Working In Oncology
Working In Oncology

Episode · 1 year 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 work behind the scenes to shape the future of oncology. The more knowledge the oncology community shares with each other, the more we all grow. Let's get into the show. Welcome to working in oncology. I am your cohost today, Alicia Evans, and I'm joined by Dr David Lafia. I really see nice to meet you. Nice to meet you, Dr of Lafia. Welcome to the show. I've been really looking forward to our conversation, so I've been following your blog and I think that you provide so many valuable updates on covid and I'm eager to hear your insights on how the pandemic has effected you and your 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, your background and what you do? Yeah, my pleasure, Lisa. I'm a hematologists on cologists up in Seattle and I've been in practice for about thirty years now, and my practice is a little bit unique. It's a hybrid in so much as about half the patience I see have HIV or AIDS and are living with HIV. So I've had a long background with viral infections and the suppression and of course the other half of my clinic is devoted to cancer care and 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 and for the HIV folks I do primary and subspecialty care and for a lot of our cancer patients we end up being their primary providers to but my initial work when I was a fellow at Youcla was in viral infection. So a virus which was the original thought to be vicrus of HIV was a virus called htlv one, and that was originally thought to be the virus that causes and you know, suppression, and it was subsequently learned that now we had a different virus, the HIV virus. But my research was in both Htov one and HIV, and so I've had a long interest in, I mean a suppression Viral Infections and, of course cancer care and how the treatments we give can further amnut of suppressed patients and the consequences of that. Well, that's really interesting. But if we could take a little step back, what initially motivated you to become a doctor? You know, my father was a vascular surgeon and when we were kids, at my brother and I would, believe it or not, we would scrub into CASS with my day. We would just be watching, but we had a kind of an early introduction question really when we were probably five, six, seven,...

...eight years old. Wow, and so I think that connection to medicine was really begun when we were kids and we later used to work in this office and we would go down rounds with 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 have gone into them third basement for the Detroit Tigers. So I guess some doctors are 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, and so I think it's kind of a family legacy. There are a lot of us who are physician wow, wow, that's it was your destiny pay because that so. You mentioned that your early work centered around HIV AIDS treatment and then you transition, it sounds like, more tohematology oncology. It was a you know, we're back in the S. UCLA was a big hub for HIV research and so only fifty percent of people living with HIV or with advanced as were destined to develop cancers in those days. So probably about thirty percent developed Katasistar Comma and unusual skin cancer. Another twenty percent develop confonas, and so it was kind of a natural full back in those days for Hemo physitions to take primary care or primary responsibility for them, for those who had HIV and cancer. And it was really only when antiretrovitals became available and therapeutic that infectious disease physicians kind of took up the mant home started caring for them and bigger. But so many of those patients were sick and debilitated. Often they would move to hospice and it was the Hemov gods who had the most experience with them. So it was kind of a natural subset of what I was doing as a fellow and later as intending. Okay, that makes so much sense and that's a lot of I didn't realize that about the history of htch treatment. 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 you to start the blog and like, what were your goals out, what messages you want to send with that? Yeah, I think originally I was incredibly frustrated with level of misinformation that was going on and in so many ways it was reminiscent of the early era of HIV infection. To how was the virus spread, who was affective of what were the prejudices that were coming out in really full force, and it was just... reminiscent on a superficial level. Now it turns out that there are a lot of differences between them, but in that early phase, when it was being referred to as the China virus and there were a lot of other negative stereotypes going on with it, it was very reminiscent of what people living with HIV were going through in their day too, and so it's hard to imagine now, but when HIV became a thing back in the late s and early S, Ronald Reagan refused to use that word AIDS in any public address and there was a lot of paranoia also about how do people get HIV, where did it come from? How would people 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 on struck me as very similar, or that there was a lot of overlap during those first six months when covid became a big deal, first in China, that Europe and then in the United States. I understandabile. So you you have been on the front lines of an anti misinformation and it pass and you just thought opportunity to combat that the second time exactly, and you know it's kind of ironically show. Originally I was sending it out to just physicians in my medical center and typically it would be cut in pace on an email of like a new y times article or a Seattle Times or Washington Post article and 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. Why don't you start a blog? And at the time it was like what's a blog? But I have a younger son who is into digital arts and has a degree in digital arts, and so, between my older son encouragement and my younger son's willingness to help, started doing it as a blog and in that context started sending it. Once it became a blog not just for people in my medical center, physicians, but really for patients and particularly with a focus on general information, but subset information for Covid and cancer and Covid in HIV. So if you could provides an insight. So how do you feel covid has effected Cancer Care? You know there's been so much written about it and you know the research is just coming out, but I think in the beginning, I think all of us were a bit shock, like we're our patients, what's going on? And you know the New York Times referred to it as this eerie silence in emergency rooms, like how come no one is having heart attacks? During the early days at Covid, you know, and of course we realized that people were having their heart attacks and the strokes just as 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 the United States, now we really understand it's probably quite a bit more than that and a lot of people died either directly...

...from covid and the fear of coming to emergency rooms or died from strokes that could have been prevented or could have been treated but didn't come quickly enough to the emergency room. So the spillover effect came with our cancer patients too, as they became reluctant to come into clinic, and it also was compounded by our own concerns about I mean of suppressing those patients, not knowing what the effect of our treatments might have on their risk of covid. And of course there were a huge number of patients who 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 at getting their coal and Oscaries, people who aren't coming in for their well physical exams, were cancer is sometimes picked up. So it had all of these kind of downstream effects, and so that was one huge area which affected US enormously. 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 and in terms of Covid, in terms of not having those patients come directly to the clinic but, when possible, do these meetings by video. And I said, you're kind of helping them to bridge gapputs some telehealth. Yeah, but it, you know, just as we've seen so many, many disparities magnified 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 use their computers? You know, who are the people that were really connecting to in these video visits? So it's heightened disparities on a lot of levels to even though it's maybe has potential for leveling the playing, you know, the playground in certain areas as well. And a Polish I think a really big area is that. You know, the effect of you know, we're now finding, you know, what is the effect of our chemotherapy, and our I meanough therapies, on the covid vaccinations themselves, and one of the things we've realized is that a lot of cancer patients who've gotten their two, were there 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 so many levels. It's almost like this huge pie of like from people not wanting to 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 with them by video. What are the pluses? And then is that and followed through to what are the effects of our tree with you know, we've done it both ways. We've tried to limit treatments during covid and that's had a boomerang effect to so many things that we have good intentions with covid but they kind of boomerang on it and many people delayed their treatments thinking that it was too dangerous to receive treatment, and now we see that there were many adverse outcomes and people who really did need... get their treatments but because they or we delayed their treatments for fear of covid cause new problems. So many things 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 to encourage them to come in? And today's environment? You know, I you know, I think we had gotten through a big hump until the last search with 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, missing routine care, and then we kind of fell smacked up into it again with Covid Delta variant, which was high, much more transmissible, much more, you know, problematic in terms of preventing people getting it. So we kind of had to do the same thing all over again and it's been really you know, I'm thinking about my life in the clinic, but also my life upstairs with our patients. They're, you know, lukemia patient typically will spend a month in the hospitals getting induction, chemotherapy and the devastation of not allowing family 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 had to kind of stop all over again and for a while there we eliminated all visitors from the Medical Center. And now and we kind of, depending on the 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, you know, need the patients who need their families. Of the parts, absolutely so maybe facilitating that in some other way. I pads facetime to provide that support exactly, and those who are those are you know, I think people are becoming increasingly used to it. But again, if you think of most of our cancer patients as being in their s or sometimes even older, and their facility with using an high pad or a smart phone is really limited and our nurses do a great job of helping them through that. But it is shocking to see how many people come in without a smart phone, without an Ipad, you know, something that we all take for granted is not as easily used and so that's still remains a huge career, unfortunately. So we were just having so much about technology and it is really change how we think about changing about treating cancer patients. So can you tell me a little bit more about how do you think artificial intelligence, AI and genetic sequencing is shaping the future of cancer care? Ai Is a big topic and one that I probably 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 our patients. 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 have fifty blood and most a hundred patients in clinical trial. But if you can harness 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, and so 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 well we could use it to improve outcome? So that's one big area and I think that's showed US gives us a lot of insight about what area codes don't get free access to care. Remarkable presentation a year two about prostate cancer in Chicago, you know, and Chicago has some of the toniest areas, kind of like your your area in Florida. There's some really beautiful areas that are very well resourced to say the least, but they're areas of Chicago that are devastated by poverty and outcomes of prostate cancer and African Americans in those communities is among 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 how you 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 little bit different than artificial intelligence, yeah, is really, really important. Now you also mentioned a second thing that I don't remember. Oh yeah, so I was wondering about progress in genetic sequencing for cancer treatments. So that is a huge aread to and so the ability to do next generation sequence testing tumor tissue or blood samples on has had a huge inputt huge potential for moving our fields forward. So, for example, I do LOOKYMIA MOMPOMAS and we use next generation sequencing to plan the treatments that we know have the highest likelihood of working based on twomor mutation patterns. And there's a whole area right now of studying blood. You know, it's kind of ironic because we have, I forget the name of the woman who is on trial right now for claiming that she could do a hundred different tests. Oh, yes, most of the homes you know. Yes, that's Elizabeth Holmes, made claims that she could take one drop of blood and, do you know, a hundred different tests, and wouldn't that be wonderful? And of course but be. But it was a shell game. Yeah, but there are a lot of efforts try now to take a sample blood and look for tumor sequences within the blood DNA codes or complementary DNA, and that allows us potential for diagnosing or identifying recurrence of cancer months before might show on an...

...x Ray, and so that's really powerful technology to so I don't do a lot of non humanologic cancers, one for us or lung or coal with but those are all standard now for those kind of cancers. To do next generation, generation, sequence testing and it provides huge insights into providing non traditional forms of chemotherapy, not the typical cited toxic chemo that causes hair less of nause e dominate, but typically targeted therapies that 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. So you know, I think of so many of the cancers that I treat it when pomo would be example, my Lomo would be another, where we treated 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 completely different, and so it's made it very dynamic and very much changing every six months, two years. And you know, we used to add often, yeah, how to get one or two drugs a year from the FDA that were 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 a big impact on people who are living with cancer. So we've talked a lot about all the different progress that we've made and we've also talked about the inequalities 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 lot of things and I think that in terms of, you know, equity and diversity, those are things that are becoming very common words to use these days and it's going to be really important that these just don't become part of a lexicon of discussions but rather have real bite to it. And I think that more than just left service right exactly, and I think that a lot of medical 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 and the way that we navigate patients through our clinics and what are the bearers that we put into getting care, and so those are, you tsue, huge issues and, you know, I think the other area is the price of care, which is, you know, something we can all appreciate and it's a catch twenty two and I was invited helped in a situation with one of our retired physicians. So this is a woman who's worked for thirty five years as a primary tare provider and she developed one cancer and is suddenly she's looking to get an experimental tray drug good had...

...been experimental but is just moving through its FDA approval process and is now available. That drug costs a hundred and Thirtyzero dollars under oh my goodness, and you know she's hanging on to that drug. 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 it a little bit better and particularly sensor enough metrics to say that, even though we have availability of cutting edge treatments, the general health of our populations are not as good as other countries, you know. And so again, very top heavy in terms of high technology, but very low emphasis on getting patients equal 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 do so maybe just discussions as a group to change ish that process. I think you're partnering with politicians to I think I'm really going to be important and again I 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 of showing us how poorly we do many aspects of medical care and hey, maybe this is an opportunity of time to do things a little bit better, reimagine how develop those processes. Okay, that makes sense. So now that we see it on the news, there's no escaping the inequality and equity of our healthcare 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, you know it's been people of Color, people of low socioeconomic status, it's people who 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 to get vaccinated. Right now, and ninety percent of our inpatients are filled with people who have not yet got in their covid vaccine. So again, that level of misinformation of mistrust that's going on is really profound, unfortunately. So your blog is so full of insights on Covid, but I know that at healthcare professionals are usually really hesitate about putting their views on the web. I know that from my guests and also for my audience. So they're afraid to put their views out. They don't want to be, you know, misconshoed as representing the hell system that they work for. Do you have any tips for 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 and you know, I feel like I'm you know, I'm not a so I think that certain mediums can grow very quickly, like Youtube and twitter, and if you develop a huge population or a huge following, inevitably you're going to offend some groups, or it's very hard not to, and I think that the best you can do is be careful not to speak infirmatory when you know US informatory terms, and if you do have frustrations, not to show them in that way. I think it's no different than when you're a physician and you can be really frustrated with your patient. I told you not to smoke or you needed this test, you don't, and that just the kind of browbeating gets nowhere. Might not be the most effective approach actually, but you know, we're getting, I think physicians in general now are getting pressured to either 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 and again. That puts us in a very uncomfortable way and I think the same way that you would navigate those very carefully and deliberately. Focusing on education and trying to be consistent is helpful when you're communicating as well. You also have to realize that you're not going to be able to convince everyone and the you know, 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 explaining why certain medications may not work, why others are more useful. In that context, it's no different than when we talk to a cancer patient and we're talking about it, you know, a whole suite of different treatment options, whether it's, you know, a recreational drug that helps them cope with their anxiety or the compression or the pain with their medication, or whether it's choosing the 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 based on reality. You know, and you're still enough data out there that says that physicians and people in Healthcare like nurses, are still very well respected and the people will listen to him. That said, if you have someone who's anti vaccine and, you know, gets their information from an alternative source than a reputable medical one, you have to realize that you can only provide the information, but if you start getting into debate or trying to fight it out or do get out, it's not going to work. I've seen many columns or 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't want to do if you don't want to put too much personal information and personal opinion out there unless it's back by science.

And so I think that's a really key pack as well. Excellent. So maybe bring some of your bedside manner into the social media or the blogging space and make sure whatever opinion do you have our big based on fact and not just opinions or exactly and and provide references. You know, and who would give twitter? It makes sense for them to say, Hey, there's this really great acticle in the new one journal, check this out. This is why it's important. You know that stuff is really useful. Or if there is an important announcement that's coming up, hey, the CDC just emphasize today that we should be getting flu shots along with covid boosters. That's important information and that help gets that information out there too, and so I think there's like this really important space of getting really important information out, hopefully not in a way that a we amates peopling. 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 whatever your 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 be helpful in this content. Thanks. You know. I think one of the things I saw, though, if that was really interesting, someone was talking about why he didn't trust the CDC, you know, and you know he made the point that, you know, if the CDC had been more transparent early in the covid and admitted the things that they weren't sure of rather than prevent, you know, pronounce things as facts, that made a man. That might have made a big difference. You know, I think we all appreciate now that our trusted sources can be politicized as well, and so I don't think it's so reasonable to be skeptical. I think some sit level of skepticism is good, but not to the point where it's to distraction and to discount 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 with medical 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 you got 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 and a bit unambiguous good. So I that is that every medical center is asking for money. Every medical centers asking for donations and you know a lot of times 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 our patients? And the Benate Tara Foundation is...

...a foundation that was created by Ben at and Tara Shaw, who are from Nepal, and then as a medical oncologist who works here in the Seattle area. His wife, Tara, is a nurse and they wanted to give back to their community, which is in Jona word, Nepal, and they've been working to create cancer gear in an area that largely has not and I think it was back in Marsh of two thousand and twenty really right before covid was kind of hitting, or maybe it was February before covid was hitting here, but it was pretty clear this a ravaged. You know, Wouhan China. There was no way it was going to be controlled. And I went with Ben at and Tara to John of Porna Coal and looked at the work they did and I was just so blown away with it. And so they've devoted their life to this mission of creating a cancer center in Nepal and I think it's like one of these areas where it's only good. There's no you know, I don't mean this glibly, there's no corruption, there's no misspending of money. Is they're both reparkable people and with a foundation that started with two people just them, they're building a cancer center doing amazing work. They are devoted to looking at healthcare disparities across the board in cancer care, and Benay has been sponsoring a meeting on cancer care disparities for now several years. That meets here in Seattle and will be having another one this coming March. So twenty twenty two, God willing, and assuming cold is not remains the problem that it is. But it was an easy thing for me to get into and what's been to some amazing is that so many people are getting into it all, Zoe and devoting their time and their passion. They're on colleges from all over the world that are participating in this effort. and Benay and tire are not content to just build a hospital in John of port. They created a journal looking at healthcare disparities and in cancer care. The maide an issue was just release and that is going to 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 we have 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 cancer care. So we had has co updates, we had American society metalogy t updates. As I said, the cancer care disparities conferences the biggest in the US and it has luminaries who've been in this field for decades, not just the last year or two, in that too. So when I went there it was like, you know, I don't really believe these guys and I don't think I can imagine just couple doing so much work. And then when I got there I was completely blown away.

And now I've seen as it's grown from like a seed of an idea to this really powerful grassroots group with so many people working on it. So that's been a pretty amazing experience for me. 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 five years, I think. Unfortunately, with the one in March of two thousand 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 will be on Youtube for those who can travel. Oh, that sounds like a very valuable event. Don't want to miss it. Yes, that will be something for everyone, for sure. Yes, if our viewers would like to get involved in help the Atara Foundation, how can they do so? You know, I think the easiest thing would be too simply google open night, Aura Bia Yta, a one word the entire foundation, okay, and then they can go to their website. They have, I think, on the website of Theo also, which is really quite incredible. Then they, who's a very persuasive person, had one of his nurses from Billingham Washington spend it volunteer some time in joint poor and her son was in high school and came along. He created a video which is just unbelievable, describing the vision and the work and the efforts that they're doing. As it's definitely useful in it and that'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 can give a lot of information about the educational initiatives they're doing, the work they're doing in John and poor the pal as well as the work here in the United States. Wonderful. What I can do is I can make put a link to that video in our show notes. All of our listeners and viewers will be able to find that so very easily. That would be great underful. So, as we wrap up, are there any words of wisdom or inspiration that you'd like to share with our audience, who that's a tough of youth? So a couple things. I mean, my Gosh, we're still in the middle of Covid you know we're moving well into our you know your number three so of this whole thing and just incredible. But I think I would be optimistic about a few things. I think that tell a health is here and hopefully here to stay, and as we look to bridge, you know, gaps where with help people access care and think about people in rural areas, people who can't travel easily in cities, people who are bent bound or 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 covid is in the rear view mirror, but it becomes something that we utilize. And then I think that, you know,...

...for our patients care, we really need to stay vigilant. May, particularly in the field of oncology, were so much as we were about how our treatments impact immunizations and schedules of immunizations. What are the implications for doing treatment that's necessary? What are the barriers that we have in place now which could be improved? All things that are kind of like on the forefront of cutting edge care now that we're not there two years ago. So I think that be something I'd be really super encouraged. And you know, technology doesn't solve all of our problems and so there's going to be a lot of human, human effort to but it is encouraging to see New Forms of Technology being leveraged at a time when we really need so. There is some help, absolutely, Dr Evelof yet this has been a really great conversation. For any of our used or listeners who want to reach out with a follow up question, or do you just want to reach out to you, what's the best way for them to do that? I think they could email me. That's probably the easiest. Okay, I can 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 put it out once a month and then it'll be pretty much a summary of the months events. But it's, you know, it's general and it's educational, but it's not meant to be preachy. You know, will be areas where there'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 for just general absolutely I am a subscriber to your blog and it is very approachable 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 be looking 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 never miss an episode, subscribe to the show in your favorite podcast player. If you're listening in Apple PODCASTS, we'd love for you to leave a quick rating of the show. Just have the number of stars do you think the podcast deserves. Thank you so much for listening. Until next time,.

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