All right. Welcome back. So Dr. Laposata. How you feeling, sir? I'm great. Thanks, Chris. Excellent. Wonderful Well today we have I think a little bit more of a human side of the the DMT adventure So I'd love to get into it with you if you're well, if you're willing. Absolutely. Excellent. All right. Well, so Today the main focus is the the human side of the diagnostic management teams. And so I think the first question is pretty straightforward Why is trust between clinicians between? Pathologists and patients so central to the DMT process. I think it really relates to the fact that Physicians want to do the best by their patient if you're seeing somebody face to face you develop a relationship You understand you don't want to have it come out other than the best possible way so With that intention for most physicians. They have to trust somebody when somebody comes in and says this is what you should do and That trust grows over time it the seed is planted when you help them the first time then as it goes you get more and more trust and then they ask you questions all the time and that's really the ideal circumstance and at some point after you've done 5,000 cases maybe 500 cases You could have something come out not so right and it won't go away. That is they still trust you so The trust comes over time and there has to be a sense that it really works I'll give you a good example of trust when I was at the MGH We had given much advice to the vascular surgeons and there's a lot of issues related to bleeding and clotting they're doing surgeries on arteries and veins and They trusted us so much That on the floor of the vascular surgeons They had a sign up at the nurses station, which you could read walking by and it said only Pathologists are allowed to consult on coagulation cases and I thought wow we have really earned their trust That's fantastic. What about what about? Clinicians and engagement, you know at what point do you believe clinicians will begin to really engage with the DMT? I think they have to see it and For them to see it you have to produce it. You can't say this is what we're gonna do And I think this relates a lot to how you started the DMT You could say we're gonna make friends with everybody. We are gonna get permission from here there and everywhere but the reality is you can just start doing and Don't worry about the payment. Just see if it's valuable and so The way we started coagulation rounds at the MGH was I just said we're gonna do this beginning Monday it was gonna be Monday Wednesday Friday and It was such a quick hit that After two weeks. It was clear We had to do the cases the narrative interpretations saying this is the right test you should have and here is the final diagnosis That we had to do it five days a week and then pretty soon instead of being five cases a day it was 10 and 20 and When I left the MGH it was about 35 a day and as I conversed with my former colleague Who's still signing out cases she told me she was up to 80 a day so all of this is because people say I don't want to prescribe an anticoagulant or an antiplatelet medication until I talk to them and I think that that indicates that They have learned enough that they they feel like they have to engage they they don't think it's a choice Yeah, I can see the thing is that in in the world today When we're dealing with new technologies and the DMT is the new technology When it comes to consumer technologies, there's actually a bit of robustness when it comes to Engagement, you know if there's downtime actually people are pretty willing to kind of come back to it They're even willing to allow for a a learning curve of that technology, you know They're like take space environment. For example, you know space X's rockets blow up on a routine basis Seemingly and obviously they'd be they've gotten better and better and better But that seems a little bit different in the clinical world It's almost like once you've screwed up once, you know, you're verboten, right? You're done. And so how do you think about The fragility of the DMT process when it comes to the engagement with clinicians and the engagement with patients Is it incredibly fragile and how is it fragile? So I have two stories to tell to illustrate what we've been speaking about Medicine is difficult to practice and It's difficult because you always want it to come out great But there is a biology where sometimes it just doesn't no matter what we do Yeah, and we live in a society where people will place blame on the doctor Sometimes even try to hurt physicians. Yeah, and so I Think that there's a reason why Physicians might feel like it's a fragile relationship with somebody who's providing recommendations like us We have to listen to them the vascular surgeons at the MGH We're very worried about lawsuits and they asked me at one point if I wouldn't use the term these tests are recommended because They felt that if an attorney saw that things didn't work out Well, and they didn't order the test if they would be blamed. Yeah, so They asked me could you change it to maybe informative and I did so I think that this trust relationship grows over time and it it it's necessary because Everything is fragile. If you're listening to somebody and you're dealing with somebody's life It's a totally different ball game when I Was in Boston in the mid 90s. We were talking about partnering with one of the commercial laboratories the big commercial laboratories and the Contingent that came from the commercial laboratory was led by a person who Worked in Japan and was involved in selling TV screens to TV set manufacturers So he had really no understanding of medicine and when they came in the room It was clear that all they were worried about is how much money they would make from this process Well, we were worried about patient outcome and very worried about patient out. Yeah, of course because there's so many samples going through that laboratory And we didn't have clinical information about the patients really it was just a tube and a number So we realized the challenge of that whole thing each side couldn't understand the other and if but after about 20 minutes The leader of the commercial laboratory said ladies and gentlemen, it's time to leave There is no common ground and they just walked out Wow so This fragility is is has to be well understood. I Can give you another example that involved a legal issue and it stunned me. We had a speaker in one of our three meetings or DMTs National meetings and the speaker was a primary care doctor who also did clinical pathology Mm-hmm, and he saw the value of what we were providing and thought I'm never practicing without this. Yeah, right And we were looking at some data We found that there were more medical errors related to test selection for for people who were of low socioeconomic class than people of high socioeconomic class and I said Do you know why that might be and he said I'll only tell you if never you never mentioned my name for having said this So here here it is. He said every time somebody comes through my door That I see for the first time my first question to myself is will they sue me and I thought wow That's an amazing thing to have to practice medicine with that That concern over the over your head. So very tough to work through those things But we're trying to make this relationship Be less fragile by showing how much it can help the doctors do their job. Yeah. Yeah, I It's amazing with that sort of sort of Damocles can do to you from a practice of medicine standpoint it's it's it's remarkable what it might entail we the We've looked at numbers Financially across the board and obviously there there's just a lot of cost attributed to defensive medicine, right and When we think about it, there's the cost on The financial side right now doing things that maybe we don't need to do right lab tests that we don't need to do Radiologic tests and you know, maybe even therapies that we don't need but then there's also The I didn't do something Because I didn't want to find that out right and that That cost is a patient born cost, you know They're the ones not getting the diagnosis in a timely manner and the impact is is obviously severe. So it's it's really very high impact I Did have a question it's a little bit You know sort of the opposite side of the same coin here and that is When you're approaching clinicians who maybe don't respond. Well initially, what is that like for you? Has that been? Easily done and and if so, how did you do it? If not, also, how did you do it? And how'd you overcome their obstacles? Yes Well, some people don't like broccoli. Yeah That's the end I think that that's the way it is approaching positions if if they say I want to do it the same way I did it 1982 there's no convincing them, but yeah, this is a product that benefits so many people clearly it benefits because you get a faster and more accurate diagnosis that when Somebody says I want to try what you have then you go there and you put all your effort into those I think that at the very beginning for the people who say I don't need you you just say thanks and move on Right. I think that at some point people will say how in the world did we get along without this element? Yeah, because it happened in the pharmacy Nowadays my primary care doctor just says I want to use this medicine and somebody in the pharmacist pharmacy figures out the frequency and the dose and says here's the one and They don't have to know that anymore. And I think that's the same way with 10,000 lab tests you have to pick from to decide. Hmm. Why is this person got chest pain or abdominal pain or short of breath? So This has been missing it looks like our knowledge base fills this bill if we do it, right? And so I don't push the skeptical ones. I just move on to the next ones. Here's what I know I know that when people see it and it's useful to them. They tell others so I remember When we first started coagulation rounds It was in the mid 90s and this ENT doc became one of my close friends and he said one day in 1995 in addition to the test results There was a paragraph at the bottom and he needed to take this kids tonsils out Factor 12 was low and the PTT was high and he said for me. That was an automatic infusion with fresh frozen plasma We're gonna transfuse and these were in the days when HIV was still in the blood bags So he was quite worried about this process and when he read that and I said yes It's factor 12 and you could have zero percent factor 12 and they won't bleed So the patient is cleared for surgery. He said wow. Whoa, this person knows something and He's got the courage to write it down So he said I Did as he suggested and there was no bleeding and the kid had a factor 12 of about 10% and a PTT of 70? And he said I never would have done that and he told all his friends any NT So I think there are enough people who have that kind of an outcome totally No expectation that they were gonna get that and then they they got it so there were 2,000 doctors at the MGH when I was doing this in the mid 90s and I dare say that probably of those 2,000 We had about 1900 that thought this is a great idea Because there were four people in hematology oncology who were so afraid of the innovation They didn't want to try it and they wanted to speak badly about it. So What happened is those four people said I don't like this and they were well known in the institution with the other One thousand nine hundred says I am NOT doing without this Forget that it's and they made their pitches to the president one of the four people Who said we don't need it was a resident mates of the president of the hospital Oh nice and so you figure out that oh, man, this is trouble, right? No, he didn't want to upset the 1900 docs who are already sold on One of the things that May not be obvious to people on the outside of health care, but certainly is is obvious to us on the inside is the the structure certainly at academic centers is Perhaps a little bit counterintuitive there's more than one full stack of administration there's a academic and oftentimes linked Faculty group and then there's a administrative and oftentimes hospital linked You know group and there's varying flavors of this but it's it's more or less like the doctors and the hospital and the focus of the doctors sometimes is Purely academic like scientific like bench work and sometimes it's nearly purely clinical Right. These are just these are just faculty who want to treat patients and there's any combination in between and then there's the administration that sometimes is purely financial or purely clinical or somewhere in between and so most institutions kind of Pull between these two extremes as far as support Have you ever really seen major administrative support for the DMT? Yes, good question So I did and that was at Vanderbilt. So this was interesting. We've done coagulation rounds It was a success the chief medical officer came Went through the cases. He said this is the ideal teaching. This is it. Yeah, right teaching as the case appears and And he said it's so valuable So there was some support from people at the top of the clinical. Yeah clinical site and so With coagulation being a success we started to do a few others which also were successful so we got to infectious disease and We wanted to have a microbiology Diagnostic management team, right and the head of one of the pediatric divisions of for infectious disease said I'm not touching this and So there was a meeting it was organized by the administration one of the associate vice chancellors so he brought that infectious disease folks adult and and Pediatric into a meeting with people in microbiology from the lab And the people who were in microbiology In the lab were pretty clinically savvy So it wasn't like we were taking a big risk here. Yeah to start a microbiology diagnostic management So the associate vice chancellor starts the session here at 8 o'clock we're gonna do this now with microbiology and infectious disease and Head of one of those divisions said let me just tell you I don't need interference from the laboratory About which organism causes the disease and what I should do to find out more about it Yeah, and the associate vice chancellor said I am sure there are plenty of places in America That would value your skills as a head of a pediatric infectious disease division and The comeback was so swift and definitive. It was clear that we had administrative support to go forward Yeah, and in fact Vanderbilt did take it into multiple DMTs and invest money so We were clearly Taken a quantum leap from the Mass General really just coagulation into about five different DMTs when we went to Vanderbilt. Yeah, I guess I am surprised that And I mean we've we've talked about this a bunch of times in the series, but I'm surprised that Hospital administrators are Not as forward-thinking about the diagnostic process. It just feels to me like it's such a straightforward Controllable repeatable approach to good diagnostic medicine That you know in the in the in the 90s there was all this interest in the Publishing houses they they had the the movie houses and the TV, you know publishers had created like almost like in a formula a number of sitcoms that were incredibly successful friends was an example of this and so there was a lot of people sort of Suggesting that this would be the end of television that what would happen is these houses would sort of churn out successful franchises and that was the administrative state taking ownership of creativity and Hospitals have tried that with very limited success when it came to guidelines and stewardship committees and Pnt committees these other sort of committees and what they have not yet done seemingly from my perspective is reach into the diagnostic sphere and it seems like the DMT is the perfect avenue for that to happen where hospital administrators could really get behind a Diagnostic process like the DMT and it would just Supercharge a hospital very important question. Yes. I think we're all very focused on the treatment side With diagnosis and treatment being the two sides of the coin I was living in Boston at the time when The managed care was growing and there was a protest by doctors and nurses in a downtown Boston on the waterfront and One of the television personalities interviewed a nurse who was going to the Boston Tea Party ship with all these forms in a bag and they were all carrying bags and the TV announcer said to the nurse What is it that you're protesting? She said we only have a limited amount of time now to see a patient It's almost like a bell goes off and if you don't have the answer, that's it And she said the hard part of medicine is getting the diagnosis You have to think about all the things you see and then put this puzzle together About what a chest x-ray looks like it supports the lab test. Yeah. Yeah, you can't do that in two minutes so we're going to the Tea Party ship and we're gonna throw all these slips into the Boston Harbor and Of course, they threw them into a net so they could easily harvest them. Yes Here it is in the 1990s and and this nurse really hit it right on the head. The hard part is getting the diagnosis nowadays, I think with so many great treatments available not that we have treatments for everything but You say I have an infection with this particular Organism and you'll get three or four antibiotics that are supposed to work You can't stop the bleeding and somebody's got a factor 8 inhibitor. Boom. There's an answer in their products The real issue is do you have a factor 8 inhibitor? So the diagnosis is the hard part and that's what we're giving people answers for Yeah, it is. It certainly feels as though when Hospital administration focuses on The hospital they're thinking in terms of treatment, you know 20 percent or 20 times more than they're thinking about No, it's treatment treatment treatment treatment treatment and then this sort of passing glance at diagnostic medicine and it's amazing how you know the first step in any journey is The most important step, right? Like if you if you're Intending to go from here to Canada if you start out going south Every one of those steps is wrong, right? And so it's amazing how You would think that because every subsequent step becomes less valuable, right? It's incrementally less valuable and it's hard to believe that we Don't think of it that way administratively Also, just just to say if you only focus on treatment or primarily what happens is you have to be sick first Meaning what if we tell you you have a value for a lab test? That's associated at a very high risk level for an early heart attack. Yeah friends Wouldn't it be great to figure that out? Yeah, we had the heart attack as opposed to figuring out Only what do we do when the person drops to the ground and we get him or her to the emergency? So I think that focusing on the diagnosis allows us to pick up diseases early or before they occur Yeah, it's it's interesting. Um my and my car insurer actually gives me a break on my car insurance if I release To them my location data While I'm driving so that as I if I were to drive erratically Then they would say okay, you have to pay more money. And so How much does that cost them almost nothing? It's like compute and They have to have an app that runs on my phone and this is you know from a cost perspective very little relative to if I get you know If I rear-end someone the cost of the body work and whatnot is Exponentially more it's that's the treatment the treatment is if I'm in an accident How much do you pay love that and the diagnosis is are you good or a bad driver? can I optimize for your health and We spend at our health system. I think it's very similar to others. We do have you know Processes where we try to optimize for health outcomes like we have people, you know try to walk and exercise and do yoga and all these other things but There's certainly a world where the diagnostic process getting out ahead of it optimizing for health I Think would save us an awful lot more. Oh, you know, we really don't do it. You know, it's it's it's a good point. Yeah What do you What do you think about? So Imagine that I'm a new pathologist. I haven't really ever done the DMT. I don't have a DMT regionally What is a common pitfall or mistake that? pathologist might make Jumping into that role that you see so this is very very important to establish because in the end The problem is ours If you ask people what about a DMT who are not pathologists, right and they would say well I don't know what a DMT is. I haven't seen one unless you've really worked at an institution where a DMT is credible and Consistent you can't say we should have those so most people don't have so why the real reason is Pathologists have to have a sense of urgency about all of those cases So yesterday in the morning, I had a medical procedure and I had rounds where there were cases discussed and I didn't make it in But I talked to another pathologist and then somebody read what the AI had taken from all the information that was put in That clearly needed edited. It was a wrong answer. I edited that Interpretation and it went in and then there was another one. It also needed editing. That was a sense of urgency Case on Monday, the weather was bad Everybody was worried about everything outside the hospital But you know what there were two people who were sick and needed an answer about their coagulation status one of the folks who was on my Faculty when I was ahead of lab medicine at the Mass General. I was very good at toxicology and Toxicology is confusing to most doctors and I tried very hard to get him to do a daily toxicology rounds and And the residents loved it They thought it was good teaching and it was most days of the week So I said to him this is very popular the clinicians like it. Can't we make it? Monday through Friday at a specific time. Yeah, we're not Well, the why not was I need some flexibility if I don't feel like doing it on a Thursday I just won't do it then I said so Think about all the other doctors in this hospital so Can all the orthopedic surgeons just say well, I know there's two hips and three knees I got to do today, but you know, I feel like doing them. So that'll be that yeah, what I Think we have to have a sense of urgency about what we do in surgical pathology Nobody would say we're just gonna let that sit for two days. Right? Somebody has to sign it out They they need to know what's my Surgical options. What do I do here? But somehow on the CP side, it's been so focused on managing thousands of samples a day and yeah instruments run and passing inspections That there wasn't enough attention hasn't been enough attention on Helping people get a diagnosis by looking at what those machines do and so I think it's a background that I Felt was important that as being a clinician though In a pathology department having a practice seeing the other side knowing the suffering you Gotta develop that sense of urgency and right now across the board. I would say it's a big challenge to get people To the point where they say, okay I'm really gonna change my day no matter what those rounds are getting done They're gonna start at 1 o'clock or whatever time of day you pick and they're gonna go until all the cases are signed up Not until you feel like ending the rounds. Yeah, it's um, I think that What you are saying is It's important to to talk about the real benefit to what you're saying not the cost because most pathologists would say Well, that's annoying Mike. I don't want to do that I'm More or less a scientist, right? I'm a Many of the CP focused folks are either AP focused really and they do the CP stuff on the side or they're Scientifically focused PhDs or even MDs, but they really want to do their science and so this clinical work fall by falls by the wayside in in either of those two environments and What you have said and you've touched on it a few times in the past, but it's another way to show Incredible value to the health system. A lot of people are worried about mergers and acquisitions of the laboratory they're worried about lab core and quest buying out their lab from underneath them and turning them into a glorified technologist and Unable to do faculty level work and if you are the doctor making the diagnosis then you become immensely valuable to the institution for Really a pittance of work. What you're describing is not actually a lot of work. It's just regular work responsible work diligent work focused work every single day or With whatever frequency is needed, you know, maybe the tests don't even come out every day so maybe you do it every day the tests come out or whatever but that That is immensely valuable to the health care institution and it's incredible that you would just simply Forget about it. You just would let it go by the wayside. I'm so thrilled that you brought this up. So This is an interesting piece. How much should we think about how much we earn because When you do this interpretation, it doesn't pay a lot of money it's not like a surgical procedure and not certainly like looking at a glass slide, but You save money for other services So when I was at Vanderbilt We had coagulation rounds for about three or four years and then we said, you know What we should look at the length of stay for a pulmonary embolism sort of right in the center of coagulation And it turns out over that period of time. We went from four days to two So we saved somebody else's money. So at two thousand dollars a day Per patient who had a PE over the course of a year. That was a lot of money for Vanderbilt and it was one diagnosis but it wasn't Looking at the money that we made doing it in clinical pathology laboratory medicine. That was a patent Yeah, so the fact is you save money when you get a more accurate diagnosis quickly because you get to the right treatment right away and I think It's one of those things that looks like a promise to many well, if we do it, we will get this So yes, we will value it, but I think it's gonna take some time and it does take a an insightful Leadership group to say this is pretty obvious If we get an early diagnosis limit the number of lab tests to just the ones that are needed And we have an expert giving the diagnosis to somebody who's patient facing That's got to be good. Even if it doesn't earn a lot of money So it's hard to make arguments to the chief financial officer about anything of savings Because revenue is all that counts But I've had a whole bunch of people come from the financial office when I've been here or there and say Mike You always say this is gonna save a certain amount of money. Yeah, but we can't really quantify it. Yeah, I know What are you gonna take all the time to follow these patients with a pulmonary embolism? Go look at them over the course of years and then see how they come out. That's just not practical Yeah, it's just obvious if they're spending two less days in the hospital count that so I Think it has to be understood that All we really need to do is get that diagnosis quicker and more accurately Stated and we will do better financial and that will take a while to prove But really some people have said that's the missing part for health care That's what can stand up an institution because you waste so much money Yeah being people in hospital for example for two days when you could give them an anticoagulant when it's the right anticoagulant You're proven. You know where the clot is. You've done the right thing now go home and take this medicine yeah, one thing that's interesting about the data that you're referencing is that as You might expect the lion's share of the reduction in that length of stay was the reduction of length of stay for outlier patients so what was happening is the run-of-the-mill patient comes in and Was going to be discharged within you know one two, you know, two to three days but What you did was you essentially reduced the number of patients who stayed in the hospital for you know, an extended period of time and At first you think to yourself. Well, you know, there's mean and median and so you really didn't have that much of an impact on that many patients But that's sort of missing the point because if a patient stays in the hospital for an extended period of time The probability that they will have a worse outcome Increases nearly exponentially. Absolutely. And not only that I'm talking about a worse outcome from the the pulmonary standpoint but it's also true that patients are just It's it the hospital itself is an unhealthy environment, right? There's all kinds of bugs that are in the walls And and so what you want to do is send someone home because then they're less likely to have some other Complication. Absolutely. So in in reducing those outliers You have an an incredible impact on those individual people's lives Not to mention the fact that you also have the reduction in length of stay which saves you money You know, especially now with with DRG billing Every single day is a dollar, you know, a penny saved is a penny earned. So it's it's a really very important point I just make one comment to support what you said. We had a new president join us here at the institution Several years ago and of course, there was a Ceremony to honor the outgoing president. Yeah, of course So we were in line and when I went up to shake his hand he said Mike I can't explain it. But from the time you got here We were able to make financial Changes in the positive direction and I can't explain what it is that you did and how it impacted us But it was very clear It was associated with your arrival and you're doing things that were innovative in laboratory medicine So he was an ENT surgeon. He probably didn't really Understand all of it. Mm-hmm. But but he did notice the temporal association that when you start providing advice by experts To practicing docs in the hospital, you're gonna save one. Yeah, I I'm interested in Any sort of DMT failures that you might Oftentimes, you know when you and I get together we're gonna talk about all the successes the reasons why DMTs matter But there there is the opposite side of that coin, you know, are there technical challenges? Are there? Philosophical challenges that have led to DMT failures Specifically, you know in the interpersonal, you know dynamic that you might consider there's something that that really ruins the MPs I would say there are a thousand ways to get it wrong and probably one or two ways to get it, right? Yeah, my boss told me that about Experiments when I was doing Work as a postdoctoral fellow. I said I did this the same way as I did the last Yeah, of course, but it didn't come out the same and that's when he said there are a thousand ways to screw up an experiment one way to get it right and so Sure for all the things that we've talked about people not having a sense of urgency people calling themselves experts when they're not So all those can tube at the empty and if somebody isn't at the top who understands all of that Yeah, then some of that's just gonna occur. Yeah, and then pretty soon it will go down Yeah, so you have to have somebody who can say Do that don't do that do that. Don't do that. I don't know if you've watched the Televisions show the pit which talks about the emergency room And it's set in Pittsburgh and it seems like the guy who runs this emergency room I was constantly being called called dr. Rami called up And yeah, of course without him the whole thing would fall apart because he'd say no no don't do that do this do this And there has to be somebody to guide the ship You just can't let it go and sail in the water and expect to get to your destination. Yeah Well, I I'm curious to know sir. Is there anything else that we would need to discuss? That you really want people to know about the human side of the DMT That would be something that they should take with them. Yeah, I would say we should wrap this up just by saying Don't wait for an outcome study to find out how somebody who we identified with von Willebrand's disease is doing Following them for 10 years to see if they had this many bleeding episodes or that many over the course of a year just understand Because you needed to get started that if you identify people who bleed and you understand What it is they're bleeding from and that allows you to pick the right treatment. They are gonna do better So I think this issue of Prove it to me Before you ever get started is really it what has held the DMT back I think it's people saying if this DMT comes alive, they're gonna say I'm supposed to be doing it Yeah, and I don't feel comfortable doing it. So a lot of people are saying that even internally on the pathology side Because they're reluctant to dedicate all the time and emotion that's necessary to do it. Yeah, it's hard to in When we have a randomized controlled trial in general what we have is Let's take a therapy trial we have an incumbent therapy and then we have the new therapy and then we compare those two therapies and We try to prove To a standard That the new therapy is better than the old therapy so the therapy had the first therapy has some efficacy and then the new therapy has perhaps more and And we oftentimes use a 95th percentile or 95 percent confidence that the new therapy is better than the old That entire paradigm is Useless when we're talking about knowledge So if someone Doesn't know something and They're doing the wrong thing and you know that they don't know that thing and you inform them You don't need to study it To say it's better to know the thing than not know the thing. Thank you for saying right exactly, right? It's not there's no need to study it. Now. What you could say is How of an how much of an impact is knowing? And you could say well, it turned out that the impact was not as big as we thought it would be okay, but You don't actually know All you know is what happened in the last cohort of patients the next patient In fact knowing what appropriate treatment should be Could be all the difference So there's no it doesn't matter see how many times you studied it It's still the next patient in fact knowing their diagnosis and treating them appropriately Could mean all the difference between life and death or good outcomes and bad outcomes So it's really hard to see a world where Doing the right thing isn't always in your best interest and it's really just that should I do this right thing or that? Right thing. I mean, you're only human right? You only have so much so many hours in a day but it's not It's hard for me to see a world where just Going blind is better than having at least a view out of the cockpit. Well Well, thank you very much, sir. I appreciate it. Looking forward to next time. It was fun. Yes, sir Okay
