're doing a point of care testing. We're doing more immunizations, but the time factor, workforce conditions so that you have time to do a little more. And we are working on that. How do we, you know, there's more need there, but how do we get more time to take care of those needs? So when did, you know, so my question is this, and again, you know, help me understand, years ago, you know, when we had our coroner pharmacist, at that point, could pharmacists provide vaccinations? Could they provide assistance with blood pressure monitoring? Can they, were they able, or did they provide? insights into, for instance, smoking cessation like they do today. Could they have done that back then or did the scope of practice expand? That's the magic word, a scope of practice. Our scope of practice did expand about the turn of the century, I'll say 1999, 2000. pharmacists became available to take care of immunizations for the company, for the country, excuse me. Yeah. And we have, you know, we've taken that and we have done a tremendous job with it, especially the changes that you saw with the COVID-19 vaccines. We were able to get a lot of people vaccinated or immunized and a lot of lives were saved. But that takes, you know, more people, more pharmacists. more time to do that. So the smoking cessation, that's another thing that we've taken on. So we've taken on a lot of responsibility, but we need expansion of time or more bodies of pharmacists to be able to do all of this. So let me ask you kind of a complementary question. Did in order to be licensed, today as a pharmacist, whether it be in Minnesota or any state in the country, have licensing requirements changed as well, given the fact that there are more responsibilities that are being given to pharmacists today? All of that fall under your license to practice pharmacy, under your scope of practice. What had to happen was that the states had to implement rules and regulations so that the scope of practice could be increased. So that's where all of that begins to fit under the umbrella of pharmacy. You understand that, what I'm saying? Yeah, absolutely. Okay. Makes sense. So, Rhonda, your insight into this? Well, I would say the same thing. And then the other thing is, there's the other piece that we don't talk about. And this is one of the things that is very much in keeping with Dr. Newsom's initiative, is the mental health. and well-being of pharmacists and pharmacy staff. So you couple this huge leap in responsibility, more tasks, more things to do, more visibility. And then you're working in an environment where people are not necessarily well. So even when I'm teaching students, people don't come to the pharmacy like they used to, to get... know, a root beer float or a soda fountain beverage, they're coming because they're not well, or they're there to help take care of a family member. So number one, you have to remember that we see people in pharmacy when they're not at their best. And as a result, sometimes pharmacists are also subject to harassment and workplace violence, and people not necessarily be being kind. I know and Dr. Newsome State, they have some very strong legislation in terms of what happens if a customer or a person tries to harm a pharmacist, but we don't have that across the country. So you imagine the stress and burnout can also be coupled with this increase of duties along with experiencing this unprecedented. And I would say it's unprecedented because I haven't seen it in 15 years where people are... their mental health is not well. And as a result, can be very aggressive and hostile on some occasions. And so you just gotta try to balance all of that. I'll ask this question as it relates to, you know, the mental health portion of it, because I know that right now in this country, drug prices are going up through the roof. We know that in our communities, people are not able to, in some cases, their drugs, is that causing an increase in pressures on pharmacists, I mean, or what's happening with that? Pharmacists is where it's discussed. You get your medication, you go to the doctor, you get your prescription and you come and you find out that yes, I have a treatment plan, but I can't afford the treatment plan that the doctor has offered. And that's very discouraging, but pharmacies do not, we do not give the drug prices. That's not determined by us, but yet we're the people that are on the front lines to listen to the complaints about it. Yeah. You know what, hand in hand, Clarence, with your comment is communication. So one thing that's kind of struck me is the communication that a pharmacist has with a patient has morphed into a variety of different things where they've really, almost to a sense, a pharmacist and a pharmacy has become kind of a community health. program in and of itself. Besides dispensing the medications, they also assist on a lot of things, which when I was growing up, that didn't exist. And then the other component of communication that I wanted to touch on and ask you about is communication with healthcare providers, like physicians. So when they prescribe, it's... oftentimes, frankly, the pharmacist that really understands a patient and all the drugs that they're on and the possible interactions. So how does that communication happen with a physician, for instance, to, you know, maybe pull up a red flag for a patient? I think that's a great question, Stan. And I want to kind of take a step back because when I have an opportunity, I want to look at like the systems aspect. And so when you talk about drug prices, there's so many variables in terms of we have formularies, different people have different insurance coverage benefits. And it's really, how do you even try to manage that as a physician when you're like, okay, well, I'm going by... clinical guidelines and guidelines says, well, this drug or this medication is the best for my patient. And then it comes back and then you can't afford it. Unfortunately, like I think all of the systems are kind of bogged down a lot of times. Physicians now when we're holding or we have to send a fax, it might be two or three days before a person can get their medication. So there's all of these variables that make it somewhat difficult sometimes to kind of navigate that communication. You really have to make sure your patients are, you know, have a certain level of health literacy. I would say Minnesota though is very unique and very different in the fact of their CHIP and S-CHIP program or Medicaid and Medicare program or even what we call, you know, Minnesota care. our program is probably, I would say, the most expansive in the nation and the most inclusive in terms of medications that are covered. We are also one of the last states to implement co-pays, which are usually either now one or three dollars. There's some variables, but again, what other states are experiencing, we probably don't have. We have medication repositories like a program round table RX. We have a lot of different things here where we're able to help navigate and refer people, but I don't think that is always the case. I would suspect it's very different in Dr. Newsome's state of Arkansas. Yeah. So let me ask you. Yes. Go ahead. No, no, go ahead, Agilentura. I'm sorry. In Arkansas, we have like a copay system that has been in place for years, but the copays are not bad. You're not meant to sign Medicaid program. Fantastic. We talked about the lack of pharmacists. Will AI help us in the future? I mean, we have a lot of pharmaceutical deserts and places like that. People are needing their meds and things like that. Will AI be a factor for use in the future? I think we can just kind of step back and look at like the like Dr. Newsome highlighted is the scope of practice right and how that scope of practice is defined by rules and regulations and so I think what is happening right similar to a lot of fields. We don't have the tools and technology that have been able to be incorporated into regulation. So that people can use technology. So we're a little bit, I think behind, but I will say the National Association for the Boards of Pharmacy have been very instrumental in developing guidelines and best practices and things that can be used to guide the practice of pharmacy. The challenge is kind of getting those things into statute and regulation. In particular, when you think about like, automatic dispensing or remote services or those type of things. Again, we have to because we're licensed professionals, we have to operate within our scope of practice, but also follow those roles and regulations that are both federal and state mandated. So let me bring up a couple of things here. I kind of want to circle back to communication a little bit. Medical records versus like pharmacy records. Okay, so do they talk at all? So like, you know, my medical record just personally is in epic. Okay, so does the pharmacy records in my pharmacy? talk with that system or are they completely separate or what? Where do things come forward with communication? I would go ahead, Dr. Newsome. I was going to say I don't have a hard answer for that one. That's all new technology. Yeah. So there are different systems out there, but the key thing is getting them to be able to communicate with each other. So that's going to be a large challenge that lies ahead of us. Yeah. And I can say at least from the Minnesota perspective. So I do know, and I mean, this goes back to me talking about me being a historian. Um, but, uh, former president Barack Obama was one of the people who said, okay, these, these records have to, um, you know, um, be used in electronic. And so now what we're starting to see is that data is starting to go back for the systems that use Epic here. you're able actually to get claims information to see when your patients are picking up their medications and when they got it filled. I actually was in Georgia, had an allergic reaction, came back here to the clinic and they were able to say, hey, I noticed you got a steroid dose pack when you were in Georgia. Are you okay? And I was like, oh, okay. You were able to get my claims information. So a lot of that information now is starting to be shared, but as Dr. Newsom pointed interfacing some of these technologies is challenging. Like for example, I don't have access to the information that Walmart or Walgreens or CVS might have. You know, pharmacies aren't able to share information either. A lot of patients seem to think that we do, but we don't. And there are good reasons why you just don't want information shared in an unregulated fashion. Yeah, yeah. So, you know, another... Another thing, you know, we'd be remiss if we didn't at least touch on it. And Clarence and I have agreed that we need to do a whole show on this because there's such interest around it. And that's and I kind of we can use this as an example. New new drugs that are coming out. All right. And one of them that's high on everybody's list are these weight loss medications. So give it give us your sense of. of weight loss medications, their use, their benefits, maybe the dangers that we have to look out for. And then kind of a sidebar on this is are medications getting to the point where it's, fits everything for everybody and you don't have to worry about gaining weight because you can take a drug that'll basically control it for you. That's, I think that's a very controversial subject, but I want to take a step back and remove it from the medication thing. And I have to be very careful because of my role and what have you, but let's look at what obesity is, right? Obesity, African-American people are disproportionately affected by obesity. Obesity is tied to problems with osteoarthritis. It is. tied to cardiovascular problems, it is tied to lipid problems, and it's tied to a, you know, even for some people, their mental health. So when we're looking at anything that affects obesity, we have to think about the risk and benefits of all of those conditions that it could possibly affect. So for example, if a medication can... in general, decrease your weight. Ideally, that's improving your cardiovascular health. It's working on your lipids. It's working on how you feel about yourself. The challenge is, any medication, there are risks and benefits. And so this newer class of medicines, which a lot of times started out as diabetes meds, had this side effect. I mean, I will kind of do a history thing here and then I'll turn it over to Dr. Newsome. One of the medications that we use for erectile dysfunction, Viagra, was a lucky accident. That medication actually started out in clinical trials to be used to lower blood pressure. And what happened is it did not work on blood pressure. And so the manufacturer went to come back and say, hey, I need to get my study medication back. People were like, uh-uh, I like this medicine. And so they were able to tease out that there was a side effect that was associated with it, which actually now is an indication for this medication, which is what we're seeing with the GOP1s, that's the class of this medicines, that initially started out for diabetes. but had the side effect of weight loss. And so, but again, when you think about it is side effects, right? I think we're coming to know more and more about them. Every day you're hearing something different as a potential side effect. There isn't a catch-all fix-all. My family has struggled with. weight and obesity, my community struggles with that. I will tell people if I thought that there was a magic bullet that would fix it without any potential harm, I would certainly be first in line and recommending that for everybody. So that's my take on it. Dr. Newsome, do you have any comments? My main thing is the long-term side effects of these medications. We're seeing the results right now that we're losing weight, but what else is going to be going on as we look at it in the future? And once you lose the weight, how do you wean yourself off of it or will you ever be able to wean yourself off of it? And another long-term thing that we have to look at is, you know, something that we're not looking at is the mental health, not only if the person is dropping away, but the mental health of those that are around that person, the loved ones, you know, how do they react to things? How is that person approached? So it's so many things we have to look at, so many. Yeah, you know, I guess, you know, maybe a real takeaway is, you know, question. you know, the quick fixes out of the gate, you know, maybe, you know, there's a lot of different variables that any person should consider going forward. But we'll get more into that in an actual show, Clarence. Yeah, so Dr. Newsome and Dr. Ronda, I'd like for you to just share with us your passions. I know that you, you know, Dr. Wendor, you are the national president and Dr. Ronda, you're the Minnesota president, but you have a passion in your leadership. I mean, Dr. Lenore talked about her mental health, mental health for pharmacists. Would you just share with us a little bit more about that as we get ready to close out our program? Dr. Lenore, you're first. All right. I've had a long, long passion with pharmacy, just taking care of people, going to work every day. Each day is going to be different. You're going to have different challenges each day. But go forth with a positive mental attitude that you're going in to take care of people for that day. And just take it one day at a time. I live in the southern part of the state, not far from the Louisiana border in a rural area. But I take care of the people in my area. And like I say, now that has been transformed to being with the State Board of Arkansas for 32 years now, and now on a national level with NABP. So it's just those little things you do every day that has come out with large outcomes for me. But most of all, I love my job and I love what I do every day. Thank you. Dr. Rhonda? Well, that's a tough act to follow. And I mean, I will just say this, just seeing Dr. Newsome, right? And I think it's because of people like her, I know I can. She's had a lifelong commitment to the profession of pharmacy. But she's also very available and approachable. And then just her demeanor, right? We talk about. this level of stress and burnout and even perspective, right? To maintain a perspective one day at a time, one encounter at a time. But as you know, my passion is really about creating systematic change and really arming people. And I will never say build empowering. I won't say. I'm gonna give you the power, but really about increasing the knowledge base and capacity of community members so that they can advocate for themselves. Like we've all sat here and talked about a variety of things like the changes in reimbursement, pharmacist burnout, practitioner burnout, community burnout. And then now we throw in there some blockbuster drugs and changes and how do we navigate that? And so that is the change that I like to be a part of and much like that Dr. Newsome, I am very, very much enjoying all aspects of my career, be it from being in the actual pharmacy to hosting community forums, to just talking to people on the corner or even being involved in clinical trials. I am really living my dream and I wanna use my gifts to make a positive change. You know, one thought that I had, I remember distinctly when there was research that was done where the researchers asked people, who do they trust in their care, in their healthcare? And always number one came out one way or the other, their primary care physician, if they had trusted one truly. But then... right up there, right next was their pharmacist, right there with their, and given even given all these changes that we're all witnessing, I still believe that, I really do. I think that there's some kind of a bond between a patient and their pharmacist, really. And I don't see that being compromised, at least perhaps that's my hope. Clarence. I just wanna say, I thank you both for being here. I know that this was a, we had, we talked about a lot of different things as you have noted, Dr. Rondevary, but I think it was a great time for us to enter into this conversation. And we do want to talk more about pharmacy, about its impact and about how it affects our community. And so I just wanted to say thank you both for being a part of our show. Back to you, Sam. Well, it's been great. And this is only perhaps the tip of the iceberg as we alluded to in their show. We'll have a show on weight loss medications because that's really kind of high on people's radar screen right now and of interest. So stay tuned to that for our listening audience. Our next show will be on hospice care, which also, you know, we all face it. one way or the other, so stay tuned for that. Thank you to our guests. I greatly appreciate your insights. Second to none. So with that, I'd like to say to everybody, keep health chatting away.