Why "access" to poor healthcare can be more dangerous than no healthcare at all

Many advocates of nonphysician practice argue that we need to allow nurse practitioners and physician assistants to practice independently because of a “provider” shortage.  The mantra “access” seems to supersede all other arguments – including concerns over patient safety.  But is ‘access’ really all it’s cracked up to be?  The answer is no, and here is why. A 2018 Lancet study analyzing 137 countries found that more people die worldwide due to POOR QUALITY care than die due to a lack of access to care (reference below).

Linda Anegawa MD, an internal medicine and obesity specialist, discusses concerns over safety when non-physician practitioners provide healthcare independently without physician supervision, and describes her own story of how a trigger point injection by a nurse practitioner resulted in a punctured lung. Rather than sending her to the emergency department, the nurse practitioner told Anegawa that her shortness of breath was just "procedure anxiety."  The truth was that the NP had caused a pneumothorax, or punctured lung, which can be fatal if left untreated.

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Lancet article
M.E. Kruk, A.D. Gage, N.T. Joseph, G. Danaei, S. Garcia-Saiso, and J. Salomon. 2018. “ Mortality due to low quality health systems in the Universal Health Coverage era: a systematic analysis of amenable deaths in 137 countries.” The Lancet, 392, 10160, Pp. 2203-2212 

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31668-4/fulltext?fbclid=IwAR1uwXVAsi-pOXSTEzJRTyX9nbdLtf8V-cGYMK6BuK_p77lTpNegyaCuUaI

Commentary: https://www.npr.org/sections/goatsandsoda/2018/09/05/644928153/what-kills-5-million-people-a-year-its-not-just-disease?fbclid=IwAR352fPMuZ9Z482Qb6_nFGQ-2bkcovCA3UdARsJDCvdbiHrLvhUasl0VxLo

PhysiciansForPatientProtection.org

Transcript

Rebekah Bernard MD: 0:07

Welcome to'patients at risk' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard, and I'm joined by my co host and the co author of our book, patients at risk the rise of the nurse practitioner and physician assistant in healthcare. Dr. Niran Al-Agba.

Niran Al-Agba MD: 0:26

Good evening.

Rebekah Bernard MD: 0:27

Many advocates of non physician practice argue that we need to allow nurse practitioners and physician assistants to practice independently because of a provider shortage. The mantra of access seems to supersede all other arguments, including concerns about patient safety, but is access really all it's cracked up to be? The answer is no. And here's why. A 2018 Lancet study analyzing 137 low to middle income countries found that more people die worldwide due to poor quality health care than actually die due to a lack of access to health care. Today, we are joined by a physician who is also a patient. Dr. Linda Anegawa is an internal medicine and obesity specialist who experienced a potentially life threatening event when she received care from a nurse practitioner. Dr. Anegawa, Welcome to the show.

Linda Anegawa MD: 1:20

Thanks for having me.

Rebekah Bernard MD: 1:22

Well, Linda, I heard you speak at the physicians for patient protection press conference when they were having discussions about California's independent practice for nurse practitioners. And I was so impressed with everything that you said. But in particular, your story really made an impression on me. Can you share your experience with our listeners?

Linda Anegawa MD: 1:40

Absolutely. Yeah. So I'll preface this by just giving you a very brief background for the first 12 years of my medical practice - and I've been in practice now for 22 years- so for the first 12 years, I was an academic primary care physician, medical school faculty, and also medical director of a variety of different health facilities. And during this process, and during this phase of my career, I probably taught 1000s of trainees be they medical students, medical residents, clinical fellows, as well as nurse practitioners and physician assistants. And so I think, not to kind of like toot my own horn. But I definitely am somebody who felt very confident in my ability to kind of mentor, supervise and instruct all of my trainees on how to take care of patients safely. And it wasn't like I was kind of one of the newest faculty members or anything like that. I'm old. Right. So anyway, what occurred to me what happened was, as my role as a medical director of a physical medicine and rehab facility a number of years ago, it was my responsibility to train nurse practitioners and physician assistants who were new to the practice in the aspects of seeing patients doing histories and physicals, evaluating them for different treatments, including like physical therapy, referrals for chronic pain, as well as some kind of low level procedures. I'm not an interventionalist. But as a primary care internist, you know, I'm certainly comfortable doing things like trigger point injections. And that was one of the main procedures that I did train our nurse practitioners and physician assistants. And for those of you who don't know, a trigger point injection is a very simple injection procedure done for pain relief, where the belly of the muscle is injected very shallowly by either saline, or else a pain relieving medication like lidocaine, and it helps to relax the muscle and people feel better quite quickly. And it's generally very safe. It's an outpatient procedure. It's done in doctors offices, all over the country. So anyway, so I felt really comfortable training my students in doing these types of procedures. So one day, as it turned out, I ended up becoming a patient of this clinic, I do have some neck problems, and I have pain that flares up from time to time and one day, I was just having a severe severe flare up of my neck pain was causing an excruciating headache. You know, I couldn't function I mean, we doctors or patients do, right? I mean, you know, we get sick, bad stuff happens to us. You know, I guess I could have left the clinic and tried to get an appointment with my own primary care doctor who was about an hour away or I suppose I could have gone to an urgent care or the emergency room or something like that. But you know, I had a busy schedule. I was seeing patients myself and I was trying to get through it right. So when one of the nurse practitioner trainees who I taught myself, just said, Hey, you know what, like, I'll do it for you. Like, you'll feel better quick. And I was like, Yeah, you know what sounds like a good idea. And it'll like hopefully save the day for me here. So I can continue to continue taking care of patients and doing everything that I needed to do. So she proceeded to do a trigger point injection in my trapezius muscle, which is like this big, bulky muscle right up here at the top of the neck. You know, I was anticipating feeling great within a few minutes. But what actually happened with something very different, I immediately felt a very, very sharp pain deep in my chest, I had a hard time catching my breath, even sitting on the table. So she was like, 'are you okay? Are you okay?' And I was like, 'Okay, no, I think I'm okay, it's probably just a little tighter, something like that. And then I stood up to get off the table and walk back to my office, and I couldn't stand. Like, I literally felt like, you know, I couldn't breathe at all, like, I couldn't get air into my chest. And I literally just collapsed. And so of course, when that happens to you, it's a very frightening thing. I'm pretty healthy person, I tend not to have any major medical problems. And so what I recall happening next was the nurse practitioner saying to me,'oh, you know what, it's okay. Like, you're probably just having some post procedural anxiety, take some deep breaths, try to relax, you know, you're probably like,' and she was kind of like smiling, and 'Ha, ha, ha, ha.' And I was like, 'okay, okay, maybe.' And I don't know how but I dragged myself back to my own office, which was a couple of doors down. And after, like, I really couldn't get off the floor, it was quite a profound thing to have happened. And so at that point, I went ahead and called my husband picked me up and took me right to the emergency room where the attending physician there did a chest X ray and diagnosed me with what's known as a pneumothorax, which means my lung was collapsed. And so I guess, here's the thing, you can get a pneumothorax, quite commonly, as a result of these trigger point injection procedures, it can happen to a doctor performing the procedure, it could happen to you know, really anybody who's doing it, I think, though, what that experience, illustrated to me was that the person who performed the procedure may have been competent at sticking a needle into the muscle and injecting, but in terms of her ability to step back and see me as a whole patient and assess what could be going on. I mean, that requires knowledge of physiology, anatomy, pharmacology, everything physiology, right. And I think it was clear that despite my training, despite my walking through her through the procedure, despite talking about all the complications, which of course I did, you know, as a teaching physician, it still didn't matter, there was a gap, a disconnect, if you will, that can't be remedied, I think by just trying to kind of teach someone in a patchwork way, in the clinic without that deep fund of knowledge that physicians receive through our, you know, decade plus of supervised training. So that was my experience.

Rebekah Bernard MD: 8:26

and not even to say, like, even if you didn't know what was wrong, to at least have the insight to say, 'wait a minute, this is not procedural anxiety, this person is not able to breathe, this person is having trouble ambulating I just stuck a needle into their body. Maybe we should evaluate this a little bit further,' maybe it wouldn't occur to her that that you had a punctured lung. But just to say that there is something going on, at least to evaluate it. And I think that's something we call non intervention. And we've in our book, we talked about how a nurse practitioners and physician assistants are less likely to intervene when medically necessary. And of course, on the other hand, sometimes they over intervene when it's not medically necessary order more lab tests and diagnostics unnecessarily. But this is a much more serious issue, which is a failure to intervene when you need to.

Niran Al-Agba MD: 9:20

The second piece of it that I think is really interesting that we that we often talk about is, look, I'm not an internal medicine physician, but it's the ability even though it's not my specialty to at least get some basic pieces is this anxiety is did your heart rate change? Is your blood pressure different is shortness of what are your breast sounds sound like some really basic A, Bs and Cs.

Rebekah Bernard MD: 9:40

Yeah, I think that's that's 100%. Right. So, Linda, when I heard you talking at that press conference, and you shared your story, and you said a couple of things that I thought were really insightful. First of all, you talked about the importance of physician oversight and the dangers of unsupervised practice, talk to us a little bit About what proper supervision looks like.

Linda Anegawa MD: 10:02

I think that's a really, really good question, Rebekah. I think that at a bare minimum, and I should say that I do live in a free practice state, where nurse practitioners are permitted to practice without any physician oversight at all. But to me at a bare minimum, that nurse practitioner when performing a procedure should be supervised by a physician who should be there and should be able to identify and manage the complications, right? I think that's the key. You don't know what you don't know. Unless you've, you know, been through the training and you understand the physiology. It's just like Niran was just saying, I mean, yeah, you're a pediatrician, you don't remember all the nuances, but you have an idea of what you need to look out for, and a way to assess the patient when they're hemodynamically. If they're hemodynamically, stable or not, right, which is absolutely key. So I think a taking even a step back from there, though, Rebekah, you can't have proper supervision without proper training. And this notion that somehow lesser trained individuals can be thrown into a clinical setting with online diplomas, and be expected to perform at the level of a physician makes no sense. So first, people have to be trained properly. And, you know, make no mistake, I actually really strongly believe that nurse practitioners and physician assistants play a very valuable role in the health care system, but not without physician leadership, not without physician oversight. I mean, it's simply impossible to learn what we learned in medical school with, you know, a few months of shadowing, or even less sometimes,

Rebekah Bernard MD: 11:52

I think your story, and what happened to you is a perfect example of why we need that supervision. So if the if this was in a doctor's office, or a nurse practitioner office, where there was a physician on site, and the patient has a bad outcome, then that's the time where you need that involvement set to say,'Hey, do I need to do something else?' Because if you had known that something was wrong, if you were getting that care in an unsupervised situation, and you weren't a physician yourself, you know, potentially you could have died from that. If she had said to you, 'hey, this is just anxiety just go home just rest, you'll be okay.' We might not be talking right now. And I don't mean to over exaggerate. This is true.

Linda Anegawa MD: 12:34

Yeah, no, absolutely. And so I think that's what's also very striking to me, too, because I was in this odd position. This was someone I trained. I was kind of her supervisor, I was also a physician, right? So I knew the complications, I knew the wrong things, the bad things that can occur, because I've seen them so many times. But yeah, I mean, what if this was my mom, what if this was my sister? I mean, you know, they would have had no idea and you know, they're, they're the kind of people where it's like, anybody with a white coat speaks, they're going to be like, 'Oh, okay, you know, sure.' And nowadays, what's so challenging is everybody has a white coat. And it's almost impossible in a hospital in a hospital setting to really know who has what credentials when they're taking care of you. Right. And I think that's what's also so disturbing to me about all of this.

Rebekah Bernard MD: 13:22

Yeah. And you said a couple things in the press conference, and I wrote them down, because I thought they were so good. You said,'nurse practitioners cannot provide unsupervised care, because serious errors occur when you don't know what you don't know.' And you said 'nurse practitioners should be part of the healthcare team. Absolutely. But are they equivalent to physicians? No.' And then you also said something that I thought was really interesting. You said, 'can they be trained to perform independently and safely like a physician?' And you said, 'No, not without medical school.' And basically, it's what you're explaining is that you just have that gap. And so would you say, then, because some people will tell us well, we just can send them for residency training or fellowships or additional training? What are your thoughts on that idea? As far as Can we do that and then have independent practice?

Linda Anegawa MD: 14:11

You know, that's an interesting thought. So I don't really know what their residency programs are proposed to accomplish or what type of training they actually do other than kind of have the nurse practitioner shadow in a clinical setting. So that might help with exposing them to management of maybe a few selected garden variety cases, like let's say, in cardiology, or orthopedic surgery, or dermatology, but it simply cannot replace that deep fund of knowledge that doctors get from studying physiology, pathophysiology and also a superficial you know, so called Residency does not equal the time that we spend training to be independent, right? in quite the same way, a one year residency for a mid level practitioner, how can you compare that to the three to seven years of highly rigorous 24 hour, seven days a week training that most physicians have to go through. I mean, when I've heard things about some of these residency programs, to me, they almost sound like, like a glorified like, you know, nine to four job where you clock in and clock out. And there's really not the same level of responsibility that we had during our training. So, I mean, while these programs might may help in furthering knowledge, it's just not a replacement. And I think anyone who calls it a replacement, or alludes to the idea that it might be equivalent, is really putting the lives of patients in a lot of danger.

Niran Al-Agba MD: 16:09

Or seeing that you talk about a fund of knowledge, because I think this is something that gets lost. You know, we're three primary care Doc's which I think is a really important part of this. And specialists are wonderful we need we need them. But I hear a lot of them say things like, Well, I don't use everything I learned in medical school, I use very little of this or that whatever it is, you know, people laugh about the Krebs cycle, for example. And it's one of my favorite ones to use. Because I feel like I literally use 90 plus percent of what I learned in medical school, every day, and sometimes maybe not for a month or so I don't have to talk about the Krebs cycle. And then I find myself with a kid with another metabolic thing or their lactic acid is whatever it is, or their newborn screen comes back abnormal and have to go back and figure out what biotinidase deficiency is, you know, so again, I think that gets forgotten sometimes. And you can some specialties are more protocol driven. And I think they've been it's been able to sit do follow ups and things like that a non physician, but I think it's really hard in primary care what seems easy to some, we already know all of us having worked in primary care. To me anyway, I feel like I use everything I learned in medical school, every Cotton Pickin day. And that's the fun that's missing. It isn't even shadowing someone to see that one person with a metabolic disorder. It's understanding everything else in between that led up to that. Where does glucose come from? How does it get made? When you're out of it in your liver? You know, what did you go to your muscle after your muscle? Where do you go? And why do you make you know, ketone? But I mean, I could just go on and on about these discussions that seem esoteric to some, but they're really important, especially with children, I'm sure with adults, you know, it's the same. There are elements of it that we use every day. So what do you think about especially internal medicine? Do you feel the same way that you use a lot of what you did in medical school that is missing from non physician training?

Linda Anegawa MD: 17:59

100%. I mean, because here's the thing, if we don't have that background in physiology, and you know, the pathophysiology of disease states, if we are not able to come up with a full differential diagnosis, which means the whole list of possibilities that a patient can have for their symptoms, what ends up happening is, every cough becomes an asthma flare, right? Even if the patient has no history of that, and they're 75 years old. And further questioning reveals that they have weight loss, and they have arthralgias. And they've got blood tinged mucus, right, you know, why would a 75 year old person out of the blue suddenly develop asthma, right? When you know, you and I mean, you're a pediatrician, you don't treat 75 year olds, but I can tell you're already thinking malignancy, lung cancer, pneumonia, I mean, even sarcoid, there's just so many different things. In the same way every rash becomes eczema, and I just had a patient the other day in my clinic, who had been treated repeatedly by a nurse practitioner with topical steroids for eczema who actually had Stevens Johnson Syndrome, but it took me doing the history and really considering all of the different possibilities for what this rash could be. But if I didn't have that background, if I didn't have that education, how am I supposed to think of it? I mean, in a way, it's like, well, gosh, it's not the nurse practitioners fault. You know, like, she didn't even study that. But it is the fault of our society and our health care institutions, if they play such lesser trained individuals in positions where physicians need to be present.

Rebekah Bernard MD: 19:57

Yes, and especially we always hear about it that we need access access access, especially in underserved areas. And I'll tell you having worked in a rural and underserved area for six years, those patients were some of the had some of the most complex medical conditions and had some of the highest medical need. And I had to use every little bit of my skill set, and do a ton of research and reading and studying. And I was already a fully fledged physician to help correctly diagnose them and treat them and manage their conditions. And yet, this is the place where a lot of times we're sending non physician practitioners, instead of investing in physicians in these areas. And I want to talk about this provider shortage. I don't like to use the word provider, but they always say that, so they'll call it a gap. And the first of all, the question is, is it even real? Do we have a physician shortage? I mean, I think we do in primary care. I don't know if we do across the board. And we do, we did explore in our book that the United States has less physicians per capita than 24 out of 28, developed nation. So we are very, very low, as far as primary, any physicians, much less primary care physicians. So what they often say is, well, let's have nurse practitioners and physician assistants fill that gap. And that's originally what both both professions were created to do. But the truth is that we're not seeing them go into these areas. I don't know that they even should, let's just make that clear, because like we said, we need additions. What we're seeing statistically is that nurse practitioners entering into primary care has decreased 40% Over the last 15 years. And that efforts to encourage nurse practitioners to go into rural and primary care has not been effective. In fact, that 2012 pilot project provided$179 million to train nurse practitioners and motivate them to work in these areas. And it didn't work. After five years, the pilot project was up, only 9% of the nurse practitioner graduates went to work in rural areas 25% worked in underserved areas and get this only 12% went into primary care and not filling that gap. So we're not seeing that. And have you had any experience Linda with underserved areas. I know Niran works there.

Linda Anegawa MD: 22:17

I do but not in the way you might think. So I'm the founding physician member of a digital primary care firm called plush care. And one of the things that we do, we're in all 50 states, we never really expected that we would attract so many individuals from underserved areas, but we actually do because we have very, very affordable rates for people who don't have health insurance. So plush care is physician only. And like I said, we've been seeing people from incredibly rural states, many have not seen a physician for their entire adult life. Like I'm not even kidding. It's quite impressive. And of course, when I see them, and I'm ordering bloodwork on them, and then seeing them for follow up, it becomes apparent that they have really suffered because of their lack of access to quality physician care. So it's my opinion that number one, the digital tools that we have today brings physicians to patients in a fast, easy, convenient way. Is it perfect for everything? No, I mean, I can't do people's pap smears and things like that. But at least it's a start it's least it's a start to get people, basic screenings to get them engaged with the healthcare system. So I think that using technology and responsible ways, and providing outreach to underserved areas is 100% critical. The other thing too, is I happen to know that we have a large body of unmatched Medical School graduates who were not able to enter residency in this country. And so why we are not creating more residency slots so we can get these folks trained up and you know, get them out to the areas that are desperately needed. I have absolutely no idea because it doesn't make sense to solve an access problem by putting a lesser trained, lesser qualified individual into that spot. You know, it's kind of like reminds me of the whole argument about, you know, 8890 in California, the whole guise of of the senators argument was to improve access. Is that fair to the people who live in impoverished areas? Is that fair, just because you don't live in Los Angeles or San Francisco, and you can't afford that. So I completely agree with everything like that you're saying.

Rebekah Bernard MD: 24:43

Well, you know, what you're saying is has been studied, And I alluded to the lancet article that was recently published just just within the last few years, and I thought it was so telling because, first of all, this study was really trying to analyze the idea of universal health. coverage. So the theory was that if you gave people health insurance or health access, that you would decrease mortality and that you would improve their health. But it turns out that that's not quite true. And what they found out was that more people die every year across the world, from poor quality health care than die from lack of access. And so they were like, Well, why is this and how is this happening? And so I have an article here from the commissioner of the study, Dr. Margaret Kruk, she's a professor at the Harvard Chan School of Public Health. And what she said she was really surprised by this finding. And what it turned out to be is that many of the practitioners that were taking care of these patients were not properly qualified. Many of them it says that fewer than half followed the recommended clinical actions, they were not spending adequate time with patients, especially for children, children were really a big part of this. So in in certain parts of Africa, only 50% of the providers could accurately diagnose pneumonia or diabetes. And I would say that's probably the case here in our country among some of audit doubt, without a doubt. Yeah. And so what they said the take home message was, is that you have to focus on quality, not just access. And they also talked about equity. They said that what they found was that the most vulnerable groups, the poor, the uneducated people with stigmatized conditions, teenagers who are pregnant, they all got worse care, and they got less quality care. And I think that we're seeing the same thing. Some of the things they said here is that she said, It's an epidemic of poor quality, even if access is there, people still aren't getting services for depression. They're not getting the recommended screenings that they're supposed to. And then what was so interesting, I thought was that the what Dr. Crook said was probably the biggest surprise for me is the question of how we improve. Because when we examine the evidence of very commonly used improvement strategies, checklists, refresher trainings and supervision, we were quite disappointed in the effectiveness of those strategies, and the inability of those things to scale. And so she said this, we have to move back into a foundational strategy. So just what you're talking about, you can't just, you know, learn how to follow an algorithm or a protocol for some things that can work. But for overall general care, we need the basics, we need the foundation, and that's what medical school and residency provide.

Niran Al-Agba MD: 27:34

And I'd like to say one thing, what's interesting, just in the last few years being in rural medicine, obviously, I've become more and more vocal about the fact I treat adults, which is, in my opinion, a little bit scary, but they tell me that they're happy to have me versus, I guess no doctor, and I have a family doc, who, who's in her 70s and does locums. And I've learned quite a bit from her. So again, I mean, I think sometimes we always want to over intervene and what we need are pap smears. We need basic care. We need, you know, basic if they're tired, and they need thyroid, I mean, really basic things that, that I think any of us that had training in medical school can do. I'm always really clear about the fact I'm a pediatrician, first and foremost. But you know, again, it's funny, you told that story about a seven year old with asthma. My dad walked into my house, he was a pediatrician for many years and said the exact same thing. Actually, I think he was at when he said it, and he said, I said No dad, 80 year olds don't get asthma, that's probably heart failure. Let me listen, you know, and see if you have fluid in your lungs. And of course, we argued about what his condition was. And it was later heart failure. But but you know, again, we have really basic physiology Look, you're short of breath or wheezing, there's either fluid, there's constriction, there's, like you said, a condition or a cancer, you know, a mechanical problem, there's only so many things that can be. And there's an element to that, that prevents us from I think over intervening when it's not necessary. And that's another mistake I see of a lot of non physicians in rural areas is you have this, we're going to do this protocol thing. And sometimes you just need to sit back and either see him again, it's like hypertension, when you see it, you got to check them again, you got to give it a break for a month or whatever it is, in the beginning, you don't just jump and start on a beta blocker. You have somebody evaluate you check it at the grocery store, whatever it is, sometimes putting on the brakes is really helpful. And it's hard to know when to do that.

Linda Anegawa MD: 29:23

Just to echo that, for sure. I mean, sometimes I feel like some of the most helpful things that I've done as interventions for my patience is to literally sit back, listen, observe, and bring them in for a lot of close follow up. So I can continue to tease things out because there's usually a reason if something doesn't fit right into a protocol of you know what we think it's supposed to, there's usually a reason and if that for me, sets off alarm bells that I'm missing something and I think that goes back to my training.

Rebekah Bernard MD: 29:55

You're so right and Dr. Kruk in this article of the lancet said quote, We have to stop flooding countries with quick fixes and shiny solutions. And I always say, you know, primary care isn't really super sexy. It's not glamorous. A lot of times it's just repeated. Follow up listening, talking dialoguing, and there's very rarely those, you know, days that you feel like, wow, I really made a difference, but you do over time. And we know that primary care is associated with decreases in mortality when it's done. Well, one of the most important things that you said Dr. Onagawa, was, there are no shortcuts in taking care of the lives of human beings. And I just thought that was so pregnant. And it's so important, and I think our legislators need to hear that. And then I think patients also need to realize that their lives are precious, their health is precious, and you want to make sure that you're getting the best care that you can.

Linda Anegawa MD: 30:47

Absolutely. And everybody deserves the best care that legislators also get and that presidents get.

Rebekah Bernard MD: 30:54

Agree 100%. Well, I want to thank Dr. Linda Anegawa, for joining us and telling her story. And of course, thank you to Dr. Niran Al-Agba for joining me after a long day of giving COVID-19 vaccinations. If you'd like to learn more about this topic, we urge you to get our book. It's called patients at risk the rise of the nurse practitioner and physician assistant in health care. It's available at Amazon and at Barnes and noble.com. We also encourage you to subscribe wherever you listen to podcasts and our at our YouTube channel. It's called patients at risk. And if you're a physician and you'd like to learn more about promoting physician led care, we really encourage you to join our group physicians for patient protection. Thanks again for joining us and we'll see you on the next show.