Working In Oncology
Working In Oncology

Episode · 3 months ago

How one Doctor is Using his Online Presence to Unpack the Pandemic w/ Dr. David Aboulafia


Healthcare professionals tend to be hesitant about putting their views on the web. But not Dr. David Aboulafia , Hematologist at Virginia Mason and author at Covid Cogitations, who shares with us his best insights for developing a bedside manner online. 

Join us as we discuss: 

- Dr. Aboulafia’s generational heritage of healthcare 

- Origin and lessons of Covid Cogitations 

- How COVID-19 has affected cancer care and healthcare access 

- Artificial intelligence and genetic sequences: the future of cancer care? 

- The role of specialty pharmacies in partnering with staff and patients 

Check out these resources we mentioned during the podcast: 

- Dr. Aboulafia’s Covid Cogitations blog 

To hear more interviews like this one, subscribe to the Working In Oncology Podcast on Apple Podcasts, Spotify, or your preferred podcast platform.

You're listening to working in oncology,a podcast and video show that spotlights oncology practice staff and industry influencers who workbehind the scenes to shape the future of oncology. The more knowledge the oncologycommunity shares with each other, the more we all grow. Let's get intothe show. Welcome to working in oncology. I am your cohost today, AliciaEvans, and I'm joined by Dr David Lafia. I really see niceto meet you. Nice to meet you, Dr of Lafia. Welcome to theshow. I've been really looking forward to our conversation, so I've beenfollowing your blog and I think that you provide so many valuable updates on covidand I'm eager to hear your insights on how the pandemic has effected you andyour oncology practice and your charitable works. But before we jump into the conversation, can you tell our listeners and viewers a little bit about you, yourbackground and what you do? Yeah, my pleasure, Lisa. I'm ahematologists on cologists up in Seattle and I've been in practice for about thirty yearsnow, and my practice is a little bit unique. It's a hybrid inso much as about half the patience I see have HIV or AIDS and areliving with HIV. So I've had a long background with viral infections and thesuppression and of course the other half of my clinic is devoted to cancer careand those are focused mostly on people with humanologic Ma witnancy so my Loma,lymphoma, leukemias and the like, and so it's kind of a hybrid andfor the HIV folks I do primary and subspecialty care and for a lot ofour cancer patients we end up being their primary providers to but my initial workwhen I was a fellow at Youcla was in viral infection. So a viruswhich was the original thought to be vicrus of HIV was a virus called htlvone, and that was originally thought to be the virus that causes and youknow, suppression, and it was subsequently learned that now we had a differentvirus, the HIV virus. But my research was in both Htov one andHIV, and so I've had a long interest in, I mean a suppressionViral Infections and, of course cancer care and how the treatments we give canfurther amnut of suppressed patients and the consequences of that. Well, that's reallyinteresting. But if we could take a little step back, what initially motivatedyou to become a doctor? You know, my father was a vascular surgeon andwhen we were kids, at my brother and I would, believe itor not, we would scrub into CASS with my day. We would justbe watching, but we had a kind of an early introduction question really whenwe were probably five, six, seven,...

...eight years old. Wow, andso I think that connection to medicine was really begun when we were kidsand we later used to work in this office and we would go down roundswith them. So I think it was kind of a natural extension of that. That's said, if I had any athletic progress, I would not havegone into them third basement for the Detroit Tigers. So I guess some doctorsare made. It sounds like you, Dr Ablafia, were born a doctor, born a physician. In hard the name Abulafia means father of good health. Really, yes, I'm sephardic, which means juice from Spain, andso I think it's kind of a family legacy. There are a lot ofus who are physician wow, wow, that's it was your destiny pay becausethat so. You mentioned that your early work centered around HIV AIDS treatment andthen you transition, it sounds like, more tohematology oncology. It was ayou know, we're back in the S. UCLA was a big hub for HIVresearch and so only fifty percent of people living with HIV or with advancedas were destined to develop cancers in those days. So probably about thirty percentdeveloped Katasistar Comma and unusual skin cancer. Another twenty percent develop confonas, andso it was kind of a natural full back in those days for Hemo physitionsto take primary care or primary responsibility for them, for those who had HIVand cancer. And it was really only when antiretrovitals became available and therapeutic thatinfectious disease physicians kind of took up the mant home started caring for them andbigger. But so many of those patients were sick and debilitated. Often theywould move to hospice and it was the Hemov gods who had the most experiencewith them. So it was kind of a natural subset of what I wasdoing as a fellow and later as intending. Okay, that makes so much senseand that's a lot of I didn't realize that about the history of htchtreatment. Towards the beginning of the pandemic, you started a blog covid cognitations,agitations. God, Oh, I said it right. Have helped.Can you repeat it please? Yeah, COVID congitations, cogitations. I Apologize. COVID cogitations. So I wanted to get an idea what mode invaded youto start the blog and like, what were your goals out, what messagesyou want to send with that? Yeah, I think originally I was incredibly frustratedwith level of misinformation that was going on and in so many ways itwas reminiscent of the early era of HIV infection. To how was the virusspread, who was affective of what were the prejudices that were coming out inreally full force, and it was just... reminiscent on a superficial level.Now it turns out that there are a lot of differences between them, butin that early phase, when it was being referred to as the China virusand there were a lot of other negative stereotypes going on with it, itwas very reminiscent of what people living with HIV were going through in their daytoo, and so it's hard to imagine now, but when HIV became athing back in the late s and early S, Ronald Reagan refused to usethat word AIDS in any public address and there was a lot of paranoia alsoabout how do people get HIV, where did it come from? How wouldpeople who were straight or doing it, didn't have unprotected sex might get it? And that kind of level of misinformation, in the paranoid that was going onstruck me as very similar, or that there was a lot of overlapduring those first six months when covid became a big deal, first in China, that Europe and then in the United States. I understandabile. So youyou have been on the front lines of an anti misinformation and it pass andyou just thought opportunity to combat that the second time exactly, and you knowit's kind of ironically show. Originally I was sending it out to just physiciansin my medical center and typically it would be cut in pace on an emailof like a new y times article or a Seattle Times or Washington Post articleand just saying hey, this is what's going on now. Blah, blah, blah, and I started my son Said, you know, dad,my friends want to read this, but no one reads the inhouse. Whydon't you start a blog? And at the time it was like what's ablog? But I have a younger son who is into digital arts and hasa degree in digital arts, and so, between my older son encouragement and myyounger son's willingness to help, started doing it as a blog and inthat context started sending it. Once it became a blog not just for peoplein my medical center, physicians, but really for patients and particularly with afocus on general information, but subset information for Covid and cancer and Covid inHIV. So if you could provides an insight. So how do you feelcovid has effected Cancer Care? You know there's been so much written about itand you know the research is just coming out, but I think in thebeginning, I think all of us were a bit shock, like we're ourpatients, what's going on? And you know the New York Times referred toit as this eerie silence in emergency rooms, like how come no one is havingheart attacks? During the early days at Covid, you know, andof course we realized that people were having their heart attacks and the strokes justas frequently, but they weren't coming to the emergency room. And in fact, you know, when we talked about seven Hundredzero deaths from covid in theUnited States, now we really understand it's probably quite a bit more than thatand a lot of people died either directly...

...from covid and the fear of comingto emergency rooms or died from strokes that could have been prevented or could havebeen treated but didn't come quickly enough to the emergency room. So the spillovereffect came with our cancer patients too, as they became reluctant to come intoclinic, and it also was compounded by our own concerns about I mean ofsuppressing those patients, not knowing what the effect of our treatments might have ontheir risk of covid. And of course there were a huge number of patientswho I don't see in the front end but I see in the back end. Women who weren't getting their mammograms, men and women who weren't going atgetting their coal and Oscaries, people who aren't coming in for their well physicalexams, were cancer is sometimes picked up. So it had all of these kindof downstream effects, and so that was one huge area which affected USenormously. And then, just as we're communicating right now, by video.That was another really big kind of transformational event in care of cancer patients andin terms of Covid, in terms of not having those patients come directly tothe clinic but, when possible, do these meetings by video. And Isaid, you're kind of helping them to bridge gapputs some telehealth. Yeah,but it, you know, just as we've seen so many, many disparitiesmagnified during Covid, and that was to during the AIDS epidemic as well.How many people don't have computers? How many people don't know how to usetheir computers? You know, who are the people that were really connecting toin these video visits? So it's heightened disparities on a lot of levels toeven though it's maybe has potential for leveling the playing, you know, theplayground in certain areas as well. And a Polish I think a really bigarea is that. You know, the effect of you know, we're nowfinding, you know, what is the effect of our chemotherapy, and ourI meanough therapies, on the covid vaccinations themselves, and one of the thingswe've realized is that a lot of cancer patients who've gotten their two, werethere one or two series vaccines are not necessarily protected from covid and you know, that's where the whole push with boosters became really important. So there's somany levels. It's almost like this huge pie of like from people not wantingto come in for fear of getting COVID, people not coming to the emergency room, people not getting their cancer screening, and then even how we connect withthem by video. What are the pluses? And then is that andfollowed through to what are the effects of our tree with you know, we'vedone it both ways. We've tried to limit treatments during covid and that's hada boomerang effect to so many things that we have good intentions with covid butthey kind of boomerang on it and many people delayed their treatments thinking that itwas too dangerous to receive treatment, and now we see that there were manyadverse outcomes and people who really did need... get their treatments but because theyor we delayed their treatments for fear of covid cause new problems. So manythings come down to access. Do you have any kind of tips for us, as we see our patients daily, to help then access care and toencourage them to come in? And today's environment? You know, I youknow, I think we had gotten through a big hump until the last searchwith Delta, meaning that people were just getting comfortable coming back to clinic.There was a height and awareness about the negative repercussions of missing visits, missingroutine care, and then we kind of fell smacked up into it again withCovid Delta variant, which was high, much more transmissible, much more,you know, problematic in terms of preventing people getting it. So we kindof had to do the same thing all over again and it's been really youknow, I'm thinking about my life in the clinic, but also my lifeupstairs with our patients. They're, you know, lukemia patient typically will spenda month in the hospitals getting induction, chemotherapy and the devastation of not allowingfamily members to come in freely another really big issue. And you know,we had developed infection protocols and we've made sure a patient the visitors were,you know, properly screened and cleared. But with Adulta varium, we hadto kind of stop all over again and for a while there we eliminated allvisitors from the Medical Center. And now and we kind of, depending onthe surge and the numbers, we parse it out a little bit differently,but still very challenging to easily access family members who need their so, youknow, need the patients who need their families. Of the parts, absolutelyso maybe facilitating that in some other way. I pads facetime to provide that supportexactly, and those who are those are you know, I think peopleare becoming increasingly used to it. But again, if you think of mostof our cancer patients as being in their s or sometimes even older, andtheir facility with using an high pad or a smart phone is really limited andour nurses do a great job of helping them through that. But it isshocking to see how many people come in without a smart phone, without anIpad, you know, something that we all take for granted is not aseasily used and so that's still remains a huge career, unfortunately. So wewere just having so much about technology and it is really change how we thinkabout changing about treating cancer patients. So can you tell me a little bitmore about how do you think artificial intelligence, AI and genetic sequencing is shaping thefuture of cancer care? Ai Is a big topic and one that Iprobably can't give good answers to because it's not a part of my field,but it is moving forward and developing algorithms for care and developing patterns of outcomes. So really not so much artificial intelligence...

...but using big data to help ourpatients. So you know, when we do clinical trials we often have,particularly I'm involving some called the aids of malignancy consortia. Our trials may havefifty blood and most a hundred patients in clinical trial. But if you canharness big data from real world experiences, like through insurance data and the like, suddenly you have the information on millions of people at your disposal, andso learning to use that kind of data in a positive way. You know, we know that companies are using big data for marketing, but how wellwe could use it to improve outcome? So that's one big area and Ithink that's showed US gives us a lot of insight about what area codes don'tget free access to care. Remarkable presentation a year two about prostate cancer inChicago, you know, and Chicago has some of the toniest areas, kindof like your your area in Florida. There's some really beautiful areas that arevery well resourced to say the least, but they're areas of Chicago that aredevastated by poverty and outcomes of prostate cancer and African Americans in those communities isamong the worst, and in the world, not just in the united well,and so understanding where you live has a big difference in terms of howyou access care. What are the economics of your situation has a huge,huge implication to so harnessing that kind of big data, which is a littlebit different than artificial intelligence, yeah, is really, really important. Nowyou also mentioned a second thing that I don't remember. Oh yeah, soI was wondering about progress in genetic sequencing for cancer treatments. So that isa huge aread to and so the ability to do next generation sequence testing tumortissue or blood samples on has had a huge inputt huge potential for moving ourfields forward. So, for example, I do LOOKYMIA MOMPOMAS and we usenext generation sequencing to plan the treatments that we know have the highest likelihood ofworking based on twomor mutation patterns. And there's a whole area right now ofstudying blood. You know, it's kind of ironic because we have, Iforget the name of the woman who is on trial right now for claiming thatshe could do a hundred different tests. Oh, yes, most of thehomes you know. Yes, that's Elizabeth Holmes, made claims that she couldtake one drop of blood and, do you know, a hundred different tests, and wouldn't that be wonderful? And of course but be. But itwas a shell game. Yeah, but there are a lot of efforts trynow to take a sample blood and look for tumor sequences within the blood DNAcodes or complementary DNA, and that allows us potential for diagnosing or identifying recurrenceof cancer months before might show on an...

...x Ray, and so that's reallypowerful technology to so I don't do a lot of non humanologic cancers, onefor us or lung or coal with but those are all standard now for thosekind of cancers. To do next generation, generation, sequence testing and it provideshuge insights into providing non traditional forms of chemotherapy, not the typical citedtoxic chemo that causes hair less of nause e dominate, but typically targeted therapiesthat have much less risk of complications. Bio Technology has, I mean,to change the world of treatment, it sounds like, or slowly anyways,changing the world of treatment, you know, slowly, but now quickly. Soyou know, I think of so many of the cancers that I treatit when pomo would be example, my Lomo would be another, where wetreated it the same way for years, samp with colon cancer and prostate cancer. Now suddenly we have all kinds of different arcs of treatment which are completelydifferent, and so it's made it very dynamic and very much changing every sixmonths, two years. And you know, we used to add often, yeah, how to get one or two drugs a year from the FDA thatwere approved for use, and now we're getting several every month, you know, and so this field is churning very, very quickly and it is making abig impact on people who are living with cancer. So we've talked alot about all the different progress that we've made and we've also talked about theinequalities and the writing. Cost of care often comes up in my conversations.What do you think healthcare professionals can do to make a difference in this area, to make treatment and care more accessible? WOW, so they're probably a lotof things and I think that in terms of, you know, equityand diversity, those are things that are becoming very common words to use thesedays and it's going to be really important that these just don't become part ofa lexicon of discussions but rather have real bite to it. And I thinkthat more than just left service right exactly, and I think that a lot ofmedical centers are moving in this direction. I think they've slowly begun to appreciate, or it's been called out, the inherent biases that people have andthe way that we navigate patients through our clinics and what are the bearers thatwe put into getting care, and so those are, you tsue, hugeissues and, you know, I think the other area is the price ofcare, which is, you know, something we can all appreciate and it'sa catch twenty two and I was invited helped in a situation with one ofour retired physicians. So this is a woman who's worked for thirty five yearsas a primary tare provider and she developed one cancer and is suddenly she's lookingto get an experimental tray drug good had...

...been experimental but is just moving throughits FDA approval process and is now available. That drug costs a hundred and Thirtyzerodollars under oh my goodness, and you know she's hanging on to thatdrug. But who can pay a hundred and thirtyzero dollars a month for treatment? And that is really, unfortunately, incredibly common. So I mean,how do we get our healthcare equitable? How do we get it affordable?What are we doing? It's different than other countries and seem to get ita little bit better and particularly sensor enough metrics to say that, even thoughwe have availability of cutting edge treatments, the general health of our populations arenot as good as other countries, you know. And so again, verytop heavy in terms of high technology, but very low emphasis on getting patientsequal care, getting insurance plants that really cover the things that they need,breaking down prejudices on both sides about what medicines about and what it can doso maybe just discussions as a group to change ish that process. I thinkyou're partnering with politicians to I think I'm really going to be important and againI think this is the right time. It's kind of like the metal movement. It took a certain process to occur where people could band around it and, ironically, some of the good that's come out of Covid is kind ofshowing us how poorly we do many aspects of medical care and hey, maybethis is an opportunity of time to do things a little bit better, reimaginehow develop those processes. Okay, that makes sense. So now that wesee it on the news, there's no escaping the inequality and equity of ourhealthcare system, because it's I mean we see the numbers all the time,right and where we look at who who's been most affected by Covid, youknow it's been people of Color, people of low socioeconomic status, it's peoplewho live concentrated together and of course now we're seeing another level of misinformation,people who won't get vaccinated or refuse to be vaccinated or are not willing toget vaccinated. Right now, and ninety percent of our inpatients are filled withpeople who have not yet got in their covid vaccine. So again, thatlevel of misinformation of mistrust that's going on is really profound, unfortunately. Soyour blog is so full of insights on Covid, but I know that athealthcare professionals are usually really hesitate about putting their views on the web. Iknow that from my guests and also for my audience. So they're afraid toput their views out. They don't want to be, you know, misconshoedas representing the hell system that they work for. Do you have any tipsfor other healthcare professionals who, like you,...

...they want to express their views online, but they want to do it in kind of a safe way?What do you recommend? Yeah, I think first it is a challenge andyou know, I feel like I'm you know, I'm not a so Ithink that certain mediums can grow very quickly, like Youtube and twitter, and ifyou develop a huge population or a huge following, inevitably you're going tooffend some groups, or it's very hard not to, and I think thatthe best you can do is be careful not to speak infirmatory when you knowUS informatory terms, and if you do have frustrations, not to show themin that way. I think it's no different than when you're a physician andyou can be really frustrated with your patient. I told you not to smoke oryou needed this test, you don't, and that just the kind of browbeatinggets nowhere. Might not be the most effective approach actually, but youknow, we're getting, I think physicians in general now are getting pressured toeither provide scripts for things they may not believe in, and you know parasite, you know drugs that are used as anti parasitics for animals, oh,medical disabilities or medical exceptions for people who don't want to get back see andagain. That puts us in a very uncomfortable way and I think the sameway that you would navigate those very carefully and deliberately. Focusing on education andtrying to be consistent is helpful when you're communicating as well. You also haveto realize that you're not going to be able to convince everyone and the youknow, I don't necessarily go into trying to convince people of certain opinions.It's merely, you know, providing information that I think is accurate and explainingwhy certain medications may not work, why others are more useful. In thatcontext, it's no different than when we talk to a cancer patient and we'retalking about it, you know, a whole suite of different treatment options,whether it's, you know, a recreational drug that helps them cope with theiranxiety or the compression or the pain with their medication, or whether it's choosingthe best treatment. You know, and so it is a challenging time.I think that many people have been able to promulgate views that are not basedon reality. You know, and you're still enough data out there that saysthat physicians and people in Healthcare like nurses, are still very well respected and thepeople will listen to him. That said, if you have someone who'santi vaccine and, you know, gets their information from an alternative source thana reputable medical one, you have to realize that you can only provide theinformation, but if you start getting into debate or trying to fight it outor do get out, it's not going to work. I've seen many columnsor forums for people who are trying to get into social media. You know, these are the things you want to do, these are things you don'twant to do if you don't want to put too much personal information and personalopinion out there unless it's back by science.

And so I think that's a reallykey pack as well. Excellent. So maybe bring some of your bedsidemanner into the social media or the blogging space and make sure whatever opinion doyou have our big based on fact and not just opinions or exactly and andprovide references. You know, and who would give twitter? It makes sensefor them to say, Hey, there's this really great acticle in the newone journal, check this out. This is why it's important. You knowthat stuff is really useful. Or if there is an important announcement that's comingup, hey, the CDC just emphasize today that we should be getting flushots along with covid boosters. That's important information and that help gets that informationout there too, and so I think there's like this really important space ofgetting really important information out, hopefully not in a way that a we amatespeopling. Okay, so that seems like a relatively safe pace to start right, to take established trusted sources and just amplify on twitter or facebook or whateveryour preferred platform would be. quit and if there is something that's controversial,they'll say, Hey, this is why it's controversial and this is you know, these are some of the reasons to support this notion that it may behelpful in this content. Thanks. You know. I think one of thethings I saw, though, if that was really interesting, someone was talkingabout why he didn't trust the CDC, you know, and you know hemade the point that, you know, if the CDC had been more transparentearly in the covid and admitted the things that they weren't sure of rather thanprevent, you know, pronounce things as facts, that made a man.That might have made a big difference. You know, I think we allappreciate now that our trusted sources can be politicized as well, and so Idon't think it's so reasonable to be skeptical. I think some sit level of skepticismis good, but not to the point where it's to distraction and todiscount useful information coming from a variety of different and trusted sources. Understandable.It's a really good point. So you had done so much incredible work withmedical aid overseas, particularly in India with Ben Atara Foundation Cancer Center. Yes, and just this year you want an award for your leadership there. Congratulations. Thank you. Can you tell us more about that organization and how yougot involved and maybe how our audience could help? I would be happy to. And so this is one of the few areas where I think there's anda bit unambiguous good. So I that is that every medical center is askingfor money. Every medical centers asking for donations and you know a lot oftimes we get Johnice that's going to a new building that has, you know, really pretty paintings on the inside, but how does it really help ourpatients? And the Benate Tara Foundation is...

...a foundation that was created by Benat and Tara Shaw, who are from Nepal, and then as a medicaloncologist who works here in the Seattle area. His wife, Tara, is anurse and they wanted to give back to their community, which is inJona word, Nepal, and they've been working to create cancer gear in anarea that largely has not and I think it was back in Marsh of twothousand and twenty really right before covid was kind of hitting, or maybe itwas February before covid was hitting here, but it was pretty clear this aravaged. You know, Wouhan China. There was no way it was goingto be controlled. And I went with Ben at and Tara to John ofPorna Coal and looked at the work they did and I was just so blownaway with it. And so they've devoted their life to this mission of creatinga cancer center in Nepal and I think it's like one of these areas whereit's only good. There's no you know, I don't mean this glibly, there'sno corruption, there's no misspending of money. Is they're both reparkable peopleand with a foundation that started with two people just them, they're building acancer center doing amazing work. They are devoted to looking at healthcare disparities acrossthe board in cancer care, and Benay has been sponsoring a meeting on cancercare disparities for now several years. That meets here in Seattle and will behaving another one this coming March. So twenty twenty two, God willing,and assuming cold is not remains the problem that it is. But it wasan easy thing for me to get into and what's been to some amazing isthat so many people are getting into it all, Zoe and devoting their timeand their passion. They're on colleges from all over the world that are participatingin this effort. and Benay and tire are not content to just build ahospital in John of port. They created a journal looking at healthcare disparities andin cancer care. The maide an issue was just release and that is goingto be something. And they also do continuing medical education or CIME credits,and you know they're among the very biggest. So we have asked go and wehave ash and we have many other ways to get our cime credits,but Benat is kind of redoing that whole effort. And you know with cancercare. So we had has co updates, we had American society metalogy t updates. As I said, the cancer care disparities conferences the biggest in theUS and it has luminaries who've been in this field for decades, not justthe last year or two, in that too. So when I went thereit was like, you know, I don't really believe these guys and Idon't think I can imagine just couple doing so much work. And then whenI got there I was completely blown away.

And now I've seen as it's grownfrom like a seed of an idea to this really powerful grassroots group withso many people working on it. So that's been a pretty amazing experience forme. And that was the cancer care disparities come front to s yeah,wow, yeah, and we had one. They've had one for the last fiveyears, I think. Unfortunately, with the one in March of twothousand and twenty one had to be canceled because of code stand but you know, we'll have one on March of two thousand and twenty two and that willbe on Youtube for those who can travel. Oh, that sounds like a veryvaluable event. Don't want to miss it. Yes, that will besomething for everyone, for sure. Yes, if our viewers would like to getinvolved in help the Atara Foundation, how can they do so? Youknow, I think the easiest thing would be too simply google open night,Aura Bia Yta, a one word the entire foundation, okay, and thenthey can go to their website. They have, I think, on thewebsite of Theo also, which is really quite incredible. Then they, who'sa very persuasive person, had one of his nurses from Billingham Washington spend itvolunteer some time in joint poor and her son was in high school and camealong. He created a video which is just unbelievable, describing the vision andthe work and the efforts that they're doing. As it's definitely useful in it andthat's it. Some way someone can find it on Youtube as well,but I bet you it's on the on the BTF website, and it cangive a lot of information about the educational initiatives they're doing, the work they'redoing in John and poor the pal as well as the work here in theUnited States. Wonderful. What I can do is I can make put alink to that video in our show notes. All of our listeners and viewers willbe able to find that so very easily. That would be great underful. So, as we wrap up, are there any words of wisdom orinspiration that you'd like to share with our audience, who that's a tough ofyouth? So a couple things. I mean, my Gosh, we're stillin the middle of Covid you know we're moving well into our you know yournumber three so of this whole thing and just incredible. But I think Iwould be optimistic about a few things. I think that tell a health ishere and hopefully here to stay, and as we look to bridge, youknow, gaps where with help people access care and think about people in ruralareas, people who can't travel easily in cities, people who are bent boundor house bout, what a great thing they have to tell a health available. And hopefully this will become something that we don't let go of once covidis in the rear view mirror, but it becomes something that we utilize.And then I think that, you know,...

...for our patients care, we reallyneed to stay vigilant. May, particularly in the field of oncology,were so much as we were about how our treatments impact immunizations and schedules ofimmunizations. What are the implications for doing treatment that's necessary? What are thebarriers that we have in place now which could be improved? All things thatare kind of like on the forefront of cutting edge care now that we're notthere two years ago. So I think that be something I'd be really superencouraged. And you know, technology doesn't solve all of our problems and sothere's going to be a lot of human, human effort to but it is encouragingto see New Forms of Technology being leveraged at a time when we reallyneed so. There is some help, absolutely, Dr Evelof yet this hasbeen a really great conversation. For any of our used or listeners who wantto reach out with a follow up question, or do you just want to reachout to you, what's the best way for them to do that?I think they could email me. That's probably the easiest. Okay, Ican put it a link in our show notes. That would be great.And then if anyone's interested in looking at the COVID cogitations, usually I'll putit out once a month and then it'll be pretty much a summary of themonths events. But it's, you know, it's general and it's educational, butit's not meant to be preachy. You know, will be areas wherethere's strong opinions given, but it's counterbalanced by the articles that it's referencing.There's kind of a wide variety of stuff, for cancer, for Ev and forjust general absolutely I am a subscriber to your blog and it is veryapproachable and I appreciate it. Thank you so much, please. Ye,and it's I'm great to talk to and connect in this way and I'll belooking forward to watching your program from an now on as well. Awesome.Thank you again for your insights, so we really appreciate you being a guest. Thanks for inviting me, and all the best. Two of viewers,this one you've been listening to working in oncology. To ensure that you nevermiss an episode, subscribe to the show in your favorite podcast player. Ifyou're listening in Apple PODCASTS, we'd love for you to leave a quick ratingof the show. Just have the number of stars do you think the podcastdeserves. Thank you so much for listening. Until next time,.

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