Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. This is the CMAJ Podcast.
Dr. Blair Bigham:
Jola, today we're talking about a controversial topic and that's the fusion of medical assistance in dying, which only became legal in Canada, what, eight years ago?
Dr. Mojola Omole:
2016.
Dr. Blair Bigham:
2016. And palliative care and sort of more traditional, I guess I'll call it, end-of-life services. So we have a qualitative study. I don't think we've done a study based on interviews in a while, but this is a study of 36 professionals across Canada who work either in the MAiD, palliative care, or in both fields. It's entitled “Perspectives of Canadian healthcare leaders on the relationship between medical assistance and dying and palliative and end-of-life care services: a qualitative study.” So the thrust of this, basically, is that there is or was a bit of a mini war going on between MAiD providers and palliative care providers and they weren't necessarily playing fair in the sandbox.
Dr. Mojola Omole:
Well, it sounds more, I interpreted differently was that palliative care had a very clear goals of what palliative care should be and MAiD was conflicting with part of those goals and it's trying to understand how both of them could actually be used to center the patient's care.
Dr. Blair Bigham:
But in that process, it sounds like a lot of MAiD providers, at least from this study's results, and we'll be talking to the author in a minute, really felt excluded from patient services, almost ostracized.
Dr. Mojola Omole:
And we'll get more into detail with it with the author of why they were having this experience, because I do think it's quite fascinating. So after we talk to the author, we're then going to talk to Dr. Christopher Blake, who is a palliative care physician who does MAiD assessments to see what his real-world experiences of the two services.
Dr. Blair Bigham:
Let's get to it. Dr. Gilla Shapiro is the lead author on the paper. She works at the Princess Margaret Hospital and University of Toronto. Gilla, thank you so much for joining us today.
Dr. Gilla Shapiro:
Thank you for having me.
Dr. Blair Bigham:
Gilla, this is a really interesting study. You found initially that practitioners of palliative end-of-life care and practitioners of MAiD felt like they were operating in two separate worlds, but to me they sound like they would be in the same universe, at least. Describe how people felt.
Dr. Gilla Shapiro:
I think the quote that you're describing really does focus on one health leader's perspective that they felt like the two services were completely separate. And although this is certainly the case and many did have that experience, many more did not and many more felt like there was good collaboration and good coordination and there was wide-ranging of views that we saw about what the relationship should be.
Dr. Blair Bigham:
If we go back seven or eight years to when MAiD was first legal in Canada, was that a more dominant opinion at the time, that they were in two different worlds?
Dr. Gilla Shapiro:
I think that would be fair to say. I think over time there has been increased collaboration and coordination between the services and overall, MAiD has been more normalized, particularly within the palliative and end-of-life care community. Even in our study we found providers and health leaders saying that there has been improvement over time in the relationship.
Dr. Blair Bigham:
How did that happen? Tell me about that.
Dr. Gilla Shapiro:
So we actually have another paper that's going to be looking at what providers and health leaders thought about the introduction in their attitudes but for this study, what we really focused on was trying to understand what health leaders wanted the relationship to be. We really noticed that in the literature and in policy there was this gap about how these different services should relate to each other. There are many different ways that they could relate to each other and in different parts of the country, in different institutions, they were operating in very different ways. And so we wanted to understand what health leaders thought would be the optimal way that they relate.
Dr. Mojola Omole:
Do you think geography plays into it, where you're practicing? Would that have an effect on the view of whether or not it's symbiotic or operating on different planets?
Dr. Gilla Shapiro:
Absolutely. I think that's certainly one of the main factors about why there's lack of standardization. It would make sense that in a rural area, certain providers are the same people who provide palliative care and provide end-of-life care and there's limited access in those communities otherwise. So I think that would make sense. Whereas then in other areas, there's more opportunity to have separate services because there's more providers. So geography certainly can play into it, but there's other factors as well. For example, if there were institutions that are in some way supported by religion, that's another factor that really played into whether there was separation, coordination, or fully integrated services.
Dr. Blair Bigham:
Some MAiD providers felt pretty ostracized and isolated early on after the introduction of MAiD. Tell us a little bit more about what those MAiD providers feeling in the early days.
Dr. Gilla Shapiro:
Yeah, certainly at the start, that could have been the case. And many, not only in the research, we found that some providers felt that their views were not the dominant views or they felt not part of the mainstream palliative care. But I've noticed this also in some of my personal relationships, too, with colleagues as a clinician. For example, one of my colleagues spoke to me and mentioned that both his colleagues and his friends are wondered if he was concerned about his own safety during this period because he was speaking out about MAiD in Canada, and that really does speak to some of the early tensions and I think that really does come from it being a new practice and there being a lot of unknowns at that time.
Dr. Mojola Omole:
So now, though, I'm assuming that's changed for people.
Dr. Gilla Shapiro:
I think over time it's changed tremendously and that was the main part of what we were interested in our study, as well. Not just what policy leaders and health leaders across Canada thought should be the type of relationship between these different services, but we are also really interested in what are the different factors and themes that are really critical in supporting this relationship in the best way possible. And I think we learned a lot about what had worked well in a number of situations that has allowed for a better relationship between these different services over time.
Dr. Blair Bigham:
What surprised you the most about your interviews?
Dr. Gilla Shapiro:
I would say maybe two things surprised me. Much more than I was anticipating, there were people who did want separated services, that they thought very strongly that these services should not be even coordinated. This was a minority of people, but that this was a voice at all within the health leaders that we interviewed, that did surprise me a little bit just given this global movement towards service integration. I thought that was interesting.
The other piece that was interesting for me is how emotional some of the interviewees were. Not just passionate, but also tearful at times in discussing these issues, how much it meant to them. And I think it really does highlight that behind our decision-makers, behind our health leaders, they're people who are really conflicted and really trying their best and really working hard. And not to mention that these interviews took place during COVID, so they were very busy and they donated their time to be interviewed about this topic. So I think that also I wasn't expecting that when we started the project, as well.
Dr. Mojola Omole:
It sounds so strange, because I feel like isn't the end goal the same? To give people dignity of life at the end of their life?
Dr. Gilla Shapiro:
That's a really good point and actually, when I presented some of this work to colleagues who focus on service integration, they often did highlight this as, in their mind, strange. Service integration is considered by many to be a gold standard of care to try and provide patients with the best possible and seamless journey through their healthcare.
But for a substantial minority, not everyone by any means, but for some of the participants in the study, some of the health leaders, they thought that the goals and missions were not compatible and that although there might be some collaboration between the two different services, it didn't make sense for them to have the same team, provided by the same providers. They wanted a certain distinction between the different services. So overall, the message was collaboration, but distinct care between the two different services.
Dr. Blair Bigham:
In the palliative care literature, is there a guideline where there's a trigger point or something for someone who has suffering that is refractory to sort of multiple efforts of palliative care where the palliative care practitioner brings forward the possibility of MAiD to help inform people who don't even know that it's an option? Or would it always be the patient coming to the palliative care provider with that idea?
Dr. Gilla Shapiro:
It's really interesting. So an emerging research base, evidence base, is showing that patients want different things here too. So some patients, they might not know about the service and know that this isn't available for them and they might be planning to go to a different country in order to get MAiD. Some patients that I've spoken to have mentioned those kind of plans that, "If I ever got that bad, I think about I'd go to Switzerland," that kind of a comment.
But then there's other patients who when a provider might bring it up to them, they say that they wouldn't want that. And some people have even worn badges, don't bring up MAiD to me, comments like that, because they think that's just not the place of their health team. So I think a lot more research needs to better understand how we communicate with patients about this and what different patients might want and how that can be documented to best support them.
Dr. Mojola Omole:
In terms of when you spoke to the healthcare leaders and from your own experience, how clear is it what is the best approach that serves the most amount of patients?
Dr. Gilla Shapiro:
I don't think that there was one approach that serves patients, but a number of different themes did come out, which would be what is in the best interest of patients, the public, and providers. And all of these people work in the system and we need to figure out an approach that works for all of them. And I think that's really where people came down into a collaborative approach. Some of the different ingredients for that collaboration really included education. So better strategies to help patients and the public understand what are these different services and what do they offer and how do they differ and decreasing stigma when it comes to these services.
And similarly, education emerged as an important consideration for providers to better understand what MAiD is about and how it is distinct. And one of the other projects I'm supporting is the development and evaluation of a new curriculum for medical assistance in dying that's being provided by an organization called CAMAP, and this curriculum is going to be available for all health providers to increase education. So that's a really good thing when it comes to supporting patients and providers.
Dr. Blair Bigham:
Thank you so much for spending time speaking with us today. I know this is a thorny issue and we appreciate you doing this research and bringing the two sides closer together.
Dr. Gilla Shapiro:
Yeah, thanks so much for your interest in this topic. I look forward to future conversations about it, as well.
Dr. Blair Bigham:
It's our pleasure. Dr. Gilla Shapiro is a lead author on the research article in CMAJ titled “Perspectives of Canadian health leaders on the relationship between medical assistance and dying and palliative and end of life care services.”
Dr. Mojola Omole:
We're going to turn now to the perspective of the end of life care practitioner. Dr. Christopher Blake is a palliative care physician in Peterborough, Ontario. Chris, thanks so much for joining us today.
Dr. Christopher Blake:
It's my pleasure, thanks for having me.
Dr. Mojola Omole:
So what was your initial reaction to the study in palliative care and MAiD services?
Dr. Christopher Blake:
To me, the most interesting top line number that came out of it was the percentage of the leaders in the MAiD and palliative care domains who are supportive of the legalization of MAiD in its initial form. In this study it was around 64%, something like that. When I've looked at sort of the statistics for the general population as a whole, at least in terms of MAiD as it was initially introduced back in 2016, the support for it is closer, it seems like, to the mid-to-high 80s. So it's interesting to me that in a group of people, some of whom are leaders in MAiD and would presumably be supportive of MAiD, that there's actually a smaller proportion of people in support of medical assistance in dying in this population.
Dr. Blair Bigham:
It's not that small, though, for one third of the interview participants to actually be against MAiD seems a little bit high.
Dr. Mojola Omole:
How do you explain that? It doesn't make sense to me that the general public is more supportive of it than those within the field of palliative care. I don't get it.
Dr. Christopher Blake:
Right, it's interesting. So that's very interesting kind of contrast to bring up. One thing that I'll note, too, is that the study participants here were a mixture of leaders from MAiD and palliative and end-of-life care. So presumably the people who are the leaders in the MAiD world are in support of it. So what my assumption is they haven't broken this down that granularly as far as I can tell, but my assumption is that there's a smaller percentage than 64% total in this study of people from the palliative and end-of-life care world who are in support of MAiD.
What you have to come back to, I think, is before all of this was introduced, before MAiD came in, there was an assumption, I think, on behalf of the medical community as a whole that palliative care would naturally take the leadership role in this. And I think that there was actually in reality a lot of reticence on behalf of the palliative care community to assume a role like that and a lot of attempts to make it really clear that palliative care and medical assistance in dying are distinct practices and should have distinct processes.
Dr. Mojola Omole:
Which, that totally makes sense to me. I guess for me as someone who works in a hospital setting, I honestly always thought MAiD was a continuation or a different option as part of people dying with dignity, which is palliative care. Can you just walk us through just how the two practice operate in the end-of-life? Because it seems that from this study that I don't have it right.
Dr. Christopher Blake:
Well, I think that Jola, you shouldn't feel badly about that because I think it's a confusing thing for a lot of people.
Dr. Mojola Omole:
I rarely feel badly, but continue.
Dr. Christopher Blake:
Good, good. I'm glad.
Dr. Mojola Omole:
It's not in my DNA.
Dr. Christopher Blake:
Yeah, good. So what I would say is that if we look at what the definition of palliative care is, and if you look at the definition of palliative care from the World Health Organization, from the Canadian Hospice Palliative Care Association, from Canadian Society of Palliative Care Physicians, whoever you look at it from, the basic idea behind palliative care in the definition is palliative care does not hasten death and palliative care does not prolong life. So right off the bat, there is a, definitionally, MAiD could not be included within that definition of palliative care.
So to me, when we talk about the differences and how they intersect, I do see them as distinct practices, but I see them as different solutions to the problem of life-limiting illness. So some people may want just palliative care involved in their course of their life-limiting illness, probably a smaller proportion would want just MAiD involved, and a large number of people will have both palliative care and MAiD involvement. When we look at the most recent statistics from 2022 from the Canadian government, we see that close to 80%, about 78% of people who've received MAiD have had palliative care involvement. Of the remaining 20 or so percent who haven't, about 85% of them would've been able to access palliative care if they so desired. So to me, they're different solutions to different potential solutions, depending on a person's goals, to the problems of life-limiting illness.
Dr. Blair Bigham:
I just want to push back a little bit on the definition of palliative care. Not to question the definition itself, but something like palliative sedation, which is well in the wheelhouse of palliative care, doesn't that hasten death? Although it's not the intent to hasten death, sometimes symptoms are so bad that you really are tipping people over the edge in some ways, not with purpose, but as a double effect. Isn't that fair to say?
Dr. Christopher Blake:
So it's a very interesting question, Blair.
Dr. Blair Bigham:
That sounds like a dodge to me, Chris.
Dr. Christopher Blake:
No, I promised you that I would give you straight answers and I will. So when we look at what the evidence says is that palliative sedation in general does not lead to a shortening of life. So if you take a, they've done studies where they've admitted people to a palliative care unit and they've looked at the average length of stay on the basis of whether they received palliative sedation or not and the time to end of life was similar.
Now, I think that it's in undoubtedly true that on an individual by individual level, I mean I think that probably there are certain circumstances where it could theoretically hasten death. My view, though, is that the way that it's done, and in Canada palliative sedation is done on the guidelines on the basis of the Canadian Society of Palliative Care physicians, they've put this out, a position statement, which basically says it has to be done in the last two weeks of life, it has to be done in people who have full comfort care goals, it has to be done in people who are felt to be close to death and who have accepted a palliative sedation approach. And on that basis, when it's conducted appropriately, it's not felt to hasten death.
To jump off your point though, Blair, in terms of the definition of palliative care, we're talking about again, not hastening death and not prolonging life. We actually have seen in some studies that good palliative care, for instance, there's a famous study that showed that good quality early palliative care in patients with lung cancer can prolong their life. Certainly in patients with CHF, I titrate their LASIX to help with their symptoms, that's probably helping them live longer.
And I'm providing, in my field where I practice in Peterborough, we provide active or acute palliative care, which means I'm admitting patients to hospital who have, for instance, SPC syndrome or they have a PE or they have an infection, an infectious complication of their illness, and we're treating them for that in our palliative care unit. So I think that you're right to say that maybe that definition is something that you can question, but I think that the idea behind palliative care, and I think this is partly honestly a marketing thing, is that it's not meant to be hastening death, it's not meant to be prolonging life. And the reason for that is that we live in a death-denying culture and we don't want people to feel as though if they just go to palliative care, that's the end, because it's not.
Dr. Blair Bigham:
If you are taking care of people as a palliative care physician and many of them are asking for MAiD at some point in their care, wouldn't it make more sense for you to continue your relationship with them and see them through that? Does it feel weird to hand them off to a separate team?
Dr. Christopher Blake:
Well, I would say that I'm not just handing people off. So when I meet a patient, I stick with them for however long they're here, whether they go on to a natural death or a medically assisted death. One of the things that really disturbed me about this study was that they made mention of a case in which a patient was handed over to MAiD and denied further palliative care thereafter. That to me is unconscionable and I think that's abandonment and to me, that should never really be permissible.
So I will meet patients, I will provide palliative care for them. If they're interested in medical assistance in dying, we have a coordinating service here. I make a referral to the coordinating service. We help determine whether or not the assessments are best done in the home environment, a hospital environment, what have you. But I'm sticking with this person and if they want me there at the time of medical assistance in dying, I'll be there in the room with them. Most people don't, they want some privacy and some time with their families. But I will stick with patients and I would say it's like maybe Blair in your work in the ICU, you might be having another consultant involved in a patient's care, right? Nephrology might be on board to help manage a patient's dialysis or something like that while you're managing their vent settings and you can work collaboratively together to help provide the best possible care.
Dr. Mojola Omole:
Have you noted now in terms of the relationship between MAiD services and palliative care, are there any continuing obstacles in that relationship for it to be effective for patient care?
Dr. Christopher Blake:
Yeah, I mean I think the challenge with medical assistance in dying is that ultimately the healthcare system is made up of individual people. So that's the strength of the system and that's the weakness. You cannot force anybody to provide MAiD and just to be clear, my priors on this is that I think that conscientious objectors should of course be allowed to conscientiously object. I think that they need to be able to provide or they must provide, I think, an effective referral. That's what the CPSO guidelines in Ontario would say, is you need to provide an effective referral to a MAiD assessment if you yourself are not comfortable to do one. I think that's necessary. And I think we also need to respect patients and their goals of care and follow them along on their journey.
So to come back to your question after my long-winded side track, the challenge to me is that ultimately we depend on individuals to provide this care. So Blair was asking about an integrated model. Does it just make sense for me to just do it? It probably would, but are you going to get that everywhere? You couldn't have an integrated model across the entire country because not every palliative care physician in every area is going to want to do this. In many places they might not. Some palliative care physicians the group might and some might not. There might be some where I trained in Barrie, basically everybody who did MAiD was part of the palliative care group. Where I work here, that's not the same case.
So I think that what you really need is to have, because we have individuals involved in doing these assessments and provisions, we need to have a good systems-level approach to ensure that people are connected appropriately. We need to have the policies in place and advocate for that at a national level. I think there certainly needs to be standardization in terms of expectations on physicians and nurse practitioners about making effective referrals. I think that we need to ensure that there's adequate coordination between the teams, and that really probably means dedicated funding for a coordinator for these kind of things.
Dr. Mojola Omole:
Do you think that some of that conflict, because Gilla had mentioned it previously, comes from institutions with religious affiliation or ideological concerns? Do you think that might be what influences a bit of that conflict between palliative care MAiD and not it being that, okay, well you provide both and others don't, if that makes sense.
Dr. Christopher Blake:
Yeah, it absolutely does. I think that I'm sure that at an individual level and at an institutional level, that religious considerations are a factor in conscientious objection. I don't think that'll necessarily be the case for everybody, but I'm sure it is for some of them.
Dr. Blair Bigham:
I just have a question about that. Bouncing off of Jola, I understand conscientious objection for individual physicians. I don't understand how a publicly-funded institution can object, especially when we know that MAiID is more commonly the end of someone's long hospitalization and this is more commonly happening in hospital instead of people's home. I'm just curious, is there any progression or movement on that institutional objection?
Dr. Christopher Blake:
So just to provide some context in the first place, in the last year where I've found stats from Canada, which is 2022, about 40% of MAiD provisions happened in homes and about 30% happened in hospitals, and another 20% happened in palliative care facilities, which I assume probably means hospices or other similar settings. So you're right, Blair, there's a lot of provisions for medical assistance in dying that are happening in hospitals. And this article makes note of something that we in palliative care have seen in experience, which is that patients who are at certain institutions that have decided that they will not participate in MAiD and not facilitate it are being transferred out to receive these assessments and to receive medical assistance in dying.
Dr. Blair Bigham:
That seems like such an awful thing to do to someone who's frail and bedbound, load them up on a stretcher and drive them down a bumpy road.
Dr. Christopher Blake:
So I think that individuals absolutely should have the right to conscientious objection so long as ithey are able to furnish an effective referral to somebody else who can provide the care that the patient needs. I personally feel that an institution receiving public funds to provide publicly-funded services doesn't have a conscience. I don't know that they can have a conscientious objection. But my personal view is that it is morally wrong to move a frail, bedbound person who is asked for assistance with ending their life with peace and dignity out of a facility where maybe they're closer to their family, where maybe they've made relationships with a treating team. And I think aside from the physical discomforts associated with that, I think we also have to remember that that kind of a move inevitably would bring up questions of whether there's judgment.
Dr. Mojola Omole:
So from your perspective, what do you think is the ideal relationship between MAiD providers and palliative care providers?
Dr. Christopher Blake:
So my view is that probably the most practical relationship is the collaborative approach that they described, and they outline how that works well in a jurisdiction like Belgium. From what I spoke to you all about earlier, an integrated model might be feasible in certain places at certain times. You might have a group of palliative care physicians who also all happen to do medical assistance in dying, but that's just not going to be the case everywhere.
So I think the best thing that you can hope for at a total systems level is a collaborative approach. And to me, what that looks like is that there is a relationship between the two specialist teams involved in MAiD and palliative care and there's probably dedicated funding for a coordinator to help and assist with linking people to appropriate MAiD services. And in addition, they talk about having a multidisciplinary team, which I suppose could involve individuals like social work, spiritual care, et cetera.
And for some patients, I think it's important that we remember that MAiD itself, and I mean like the procedure, getting the medications and allowing them to die is not the sole benefit for some of these patients of the medical assistance in dying process. The actual process of going through the assessments and finding out that they'll be eligible to receive MAiD if ever in the future they decide that they want out provides, in my experience, immense psychological benefit to the patients who want it.
So I think that palliative care, in my view, needs to recognize that we don't have all of the answers to the suffering that patients go through and that unless MAiD is available and accessible to people, they will be left suffering from symptoms which for some of them, are unacceptable. And if we want to take a patient-centered approach to things, we have to recognize the benefit for patients of being able to receive MAiD.
Dr. Mojola Omole:
Great. Thank you so much for joining us.
Dr. Blair Bigham:
Thank you.
Dr. Mojola Omole:
Dr. Christopher Blake is a palliative care physician in Peterborough, Ontario.
Dr. Blair Bigham:
So Jola, I want to start with what Chris ended on and that's this idea that just going through the MAiD assessment can be a psychological benefit to people. And it made me think of my dad when he was dying of pancreatic cancer, and he was. He was very worried that his severe symptoms were not going to be alleviated. And I remember there was one night when he was readmitted to hospital where he was basically just begging to be put out of his misery. Now that was when he had a gastric outlet obstruction, he was horribly nauseous, he felt like there were rocks in his body and he needed the NG tube and as soon as the NG tube went in and two liters of gross stuff came out of it, he felt way better and he was in a totally different place. But he did end up signing up for MAiD. He didn't die by MAiD, but he signed up for it and it just gave him that peace of mind that if I feel that terrible again, it won't be for long.
Dr. Mojola Omole:
100%. And I think one thing that both of us have talked about is both of our fathers passed away from pancreatic cancer. And so for me, I am openly unabashed proponent of MAiD because I believe that people should have the autonomy to choose how they die. There needs to be dignity in death, and we cannot always avoid it. My dad chose to leave Canada to go back to Nigeria where he was born and raised to die. And so in a way, he got the autonomy and I remembered the last words he said to me before he became more unconscious was, "I am so happy I got to come home."
And I think for me, that has been such a huge part when I'm dealing with patients with cancer who we know are terminal is to always present MAiD as an option. Because even just knowing that you have this option is similar to what Chris was saying in terms of the psychological effect. And so it was heartening to speak to him after reading and talking to Gilla regarding some of the disconnect between the two services to see that we have a long way to go, but we can really improve patient-centered care for end-of-life care for our patients.
Dr. Blair Bigham:
As reassuring as it was to talk to Chris, and know that in Peterborough, Ontario, everything seems coordinated, and certainly my experience in Toronto, I don't even know if there was a difference between the palliative team and the MAiD team. Everybody just talked together. I think they were all the same practitioners. I couldn't tell that there was somebody new who flew in. So it was people who already had that relationship with my dad. And it worries me to think that in other hospitals, my dad might not have received that same benefit.
Dr. Mojola Omole:
And that to me is unconscionable. For me personally, I try very hard to, I respect people's religious beliefs as someone who's also someone of faith, I understand that. However, we all as individuals have the autonomy to choose how we practice if that's based on faith. But institutions which are publicly funded should not. And I wholly agree with that, and I do wonder if that's what needs to be addressed to improve those services for patients.
Dr. Blair Bigham:
I think we also might sometimes make the assumption that people of faith wouldn't want MAiD. My dad was a Presbyterian minister and was more than happy to sign on the dotted line when faced with the prospect of a very uncomfortable passing.
Dr. Mojola Omole:
I agree with that.
Dr. Blair Bigham:
Well, this study certainly highlights that despite the progress made since 2016, we still have a long way to go and it sounds like we need some national standards or maybe some regulatory teeth to make sure that everyone in Canada has access to what they have the right to access.
Dr. Mojola Omole:
Yes. Which is palliative care, which is not always end-of-life care, but MAiD if needed for end-of-life care.
Dr. Blair Bigham:
Thanks so much for listening to this episode of the CMAJ podcast. If you like what you heard, please like or share wherever you download your podcasts and help us get the message out. It goes a long way to making sure Jola and I are heard around the world. This podcast is produced for CMAJ by PodCraft Productions. Big shout out to our incredible producer, Neil. We'll see you back in two weeks. I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.