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SBI Podcast
The official podcast of the Society of Breast Imaging (SBI). This quarterly podcast will cover different breast imaging themes each year. The theme for the first year is: Breast Imaging Economics.
SBI Podcast
Rethinking Diagnosis: Contrast Mammography's Role in Future Care
Dr. Karla Sepulveda sits down with SBI Past President Dr. Margarita Zuley for a special live episode at the 2025 SBI Breast Imaging Symposium.
Contrast-enhanced mammography stands poised to revolutionize breast imaging by combining high sensitivity with improved efficiency. Dr. Margarita Zulli shares her journey from early research in 2016 to today's clinical implementation, revealing how this technology matches MRI's disease extent assessment while offering better specificity.
The traditional breast imaging approach—what Dr. Zulli calls the "linear care model"—creates significant burdens through multiple appointments spanning screening, diagnostic workup, biopsy, and additional imaging. This fragmented process strains both patients and healthcare systems with repeated scheduling, transportation, and extended anxiety waiting for results. Contrast mammography disrupts this inefficient paradigm by potentially eliminating unnecessary ultrasounds of low-suspicion areas and reducing supplemental MRIs, allowing for more immediate, accurate care decisions.
Beyond operational benefits, contrast mammography addresses healthcare disparities by providing advanced imaging capabilities at lower costs. Research shows women of color and those from rural areas face significant barriers completing follow-up care after abnormal mammograms. CEM, combining screening and diagnostic capabilities in one more affordable test, helps level the playing field with accessible advanced imaging.
The conversation expands to discuss remote diagnostic interpretations, an innovation accelerated during COVID that allows radiologists to perform consultations from home workstations. After five years of implementation, including hiring a radiologist living six hours from the medical center, the practice reports no differences in quality metrics or patient satisfaction. This approach grants radiologists greater control over their work environment, reducing burnout while maintaining excellent care.
Listen now to understand how these innovations can transform breast imaging practice while creating more patient-centered, efficient, and equitable care systems. What we leave on patients isn't just test results—it's what Dr. Zulli powerfully describes as our "medical footprint."
This quarterly podcast will cover different breast imaging themes each year. The theme for the first year is: Breast Imaging Economics.
You just tell us when. Okay, Welcome back to the SBI podcast where we discuss all things breast imaging and hot topics relevant to the breast imaging world. I'm Carla Sepulveda, Professor of Radiology at Baylor College of Medicine, and we welcome you to this very special episode, coming live from the SBI meeting at the Broadmoor in Colorado Springs where the SBI is celebrating its 40th anniversary. Awesome meeting and so excited to be here to do the podcast. This is our fourth episode of our inaugural year where we have been discussing imaging issues related I'm sorry, economic issues related to breast imaging, and today's going to be a wonderful addition to those first three episodes. It is a great pleasure and privilege to welcome Dr Margarita Zulli to the podcast. Dr Zulli is Professor of Radiology, Vice Chair, Quality and Strategic Development and Chief of the Division of Breast Imaging at the University of Pittsburgh School of Medicine.
Speaker 2:Welcome. Thank you, carla, excited for you to be here.
Speaker 1:It's great to be here. Thank you for having me. My pleasure, my pleasure. So a lot of talk about contrast-enhanced mammo at this meeting, and I am getting the sense, as more and more of us are starting to do contrast enhancement mammography, we are starting to understand that not only the power of that tool for our patients, but also the potential of this modality to be disruptive and change how we are approaching patient care, and so I'd like to spend a little bit of time discussing that. When did you start doing contrast enhanced mammography in your practice?
Speaker 2:We started doing it in the research setting in 2016 was the very first work that we did and we just. It was a small trial comparing contrast mammography to MRI and molecular breast imaging and ultrasound for extent of disease, and it was about 100 cases. That was a prospective study and it demonstrated that contrast mammography was equal to MRI for extent of disease and better than ultrasound or molecular breast imaging, and it was after that first 100 cases that we really realized some of the potential of this technology. Fast forward now, a decade later, we've enrolled thousands of patients in various research studies and I'm particularly interested in this tool actually to improve accuracy so that we can begin to use this technology to decrease the medical footprint that we're leaving on our patients.
Speaker 1:I'd like to hear that. I want to hear you know through the meeting you know, I think where the emphasis is really coming in the most is with supplemental screening. How can we utilize contrast-enhanced mammography for supplemental screening? But I want to talk more broadly about it, and how do you see that being utilized versus, say, abbreviated MRI and then perhaps even more that sort of episodic care that we are providing for our patients?
Speaker 2:So there's been some good literature published in the last couple years demonstrating that contrast mammography has quite nice sensitivity in dense breasts, somewhere on the order of 97% to 98% sensitivity, and it's got higher specificity than MRI. So I think what we've come to realize in the last few years is that screening mammography, and especially with tomosynthesis, is very good for women of low to normal risk who have not dense breasts, but in the dense-breasted woman, whether they have other mitigating factors that elevate their risk or not, we are not finding all the cancers that are there and I think that that was very well demonstrated by Janice Sung and her colleagues at Memorial Sung Kettering when they published a paper several years ago in radiology that showed that MRI was finding higher nuclear grade cancers at a much higher rate and mammography was really good at finding luminal A breast cancers and DCIS. And that particular paper made me realize that the reason that we have this continual problem with interval cancers is because we weren't using contrast-based imaging Right. So MRI has been around for a long time. You know we all consider it to be our gold standard. It's a wonderful test. We use it a lot in my organization for supplemental screening but there's not enough magnets in our system and, honestly, if you look even across the United States and even on a broader scope across the world, we do not have enough MR machines or gadolinium resource because that's not a renewable resource to be doing all intermediate risk and high risk or even normal risk women with dense breasts.
Speaker 2:So we need another strategy. We need to be resilient and be able to offer an or option, and in my opinion, that or is contrast mammography. You know it's got the benefit of having using iodine, which is less expensive. It's a renewable substance. You know it's a made substance. You can do the test there while the patient's there, so they have no sleepless nights waiting to get the results. And so I really think that it's a way for us to begin to collapse the paradigm and move towards this. I think about it as, instead of a carbon footprint, it's a medical footprint that we leave on the patient, and the more that we can consolidate that and the fewer tests that we can do to get to truth, the better off we are for our patients, the better we serve them.
Speaker 1:I love the way you're saying that, that very patient-centered approach to how can we get to the answer, and we have discussed the linear care model that we're sort of currently using. Let's talk about that and how. Not only does that impact patient care, but also the economics of that.
Speaker 2:Yes, so, historically, breast imaging and not all breast centers. Some breast centers are very innovative and they provide all same day care. Most organizations are not set up to operate like that, though. Most of us batch screening. So what that means you know. The lady comes in, she gets her screening mammogram. If you're caught up on your screens, you may read that exam that day or the next day, right. But there are many organizations out there that don't have enough radiologists and they have a thousand screening mammograms waiting to be read and a patient may wait a week or two to get the results.
Speaker 2:Yes, so now we recall the patient. Now we've got to make another appointment for the patient. That could be another two weeks till the lady gets back in to get her additional workup. What is that workup? It's typically extra views and an ultrasound and that may result in recommendation for biopsy. Now we have to make a third appointment for the patient to return to have a biopsy done. Pathology comes back a few days later. This lady still doesn't know what's going on, and it could be more than a month since that screening mammogram. And now we're on trip three.
Speaker 2:Yes, then the results come back. Oh, it's a cancer. We call the patient, notify them, let's do an MR to stage you. Then we go see surgery. Surgery says oh, I want that lymph node biopsy. Now they come back again. We have to do a lymph node biopsy. So now we're looking at five, six visits. That's six days off of work, that's six bus rides or parking lot expenses or paying for a nanny or whatever it is.
Speaker 2:This linear care model that we have evolved into as a community has been based around historic practice and has been based around the efficiency, of our efficiency and I actually don't think it's that efficient, because every time we have to schedule the same patient to come back, we have to make sure that our resources are available for that as well. What's that mean? That means that we have to have a doc available for four or five visits, we have to have a front desk and technologists available for all of those different visits, and so if we think about a return on investment or a financial or efficiency model from our viewpoint, I think that we also have something to gain by really thinking about how do we collapse what we're trying to do for our patient into a really cost-efficient strategy where we can get the diagnosis with fewer trips for the patient, which means fewer episodic staffing situations for us. So I think that it's a win-win to think in this way.
Speaker 1:So, taking what you're saying, which I absolutely agree, this linear, with multiple visits to the opposite extreme yes, where there are practices, including our own, where we will do same day workup of abnormalities on screening, yes, and in fact, in the highly suspicious cases, we'll do a same day biopsy. Let's talk about that and what are the challenges with that?
Speaker 2:Yes. So I also have practiced in that model, both in private practice and in an academic setting, and I think that it's a wonderful strategy. For some people, the pro of it is that it's a single visit the patient has. The only sleepless nights that the patient then has is waiting for the results of the test back and maybe a return trip for an MRI prior to seeing a breast surgeon if they have a cancer, that's wonderful. Surgeon if they have a cancer, that's wonderful. It is cost efficient for us as imagers because we are delivering all that care with the staffing that we have in that particular day.
Speaker 2:However, there's a human toll on the radiologist in this situation, and everybody who practices in the same day setting will understand what I mean when I say that. Yeah, because you do not know what you're walking into every day and so you go into work and the level of uncertainty and the level of emotional fatigue that's generated in the course of a day where you don't have a set schedule and you don't know what's happening from the beginning to the end of the day is higher than when you practice in a setting like I am in today. So I'm in a very traditional academic program with a linear care model, meaning that we'd almost never take patients to same-day biopsy. We will do same-day workups sometimes because we have same-day screens, but we don't go that whole way through the continuum. Working in that model, the physicians are less fatigued because they have absolute certainty about their day. The other thing is, if we look at it from the patient's viewpoint, some patients are delighted to get everything done in one visit, but other patients can find it overwhelming. I think it's a very important point, and so I think that what we need to do again is to be flexible. I think what we're discussing here today is to begin to be more flexible in how we approach our delivery of care, taking into consideration the costs that we're imposing on our organizations and ourselves human costs, financial considerations and the costs and the human toll that our patients are experiencing. Yes, when we start to introduce the concept of same-day contrast-based studies now, we run into the extra considerations of getting prescriptions for that, because you can't just go do a contrast-based study in most instances without having a prescription. Go do a contrast-based study in most instances without having a prescription.
Speaker 2:So I think that we've got a lot of thinking to do as we collapse this model, about how we can structure it in a way that's not creating moral distress for our physicians, not creating undue anxiety for patients and sort of pushing them into something.
Speaker 2:Because I guess the way that I think about this is when you approach a patient and you tell them that you think that they have cancer, you're escorting them across a threshold into a new phase of life, absolutely. They came in an average person and they're walking out a cancer patient, right, and that journey is different for different people. And so I think we have to be very cognizant, and that's one of the things that creates moral distress for us is that we don't want to be rushed in that approach. We want to give the space and the respect to that journey for our patient, to give the space and the respect to that journey for our patient, and we want to be able to do that in a way that allows us to be available to the next patient and ourselves, absolutely. And so I think we've got a lot of work to do, all of us together, to think through these things. As more advanced technology comes to our fingertips, how are we going to deploy it in a really logical fashion?
Speaker 1:to our fingertips. How are we going to deploy it in really logical fashion? Yes, well, I know we've also discussed kind of tying back to the economic theme the impact on the faculty in terms of burnout of the same day model and that unpredictability and how so many faculty want control yes, that that is so satisfying and prevents burnout. And to tie it to the economic theme, that potential of losing faculty that are overwhelmed by that model. Absolutely, not only faculty but also staff model. It absolutely not only faculty but also staff, because certainly the model requires a whole team that is willing to deal with that unpredictable schedule. When you walked in the door, just to kind of follow up on the linear model and how you see contrast, perhaps collapsing that down and the potential for that to have an economic benefit of minimizing leakage yes, in a system where we really want to take care of our patients for this entire journey of their diagnosis yes, how can you see that contrasting his mammography might impact that?
Speaker 2:So one of the things that's really exciting about contrast mammography is that you know it is our mammogram, so when a patient comes in, whether you're going to be using it in the screening situation or in the diagnostic situation, I think a lot of us are starting to understand that we could do that as our base study in a large fraction of our women. So now, what do we have? Now we may not need that MRI for extensive disease. We may not need that ultrasound for that low suspicion area that we saw on the mammogram anymore If the contrast mammogram is negative in that area. Now we're becoming more efficient with our use, and now we've collapsed the care down to screening and diagnostic or one test.
Speaker 2:The only thing that you're going to do is go after suspicious areas. So the number of biopsies that you're going to do is going to go down. The number of ultrasounds that you'll do for low suspicion areas will likely go down. The positive predictive value of biopsy should go up Right, and so that will allow us, I believe, to move to a more online practice, because the amount of resources that we're using for all of the false positives that we generate from less accurate tests are going to go down Exactly, and so I think that that really opens the door for us to begin to push on this idea of minimizing this linear care model that we've all built our specialty around.
Speaker 1:Yes, yeah, you need to write that up.
Speaker 2:I love it. I really really love it.
Speaker 1:It's just an idea. Very powerful and, I think, so accurate and, again, patient centered and empowering the patient in a difficult time.
Speaker 2:So I, but you know what I think that allows us to do, is it? I don't know how your days are, but there can be entire days where I see a whole lot of patients and I don't tell anybody that I think they have cancer. I spent the entire day discussing breast pain or looking at recalls that were not abnormal, that ended up to be benign, yes, or discussing follow-ups of benign fibrocystic changes, and I think to myself, not that uncommonly I'm not. I I did a good job today because I took care of the people that came to me, but we picked the wrong people these people are. We are giving them burden that they don't need and we're using a lot of human resource and time.
Speaker 2:Yes, and if we had more accurate testing that's delivered just in time and what I mean by just in time it's when the lady's already in my office yes, if I had more accurate testing, I could maybe see more patients and or dedicate more of myself to the patients that I've got and have more of me left to take home to my family. Yes, so that I'm satisfied in my job and I think that that feeds into retention and recruitment. Yes, so you know, one of my jobs as a division chief is to really work with the faculty and the people above me to ensure that I'm delivering the best care and working with the faculty, that they enjoy their job, that they are heard, that they have control over their lives, and so part of that as a leader means that I really need to push forward on accuracy and on streamlining and eliminating unnecessary testing.
Speaker 1:Yes, yes, I think it's so much of a goal for all of us to increase that cancer detection rate, reduce the false positives. How can we refine our practice continuously to get closer and closer to that goal? And I love how you're saying it.
Speaker 2:And so the other thing is. So let's come back around to the question that you had originally asked, which was how does that help with leakage? So we worry about leakage a lot, and I think every organization probably worries about leakage because, meaning, you know the patient schedules with you for something, or it could be that they saw a gynecologist in your system and they go somewhere else and get a mammogram. Why'd they do that? Because you don't have enough access? Or they had a bad experience because somebody was burned out last time they met them, yeah, or lots of different reasons, and so we really all of us organizationally want to ensure that the patients that are in our system come to us and we keep them through their entirety of care.
Speaker 2:And if they don't do that, not only is it not good for us organizationally, but more often than not they'll come back into the system at some point. Yes, and what do we end up doing in imaging? We end up doing second opinion reviews of outside work, which takes three times as long than to just do it yourself, exactly. And so how do we minimize that? Well, we minimize the number of times the patient has to come see us. Yes, we minimize the out-of-pocket costs to the patient by really thinking about their dollars as ours. How can we spend their money like we would want our money spent so?
Speaker 2:that we're doing only what they need to have done in the most cost-efficient way for them and in a way and in a time frame that suits them. So that could be online or not, it could be all in one day or not, but I think that's how we have to think about it, and if we're not thinking like that, we probably deserve to lose the patient.
Speaker 1:Honestly, you're right, you're right, you're right, very honest as usual, and it's an accurate assessment. I agree with you. You just touched a little bit on cost sharing and how we can help to minimize cost sharing for our patients and I'm going to tie this in a little bit with the contrast enhanced mammography and see. You know, this is such a broader discussion and ties in with the abbreviated MR and state laws that are helping to cover those extra costs for supplemental screening. Ideally find it early act would be a beautiful thing, but while we're not there, I think contrast-enhanced mammography plays into this discussion because of the cost of contrast-enhanced mammography versus MRI.
Speaker 1:How are you seeing that play out in your practice?
Speaker 2:So today in my practice we do full protocol MR for extended disease and primarily abbreviated MR for screening we use so Medicare has a circular that gives guidance on how to bill for abbreviated MR and it is using the 52 modifier, which is a limited exam modifier. So we use the standard CPT code for MR. We put the 52 modifier on it because we are doing an abbreviated exam that reduces cost or reimbursement by about 50%, so that reduces the out-of-pocket costs that the patient's going to have. I am fortunate to live in a state that already has legislation that indemnifies patients of co-pays and deductibles certain groups of patients co-pays and deductibles for MRI, and so I feel very fortunate that we are able to offer that service to patients and it's been a highly successful programmatic change is that patients who live in more remote areas, who from a breast center, let alone an MR machine. Now we're creating even more disparities in care. Okay, so glad you touched on that.
Speaker 2:So you know, a few years ago the National Mammography Database Research Group, which is led by Cindy Lee, published a paper. It was over 30 million screening mammograms that she looked at and she showed in that paper that women who are Caucasian return more frequently from recalled screenings than do Native Americans or blacks, and same for biopsy. So we have a disparity. Even when we recall them, we recall black women less than when we recall white women. And the people that come back, they come back at a lower rate. Why are they coming back at a lower rate? They can't afford the additional work. It's too difficult for them. You know we're asking them to take another day off of work and so if we add to that burden at tests that has a high copay and deductible they're even less likely to come back and we run the risk of widening the disparities gap.
Speaker 2:And so I think if we really are serious about delivering great care to every person, we have to come up with cost-efficient ways that decrease that disparities gap, and I think contrast mammography can do that.
Speaker 2:You know it is right now billed as a diagnostic mammogram and the copay for contrast is relatively low. So it's a pretty cost-efficient test and it's a screen and a diagnostic test and probably precludes the need for MR, can be delivered in a breast center that is closer and more available to rural and underserved locations, could go out and create a more level playing field for the women all over the world. But you know, right now I'm very interested in our own backyard. I live in a in a part of the country Um I live, so the city that I live in has not quite 2 million people in it, and as soon as you get outside of the city proper it's a quite farming community. It's very rural, and the numbers of women that come in in those rural areas for screening mammography is a lot lower, and so I really feel a moral imperative to find a solution that allows those people to have access in their own community for this kind of higher-level care.
Speaker 1:Yes, Thank you for tying it into that, Absolutely. I think there's been some interesting charts shown at the meeting just showing the maps of where the. Mri machines are versus mammography machines and just what that means for access.
Speaker 2:And I think MR is a fantastic tool. It has been a powerful tool for our cancer detection rate and for the care of our higher risk women and I think it always will be a very important tool. I just think that we really need to be resilient and consider and understand that it's not the end, all and be all and we really need to consider an alternative and I think contrast mammography is that alternative and I think contrast mammography is that yes, okay.
Speaker 1:Well, I'm going to uh close out here with I know, as the vice chair and the the section chief, that you have to look for efficient practice models. Yes, and how do we deliver this excellent care in the most cost efficient and practice efficient way? And you have given several talks on remote dyads. Yeah, and I want to hear how that played out in your practice, and I think it was brought on in part by COVID. Yes, but I'd like to hear where you are now, sort of five years out with it.
Speaker 2:Yeah, so we brought it on in COVID. When we went into COVID, everybody was on site all the time and I was burned out. I'll tell you. I'll tell you my personal story. I was burned out and I was considering retiring and then COVID struck and we had to come up with a way to see the patients and to protect the physicians. And so my system invested in home workstations for every single breast radiologist and so all of my faculty, my entire den, is taken over by computer monitors now. But what it did was open an entire new world. So I hired a faculty member who lives six hours away and she sees patients in our office remotely and I started out doing that. It's the same schedule that if she were in my building, so she sees the exact same types of patients at the exact same schedule. I had her come in originally and work with the technologists that she would be working with on a daily basis to build a bond, especially with the ultrasound tech, so that she had confidence in the ultrasound tech and they knew how each other worked. That was a wonderful way and I actually was on site seeing a separate group of patients. In case the whole thing blew up. I never from day one got a call from her asking me to go talk to a patient. So she has a little video camera. She has the same workstation I do at home in her living room. She's got a video camera so she video, she teleconferences with the patient. It's telemedicine. She reads the case. The very first day she saw a lady in her 80s with a four centimeter breast cancer. She video chatted with the patient. She told the patient she had cancer, the tech was there, they went over the images together and the patient was completely comfortable and didn't need to speak to me and I knew we were off to the races with that Fast forward now.
Speaker 2:That's been going on now for five years. And the beautiful thing is now all of my faculty have homework stations and I am actively I actively tell them this nearly every month Work from home, your child is sick, you have a head cold, the plumber's coming, whatever. You need to get home because you're going to whatever. You can work from home an hour a day. You could leave it two o'clock and finish your cases. You can be there all day. You don't have to. You can come in and work here. What does that do? It gives them that control, and we were speaking about burnout and fatigue and control is what people want. You know, going to yoga classes and meditating is great for burnout, but what we want is control over our lives and have that agency, and I think that remote diagnostics allows us to do it, and we have seen absolutely no difference in this physician's recall rates, cancer detection rates, timeliness of turnaround in the office the patients aren't there any longer. We've had no decrease in patient satisfaction scores. We're actually writing up our initial experience Amazing.
Speaker 1:So it's been an absolute home run slam dunk Awesome, I love to hear that. I love to hear that. Okay, any other thoughts you have? I have a final question. I always pepper a final personal question. Any other final thoughts you have on contrasting hits, mammography no, I think it's disruptive.
Speaker 2:I think that the hardest no. And then I have one. You know the heart that what I've. So from my experience, the hardest part of this is figuring out the operational implementation on the tech side. So now you're putting in an IV, you have to know how to handle contrast reactions, you have to learn how to use an ISTAT machine and do GFR checks, and those are hurdles that the staff need to learn and do GFR checks, and those are hurdles that the staff need to learn. And so really realizing that that's actually a big deal and really deserves attention.
Speaker 2:And we spent a couple years working on that. I have an absolutely fantastic director that I work closely with and we've gotten over all of those hurdles and they are most definitely surmountable. But just know, going into this, that there's got to be a lot of planning, not just for the radiologists of how to read it, but on the on the operations side of how to implement it. How much more staffing are you going to need? How much earlier does the patient need to come in to get the IV? Those sorts of things need to be thought through, got it?
Speaker 1:Got it Okay. Got it Okay. Now for a little personal question. Yeah, you know something we have discussed as how much we love what we do, yeah, and sort of the sisterhood that we have found in so many of our awesome colleagues through the years. I'm curious, what led you to go into breast imaging initially? I know you find it a very satisfying life choice now but what was the initial thing that brought you in?
Speaker 2:So I was going to be a surgeon. I could see that, yeah, I was full on going to go into surgery and I remember very clearly being in the operating room with one of the breast surgeons and realizing that the radiologist was telling the surgeon what they needed to know to do the surgery. And it really occurred to me that the radiologist is actually the person solving the Rubik's Cube, if you would, for the patient, and I really like that diagnostic challenge. So that's what made me pick radiology actually is. I really love the puzzle and I tell my trainees all the time you know, the answer is on the images. If you really are a student of this, the information's in front of you. You just have to know how to put it together. And even if you can't come to a discrete diagnosis, you are so important as a consultative physician to the person who's ordering the test. Absolutely, I love that. I do too.
Speaker 2:Yeah, what got me into breast imaging is my mother-in-law, my, my husband's an only child, and Larry. Larry, when he was seven, his mother, who was 28, was diagnosed with breast cancer. She palpated a mass. Wow, yeah, 28 was diagnosed with breast cancer. She palpated a mass. Wow yeah, this was in 1972, before really there were. I mean, we were doing zero mammograms. It was terrible. And her they. She had a radical mastectomy and was told she should get chemotherapy or she would die and probably was going to die, oh God.
Speaker 2:So she elected not to have chemotherapy because she wanted to raise her only child and be healthy as long as she could. So she never had choices. She yeah. So she didn't take chemotherapy. She just turned 80. She just turned 80.
Speaker 1:Wonderful, yeah, wonderful.
Speaker 2:And so you know her journey through this. She had lymphedema, I mean, she had everything.
Speaker 1:And her bravery and the journey that she had motivated me, thank you, thank you for sharing that. That's very personal and I appreciate that. Well, we're short on time. These conversations could always go on and on, but thank you so much for joining for this episode.
Speaker 1:Thank you, thank you, it's been a pleasure Thank you Really appreciate your time and we look forward to joining you next season Theme yet to be announced, but uh, we will be coming back at you in the fall with uh next year's four episodes. Thank you so much for joining awesome thank you have, you had training? No, I swear.