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The Medical Brief
The Future of Anesthesiology: Sit-Down with ASA President Dr. Don Arnold
On this episode of The Medical Brief Podcast, the guys are joined by Dr. Don Arnold, M.D., FACHE.
Dr. Don Arnold, ASA President, shares his journey and outlines his vision for advancing anesthesiologist-led care while navigating healthcare's complex challenges. He also unveils the ASA's strategic plan in 2025.
Dr. Don Arnold
https://www.asahq.org/about-asa/newsroom/news-releases/2024/10/asa-names-donald-arnold-new-president
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This is the Medical Brief, powered by Sir John, where we have conversations with leaders from across the United States and the world medical leaders and we're lucky enough here on this episode to have Dr Don Arnold with us and, of course, dr Brian Schmutzler and Dr Ankit Patel also join us here, as usual, on Vahid Sadr Zadeh. All right, we'll get started, gentlemen, without further ado. Dr Patel, if you want to make the introduction here, we can start, absolutely.
Speaker 2:Well, I want to thank Dr Arnold for taking the time to join us tonight in this conversation. I think one of the things we wanted to ask and learn about was we really want to learn about people in high positions that are influencers, leaders, thought leaders and Dr Arnold was kind enough to share his time with us. So we really want to learn about you and kind of learn about how you navigated your way to becoming our ASA president and what goals you have in mind, and kind of we'll go through all those things. But first we want to know tell us a little bit about yourself. Where are you practicing, where are you working and what was the pathway that you took to get to our current president?
Speaker 3:Right. Well, thank you, and it's a pleasure to join you this afternoon. I appreciate this. I'm a practicing anesthesiologist with Western Anesthesiology Associates at Mercy Hospital St Louis in St Louis, Missouri. I have the privilege of serving as chair of the department and I am the system physician lead for the Anesthesiology Specialty Council. Mercy is a health system with facilities hospital facilities in four different states and outpatient facilities in four others, so a big footprint, and in my day job I get to coordinate and work with the anesthesiologists from across the health system. So that is a real joy, not only clinical practice, but the ability to connect with others within our health system and collaborate to advance anesthesiology care.
Speaker 4:So then, how did you kind of roll all that into getting involved with the ASA and then becoming our president-to-be of the ASA?
Speaker 3:Yeah, I probably wasn't self-aware enough at the time to realize that I was being mentored and sponsored along the way. My pathway into anesthesiology was through an anesthesiologist at the University of Wisconsin, Betty Bamforth, who was one of the deans and actually encouraged me and gave me, and both of them were significant influencers in my career. And as I was finishing training, I needed to come to St Louis, Missouri. I was the trailing spouse, my wife also a physician no-transcript.
Speaker 2:So we'll eventually get into some of the work that you're looking to do this year and kind of hopes and aspirations we have. What was it about, you know, becoming the ASA president? Prior to becoming that? That you found was something that was like you know what I kind of want to do, that I want to do that so that I can do this. What was it for you?
Speaker 3:Right. I think I had the opportunities to serve in a number of roles within ASA chairing committees serving on the board of the Anesthesia Quality Institute, serving on the board of the Foundation for Anesthesia Education and Research and along the way I received really a lot of encouragement. I didn't start my work in ASA deciding, all right, one day I want to be ASA president. That wasn't the plan. My plan was probably shorter, more limited and it really was the next opportunity to serve. Who do I get to work with and how are we collaborating to advance asa and advance the profession? And additional opportunities presented themselves along the way and, honestly, I received a lot of, a lot of encouragement from some good professional friends from across the country. That made me think that I need to continue to take steps in leadership.
Speaker 1:Can you go ahead.
Speaker 2:It sounds like you've got a lot of support around you for the past several years to get you to this point. What if you had to look for the year? What are the top things that you are looking to accomplish as the ASA president?
Speaker 3:Right, Thanks. What we've done this year is sort of restructure the strategic plan for the organization to try to create four core strategic priorities. Four core strategic priorities these are the things that, not only this year but probably for the next three to five years, we think have the greatest potential to favorably change the arc of the specialty and the arc of ASA, and one of those is to advance anesthesiologist-led care delivery models with an eye on quality, safety, patient experience, provider experience and value. Second is to strengthen visibility and voice for the profession, and that has a lot of layers to it. Right, it is not only looking for ways that we can identify and advance anesthesiologists who are serving in elected office with NGOs within their health systems, but looking to identify those anesthesiologists who are looking to serve in health care broadly and anesthesiology leadership specifically. We also are looking for ways to connect our ASA more effectively within the healthcare ecosystem to create synergies with other medical societies.
Speaker 3:Where can we create alignment that serves a shared purpose with other organizations? How can we help equip anesthesiologists in their local departments and practices to be more effective and more influential and seize opportunities within their facilities and health systems? So there's a lot of that visibility and voice. We are looking to identify evolving technologies that are important not only for ASA as a member organization, but also anesthesiologists in clinical practice. Where are evolving technologies? Taking patient care and improving the ability of anesthesiologists to improve outcomes, so that has not only a society level but a direct clinical practice and patient serving piece. And finally, do everything we can to ensure the economic integrity of the specialty dealing with Medicare, dealing with commercial payers, dealing with hospitals and health systems? We are standing up an entity within the ASA it's called the Center for Anesthesia and Perioperative Economics, so bringing this to life and creating this as a hub to help with development of policy and research.
Speaker 4:To dovetail a little off the finance part of it. I think one of the big things we're seeing and, dr Patel, I think you could probably back me up on this we're seeing, obviously a lot of demand and not enough supply, which I think is an economic issue for not only you know us as a specialty, but a big time economic issue for the healthcare system. How do you, how do you see us navigating that over the next two, five, 10, 15 years? You know, how do we, how do we, not only you know, make enough anesthesiologists to cover what we need to cover, but also, kind of, you know, keep quality up and all that sort of stuff?
Speaker 3:Right, you know that's one of the key questions of our time and ASA has held two workforce summits and in that work has convened leaders from academic anesthesiology, from large group practices, from smaller, independently managed practices, from the American Hospital Association, from the National Nurse and Esthetist Organization and the National Association of Anesthesiologist Assistants. So we really have tried to convene stakeholders from all sorts of different perspectives.
Speaker 3:We have also brought in consultants who deal with hospitals and health systems to be able to speak to the voice for hospitals and health systems. So we've had two of those summits and we realize, even going in, that we've got a simple issue of supply and demand and you need to work on those levers and it's not simply playing the effort of expanding coverage ratios and things like that. But how can we change practice? How can we change the pipeline? How can we strengthen the pipeline for new anesthesia providers to be trained?
Speaker 3:Where are the opportunities to look for anesthesiologists or anesthesia providers who may be outside of the United States, who are looking for a position here, even if temporary, to advance their career and perhaps return to their home country? So a piece of it is pipeline and we have been slowly, consistently increasing the number of anesthesiology residency positions. There is huge demand right now and all of the available positions are filled. There's also growth in nurse anesthetist training and anesthesiologist assistant training. So across the anesthesia workforce there is an expansion which at some point will hopefully get us to a new equilibrium. But we've got to do more than that. We have to look at retaining the ability of clinicians to practice.
Speaker 3:Covid really accelerated the number of clinicians who were reducing their FTE commitment to work, either working part-time and intermittently or working permanently in a particular site or department, but on a reduced days per week basis. People stepping on a call saying, listen, I'm glad to work Monday through Friday, but not nights and weekends. So the number of people that are available to fill what is really an expansion of demand for anesthesia services has been a little bit constrained by those factors. So a huge piece here is taking care of the clinicians and the caregivers right.
Speaker 4:Yeah.
Speaker 3:Trying to do the things that can be done to address burnout fatigue. Those may be underutilized. Burnout fatigue those may be underutilized. I think we also see physicians feeling a loss of agency and autonomy and I think that has probably influenced a number of people who've made a reduced commitment to professional work. We have the age-old issue on the demand side of doing everything that can be done to manage demand effectively. What we have seen is not only an expansion of ambulatory surgery sites but procedural venues, so it's not just traditional operating rooms. So there's been an expansion of sites that need to be covered, this traditional operating room. So there's been an expansion of sites that need to be covered. But the math of that coverage needs close observation because we need to be as efficient as possible with using staff to cover facility sites of service, whether it's a procedure, whether it's a procedural venue, whether it's an operating room venue. So that's another piece of it is how can we do this efficiently?
Speaker 1:So, dr Arnold, I just want to, before we get too far ahead, I kind of want to piggyback off that question of COVID-19. I kind of want to piggyback off that question of COVID-19. You know, every specialty has had their challenges since 2020. And kind of, where do they go from here? You know, with the ASA and with anesthesia as a specialty, what would you say some of your challenges have been since 2020? And what are some of these topics that you're still leaning into as we head into this next year?
Speaker 4:Aside from just supply, obviously.
Speaker 3:Besides workforce, I think we've seen supply chain issues, right, and that's been exacerbated. We had a huge example earlier this year with the plant in North Carolina that produced 60% of the IV fluids used in the United States was destroyed by the hurricane and it came up only very, very slowly. The ASA, even going back prior to COVID, was concerned about supply chain for pharmaceuticals, for supplies, for equipment, with the pressure that the healthcare system is under the drive to efficiency in supply chain, drive to efficiency in the supply chain. Single source providers for particular critical pieces of equipment have a certain efficiency value but there's not much resilience there, right, and that's a problem. That is significant is the resilience of the supply chain. Significant is the resilience of the supply chain.
Speaker 3:On another matter, I think, the pressure that provider groups and hospitals and health systems are under in the tension between commercial payers and those of us who are providing care. We have seen a really intentional efforts by the commercial insurance industry to decrease payment for services, to undervalue services, to no pay and slow pay for services. In anesthesiology in particular, there are huge problems outside of anesthesiology with preauthorization, problems outside of anesthesiology with pre-authorization, and actually in my practice I see this on a regular basis because of the administrative role I play in my day job. We have a huge number of procedures that are scheduled. Patients and families have made plans to have a procedure performed. Uh, it's green light, green light, green light. 36 hours ahead of time, there's a question raised about whether or not there's authorization go ahead to do the procedure.
Speaker 3:It's just outrageous. You can't make this stuff up. Nobody would believe you if it wasn't really happening. Yeah, and before we lose the opportunity.
Speaker 2:I want to make sure we give you and your team at the ASA all the credit for reversing that decision that was, as you stated, outrageous. That insurance companies can try and do, then you know, diminish our reimbursements based on how long the procedure takes.
Speaker 3:But we appreciate your work on that, based on how long an anesthetic service can last, based on information that has nothing to do with anesthesia, payment or times of procedures, really, and the thought that they were going to create that limit and then not pay for any services if it took one minute longer than that threshold was just just outrageous.
Speaker 1:How is that handed down? Is that a? Is that kind of an umbrella policy that the company has, or is it an umbrella?
Speaker 4:policy that it was three states. It was three states that they initially rolled it out in and the timing was impeccable because they rolled it out right when other one other, uh, large incident happened in the insurance industry and so they reversed it about 24 hours after that and I know that you were a big part of that at the ASA. But we're pretty accepting of everyone on this podcast, but we definitely do not have a big heart for the insurance company. So I'd love to have you talk just a little bit about the no Surprises Act, because I think that really pushed at least in my practice that really pushed a lot of our reimbursements down, and then maybe explain what that is. Talk about that a little bit and then how you're combating that.
Speaker 3:Yeah, so the no Surprises Act actually started as a really good idea, right, there are instances where physicians and an insurance company may not be able to come to an agreement on payment or contracting for a host of reasons, and it could be actually an insurance company that has very limited penetration in a particular market. It could be cared for by a contractor who is not in the same network that the hospital and health system was in. Again, there's a lot of reasons why that can occur. The no Surprise Act started by saying let's hold patients harmless, let's get the patients out of that dispute, and frankly, we think that was a great idea. An important patient protection to make sure that while they're recovering from a medical emergency or some other event, that they don't have the additional burden of unanticipated costs.
Speaker 3:We think that the legislation we think the federal legislation was well done. We supported the federal legislation, as did a number of medical organizations, because we thought it had the right elements. But what's the next thing that has to happen after there's legislation? The agencies have to write rules and regulations, and that's where the implementation was absolutely botched. The agencies allowed the insurance industry to put their thumb on the scales of an independent dispute resolution process, which really was the way to resolve the disputes between the insurance companies and the physician community and other providers.
Speaker 3:Because of the failure in the implementation, there were a number of lawsuits and actually a total of four lawsuits brought by the Texas Medical Association. The ASA filed the amicus curiae briefs in support of TMA both on the initial case and on appeal each time, and there were sequential victories by the Texas Medical Association in kind of rolling back some of the problems with the no Surprises Act. I think what you mentioned, brian, at the very beginning, is your particular practice may have been impacted. When the no Surprises Act was rolled out, we saw a number of insurance companies taking steps to force anesthesia practices out of network.
Speaker 4:Yep.
Speaker 3:Then you were providing services at the facility where you may have been for 5, 10, 20 years. You provide services there, five, 10, 20 years. You provide services there. You're forced into the independent dispute resolution process. That favors the insurance companies in just an absolutely unreasonable way. There have been some successes. We have seen over the past maybe 18 to 24 months over the past, maybe 18 to 24 months a decrease in insurance companies forcing practices out of network the independent dispute resolution process. Anesthesia providers are winning eight or nine out of every 10 cases. Okay, wow, the anesthesiologist value is right and it is, at a rate, far in excess of what the insurance companies are offering. So things we think are moving in the right direction.
Speaker 4:Because you've got to fight the independent dispute resolution and then the insurance companies, especially the behemoth insurance company, is holding back that payment even further. So you might have gotten it in 90 days. Now you've got 30 additional days because of the NSA. Then you've got an additional 90 days that they're going to sit on it again. So you're eight to 10 months out getting paid.
Speaker 3:Right and paid Right, and there's a lot of anesthesia practices that are smaller departments, small groups. You have several problems there, right, you may not have the administrative ability to access the independent dispute resolution process effectively and then the fact that that payment is withheld creates economic instability for the practices. So we do know that a number of practices needed to join hospitals and health systems because they were not able to to sustain their independent status and independent operating status. So joining hospitals and health systems or joining parts of other large multi-state practices and it may not have been what the physicians in that practice originally signed up for it may have caused a change in the arc of anesthesia care delivery at that facility or in that community.
Speaker 4:And the cost shifting, too, right? I mean, we see a lot of that and, anke, you probably see that as well. The cost shifting to the hospital, right? Well, my subsidy was X and now it's Y, because I'm not getting paid from the insurance companies, as much or at all anymore companies as much or at all anymore.
Speaker 3:Yeah, it is true that most hospital-based anesthesia departments in the United States, probably in excess of 90%, are getting financial support from their hospital and health system partners, and this is because of probably two different factors. Because of probably two different factors One, the lack of Medicare payment adjustment for physicians and for anesthesiology practices in particular, and second, the excessive market power of the insurance companies that really hold down the ability of physicians to negotiate fair and equitable reimbursement for services. So what does happen is hospitals and health systems, even in the midst of declining margins for them, are needing to support anesthesia practices as an essential service, and we're seeing more of this in the ambulatory surgery center as well.
Speaker 2:Yeah, great, doc, before we go too far, I want to ask you a question about the ASA conferences. So have you noticed annually the conference attending membership kind of growing, stagnant, declining and, based off your answer, what can we do to change that?
Speaker 3:Yeah, well, you know it's a great question. Certainly, covid was a reset right and I think, within ASA, I think other medical organizations were wondering is the face-to-face meeting a historical footnote? Is that going to go away? Is more content going to be delivered digitally and consumed asynchronously by physicians and other health care professionals?
Speaker 3:What we've seen as we've come back from COVID is actually a growth in participation in the face-to-face meetings. I do think that there's probably going to be a ceiling and it might be in terms of a percentage of members. It might be less than the percentage of anesthesiologists who attended ASA meetings 20 years ago 10 years ago because there are so many good options right now for CME and for content. But we are seeing growth and what we're hearing from our members and non-members who joined the meetings is that not only did we enjoy the content and the formats that are fundamentally different than we had prior to COVID, but the networking, the connecting with peers the kind of thing that can only happen in a face-to-face meeting. So we have seen growth, both in our annual meeting that was held in Philadelphia in October will be in San Antonio in 2025, but also the Advance Business Meeting, which is coming up in a week, right?
Speaker 4:Yeah, it's just going to be in a week, I'll be there.
Speaker 3:Yeah.
Speaker 4:Ike, are you going? I'm going to try to All right.
Speaker 3:So we're seeing growth in that. I think there will probably be a ceiling, but I think the value of the professional interaction is what we're really trying to leverage in those meeting venues now.
Speaker 2:And what can the ASA ask of us as members? So we had the same conversation with the AMA president, asked him about the physician shortage. What can we do? The ACGME is a big part of growing the physician workforce, but what is it that we could do as physicians for the ASA, just like we can for the AMA, in terms of how do we grow the physician numbers in the US? Because, like Brian mentioned earlier, we're up against other specialties that are growing at a rapid rate, whether they're AAs or CRNAs, and good relationships with both, but there is a large group of other providers growing that could do a similar role that we do.
Speaker 3:Yeah, so there were probably a few questions embedded in there, and I'll try to unpack it a little bit, what can any ASA member do?
Speaker 3:Well, first of all, realize that not 100% of American anesthesiologists are ASA members. So look in your department, look in your practice, look for a colleague. If you're in a department where individuals are deciding to join or not, recruit someone. Tell them your story about how your membership, how your participation, how ASA resources may have favorably impacted your career and your career advancement, your ability to practice. I think recruiting a member is something that everybody should be asked to do. I'm fortunate to practice in a department where, decades ago, we made a decision that every member of the practice, every member of the department, is a member of the state component and a member of the ESA. It's just part of working in our environment and realize and accept that not every site will make that choice, but if you're a practice leader, I think it's something that's worthwhile considering.
Speaker 3:Another question you asked about is the future and the potential growth of anesthesia providers in general, anesthesiologists in particular. You know long term planning for specialty needs are fraught. There have been epic misses, you know, decade, decade on projection of future needs. We do know right now that there is significant need to expand the anesthesia provider workforce. We see anesthesiology as one of the most highly pursued specialties. Right now we're filling 100% of the match opportunities and this is after several years. The number of funded programs, hospitals and health systems are also looking to fund programs and some large practices are also funding training opportunities. So we're seeing a continuing small growth in the number of anesthesia training positions, but we need to work on that. Part of our advocacy efforts in Washington is to continue to expand training spots for residencies in general, but for anesthesiology in particular.
Speaker 2:Yeah, yeah, I personally would love to see that number grow, just because I think Brian and I are in areas where, you know, there's not a lot of physicians but there's a lot of needs and we have a lot of opportunity for even training residents. But I think the barrier we have to think through is, you know, the ACGME for us is a very remote, you know, barrier. I don't know anyone there, I don't know how to connect with anyone there, I don't know how to work with anyone to say, hey, we can accomplish these metrics, to say we can start a two to four resident per year program. But I think that for me would be a huge win if we can get there in a couple of years for providers to start that process.
Speaker 2:It would be a huge win if we can get there in a couple of years for providers to start that process.
Speaker 3:Yeah, there is a pathway and there have been some new programs open, but to the point I think you're making, it's probably slow.
Speaker 2:Sure.
Speaker 3:Probably reasons for it to be slow.
Speaker 2:Sure.
Speaker 3:The pathway for opening new residency programs is now increasingly better understood. There's been some successful programs started.
Speaker 4:There's one just starting in Indianapolis at St Vincent Hospital, which is where I did my internship and trained with a lot of the guys that are there. So you know, that's a good point. We should maybe get those guys on and see what they say about how they started the program themselves.
Speaker 4:Yeah, I did a kind of controversial question just because I really you know this is, on my mind, a little bit Not super controversial, you'll be able to answer, but tell me about what you feel about private equity in anesthesia practices, because I think you know, ankit, and I see that especially in our region here in the upper Midwest, that there are some things that have changed because of private equity. So I'd just love to get your kind of thoughts on what private equity has done to anesthesia.
Speaker 3:Yeah, you know that's a great question. I actually probably frame it a little bit differently in the first instance, okay, because I think a piece of the problem or concern is based on the change and the drive to anesthesia practices, forcing them to scale, and I think we're seeing that in independently managed practices that are coming together. We certainly have seen it in practices that have been rolled up and funded through a couple of different mechanisms, private equity being one of them. We have seen academic and private joint ventures where there is a lot of scale, and I think in those settings we've had challenges because many physicians find themselves in a larger enterprise than they thought they were going to be in and it gets back to a real dissatisfier for some people is the sense of a loss of agency and autonomy in their practice, of the agency and autonomy in their practice.
Speaker 3:The private equity or the organizations that have several organizations larger organizations that do have private equity backing backing have probably brought to the market a lot of better business practices. Okay, you have more sophisticated revenue cycle management. You have more sophisticated abilities to negotiate contracts, contracts. You actually have a balance sheet that enables you to weather the no Surprises Act differently than a smaller practice and again you're talking to someone who's in an independently managed practice. In my day job, I think the challenges have been where there have been disputes between local practices and hospitals and health systems around care delivery, around alignment in terms of goals for an anesthesia practice and when there may have been RFPs that have gone out. That has brought in practices that have scale and sometimes it's an independently managed practice. Sometimes it has been a larger multi-state practice that may have private equity backing.
Speaker 1:Yeah, All right, well, thanks so much. I think you guys have any other further questions. I know we can probably talk all night.
Speaker 2:If, given the chance, I'll ask one more question. Since we kind of went on to the controversial area, I'll ask just one question about the relationship with the ASA and the AANA. And I know we work strongly together. A lot of us work very closely, very well and I have for my whole career but I do know at some level there are differences and those differences we don't align on and I don't know if you're comfortable speaking on it or not. That's okay, but I think at every state there are controversial issues that each state is faced with. That does have a big impact on patient care. I didn't know if you or the ASA have a thought on that.
Speaker 3:Well, I think I'm like many anesthesiologists in the country and I'm going to speak from my personal perspective that our work in the care team is valuable and really highly effective. I think the challenges that are faced are when, at a national level, between the organizations, when there's work done and supported by the leadership of the AA&A that moves to vote anesthesiologists off the care team. That has been particularly difficult. I think we need to be in a posture of listening and learning, because I think the country would be better served arguably better served if there wasn't the tension that exists between the national organizations.
Speaker 2:Yeah, I think better understanding would be great. I think.
Speaker 3:And the only way I think the only way to improve understanding really is to have dialogue. Sure, we expect combatants in the Middle East to have a dialogue. Maintaining a dialogue where there's dispute, I think is something critically important.
Speaker 4:Well, I'll close it out with the same question that we ask every one of our guests, that I ask any guests that I ever interview, on any, on any show. Um, one, a very short answer of what does anesthesia hold in the next six to 12 months. And then the second part is would you do what you did again? And if you would, what are one or two mistakes you could learn from?
Speaker 3:great, absolutely great questions. You know, my hope within the next six to 12 months is that you'll see ASA taking steps and providing resources to help practices of all sizes work on a couple of important issues. One is relationships with hospitals and health systems. The other is work that ASA is developing to promote the economic integrity of the specialty. My hope is that there will be plans in place and work that is visible. This is not going to be a flip-the-switch kind of problem. I think that'll be important. Would you do anesthesia again to be a flip the switch kind of problem? I think?
Speaker 4:I think that'll be important Um would I do?
Speaker 3:would you do anesthesia again? Yeah, you know, that's like an unanswerable question. I have been richly blessed, uh by uh by this specialty. Um it, my, my wife is a surgeon. Uh, I would not have met my wife I was not an anesthesiologist, and clearly the best thing that I've done in my life is marry a woman who is a much better person than I am, and so I should not say that I would do something different because my whole life would unravel if I wasn't an anesthesiologist.
Speaker 4:So then, one or two mistakes you made along the way that you would maybe change little bits here and there.
Speaker 3:Yeah, you know, we all see our successes a little more clearly than we do our failures. True, I think it's interesting that you mentioned that I read I'm reading a book right now by Dave Alfieri, who's an anesthesiologist, called Healing Grace, and it's vignettes about his practices as an anesthesiologist and how he learned along the way and how, first of all, what a privilege it is to be a physician. I think that's something we all realize. But he has been very thoughtful and very intentional about looking at very specific patient interactions and looking for the lessons that have come from specific interactions gratitude, trust, things like that. So could I have, along the way, been paused, thought a little more deeply about even small events and learn from that? Probably?
Speaker 1:Well, Dr Arnold, thanks so much for joining us here and best of luck in this year ahead. And please join us again if you would, just to give us another perspective at the end of the year and maybe we can follow up on this uh, this uh conversation okay, great thank you all right pleasure to join you all.
Speaker 3:I've got dr arnold here.
Speaker 1:The president of the asa joining us here on the medical brief, of course, with dr ankit patel and dr brian schmutzler. I'm vahid sadarazani and we'll catch you in the next episode, powered by Sir John.