Exercise And Eat Well: How Doctors Dole Out Advice
NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan, in Washington. We know the facts: More than one-third of U.S. adults and nearly one-fifth of American children are obese. Our doctors have the unhappy task to tell us to eat less, drink less and get more exercise, or else. But sometimes that conversation doesn't happen, and when it does, it's often not very productive.
While one Massachusetts doctor recently decided to stop taking patients who weigh over 200 pounds, most practitioners do see a role for themselves in the fight against obesity. What can they say or do to best help patients who are overweight or obese?
So patients, we want to hear from you. What does your doctor tell you about your lifestyle? 800-989-8255 is the phone number. Email: email@example.com. You can also join the conversation on our website at npr.org. Later in the program: God, Jerusalem and the Democratic Party platform.
But first, Dr. Ranit Mishori, a family physician who practices here in Washington. She's also assistant professor in the Department of Family Medicine at Georgetown University School of Medicine. She happens to be in Minneapolis today, and joins us by smartphone. Dr. Mishori, nice to have you on TALK OF THE NATION.
DR. RANIT MISHORI: Hi. Thanks for having me.
CONAN: And you live this every day in your practice. What's the biggest barrier to an effective conversation with an obese patient?
MISHORI: I think there are many barriers. I would say the most - the biggest barrier for me personally would be time. Patients come in for 15 minutes, for 20 minutes, and you try to cram in a lot of information and a lot of other issues, and having a conversation about how to lose weight, how to exercise, it's not something that you can do in five minutes.
CONAN: No, it's not. It's also that some people are very sensitive about this.
MISHORI: Exactly. You have to assess each patient and how ready they are. Some patients are not at all ready to have a conversation. Some patients are not ready to have their weight even be taken at the beginning of the appointment. So you can't just say to everybody, well, lose weight, go exercise, goodbye. I'll see you in three months. You have to assess how ready they are, whether they have the resources to even try to make these changes in their lifestyle.
CONAN: So are there things you don't say?
MISHORI: Well, it depends. I think - I usually don't - I try to assess whether they are ready to make any changes first. I don't just say lose weight. I try to see if they even perceive it as a problem. So I might say, listen, your blood pressure today is such-and-such. Your weight is such-and-such. Your BMI is such-and-such. Do you think it's a problem? Is this something that you feel that you need to change?
And sometimes they say no. I'm actually happy with how I am, how I look, how I feel. I don't want to change it. So we can't impose our measures on everybody. If they're not ready to change, if they don't perceive it as an issue, there's no point in me harping on the topic and trying to make them change something that they don't even perceive as needing any change.
CONAN: You mentioned BMI, body mass index. That's a term and a number that still most people are pretty uncomfortable with.
MISHORI: Exactly. I mean, BMI or body mass index is not the most accurate measure of obesity or overweight. Some other issues can also come into play. But that's what we have right now, and that's what we need to look at, and it's the best that we have. Some people and some physicians' offices, we don't even calculate it. And I think the emergence of electronic medical records has helped a lot, because it kind of flashes it right there at you. And even if you don't - if you want to avoid it, it's right there, and it tells you that you need to address this issue with the patient.
One important thing to consider is there's no one-size-fits-all conversation. And I see patients in two - the two parts of D.C., I have a very affluent patient population, and I have a poor patient population. This - I cannot have the same conversation with affluent patients as I do with poor patients, because even if I - I'm sorry?
CONAN: I was just going to say how come, but you're about to tell me. So go ahead.
MISHORI: Yes. So let's say a patient is ready to exercise. So somebody from the affluent part of town, I might say, well, let's work on three times a week for 40 minutes. And they'll go out there, and they'll maybe hire a personal trainer or buy a gym membership.
A person who is poor, and maybe it's a woman who works two jobs and has three kids at home and lives in an unsafe neighborhood, she cannot go out and run in her neighborhood. She cannot afford to hire a personal trainer. She cannot buy a gym membership. She may not even have the time, because she works two jobs.
So the conversations differ depending on the population that you belong to, where you live and what resources you have at your...
CONAN: At your disposal.
MISHORI: ...in your area, at your disposal, yes.
CONAN: We want to get listeners involved in the conversation. What does your doctor tell you about your weight, your diet, exercise? 800-989-8255. Email: firstname.lastname@example.org. And we're going to start with Ruth, and Ruth is with us from Bountiful, Utah.
RUTH: Hi, you guys. I'm about 15 to 20 pounds over, which some people might not think is really over, but I have extremely high blood pressure. And my doctor's been working with this, and he's also a good friend. And he'll pull out these pamphlets and hand them to me, and we started with that.
And now I'm just so afraid to go back, I won't even go in to have my blood pressure checked, because I know that it's high. I take it at the store. And I can't seem to lose that, and I'm embarrassed. So I'll bump the appointment, and then the day before I'm supposed to go again, I'll bump it three more months. I'll go as long as I can before he absolutely won't refill my meds because I don't want him to know that I'm not compliant. And it's just frustrating.
And a few times ago, he got so upset, and this is a good friend. He said: Well, you're just committing suicide slowly. I guess that's just going to be your life choice. And I'm not morbidly obese, I'm about 165, but he says that that amount is causing so many more complications on this genetic blood pressure problem that...
CONAN: It doesn't sound like chastising you is working, though.
RUTH: No, and I really like the guy, and he's always been compassionate and helpful. He helped diagnose my cancer when I had it. But now this is the friendly thing. I'm too embarrassed to fail him when I go in, because he is such a good doctor that I'll just cancel the appointments. I just don't want to face it. I just - and I'll be really good for a week or so after the appointment, and he gives me these diets, and then I think oh, what the heck. It's high, it's high. So what? I'll eat potato chips or some stupid thing and just - I'll just eat the wrong things. It's really not a very fun life eating that healthy stuff every day. It's really not.
CONAN: Well, the alternative is not too happy, either.
RUTH: No, and I'm a widow, and my husband's gone. So I figure what's so great between 80 and 100? Absolutely nothing. So, you know, if I cut 20 years off, he said, yeah, you won't have very fun when you're laying there having a stroke, will you, those last years? And it won't be fun when you're 60, either. He'll scare me with the stroke thing.
And then he'll say let's put you on the treadmill just so I can show you what your heart's doing. And I think I don't want to get on your treadmill, every little jiggle is going to show. You know, I mean, he's trying, and I know he means well, but I don't know. It's very difficult.
CONAN: Well, good luck to you. We wish you and your doctor good luck, and keep working on it.
RUTH: I hope he's not listening to this, because I have my appointment coming up, and he's going to know exactly who this is.
MISHORI: Well, Neal, I can tell you that this is not unusual, and I see people who are embarrassed about this all the time and every day. And I think the key is - as the caller was mentioning, admonishing the patient is not going to get you anywhere. You have to work with the patient. So many - maybe sometimes just setting the right expectations.
Maybe we're not talking about, OK, you have to lose 20 percent of your body weight. Maybe the conversation should be changed to let's forget weight loss right now. Let's just work on exercising.
So choosing the right framing of what success is is a really important component of what we try to do when we see patients, as opposed to admonishing them and making them feel embarrassed and as if they'd failed us and themselves, and that happens every day.
CONAN: Ruth, we wish you...
RUTH: Well, I do walk about five to six miles every day. I speed-walk. And that makes me starving, OK. It just makes me more hungry. So, counterproductive.
CONAN: Well, good luck, though. The exercise is important, too, but good luck.
RUTH: It's not working. OK, thanks.
CONAN: Joining us now is Sara Bleich, who's an assistant professor of health policy at the Bloomberg School of Public Health at Johns Hopkins University. It's not only the patient's weight that can make these conversations awkward. The doctor's weight can be an issue, too. And Sara, nice to have you with us on TALK OF THE NATION.
SARA BLEICH: Thank you for having me.
CONAN: And you compared physicians with normal body mass indexes to overweight and obese physicians. What were the differences?
BLEICH: That's exactly right. So we compared normal-weight physicians, who have a body mass index - which is your weight in kilograms over your height in meters squared - below 25 to those with a BMI above 25. And the punch line from the study was that a physician's weight, or their BMI, appears to impact obesity care.
So if you're a normal-weight doctor, you're more likely to provide recommended obesity care and feel comfortable doing so, as compared to an overweight or obese physician.
CONAN: And it's interesting, the study also found different beliefs.
BLEICH: That's exactly right. So if you are a normal-weight - if you're a normal-BMI physician, you are more likely to engage your patients in weight-loss discussions. You have more confidence in providing diet and exercise counseling. You were more likely to believe that physicians should model healthy weight-related behaviors and more likely to believe that your weight-loss advice would be trustworthy.
CONAN: And were you surprised by this?
BLEICH: I was very surprised. So, you know, the background to this is we had done a bunch of work where we had looked at, you know, why is it that obese patients are not getting good care when they go to the doctor. And I was at the dentist one day, and I'm looking at my dentist, and he's got terrible teeth.
And I'm thinking to myself: How can you care for my teeth if you can't care for your own teeth? And so I started thinking about this issue as related to weight, and I thought, well, could it be that a physician's body weight has an impact on how they care for their patients?
And so I thought that there might be some effect of physician BMI and how they care for their patients. I did not expect the effect to be as large as we found.
CONAN: Doesn't it make a degree of sense that a doctor who's overweight or obese might have a problem making this argument to patients?
BLEICH: It makes perfect sense. So I think from both a personal respect, the physicians themselves who are overweight or obese could be embarrassed to be giving advice to patients. And I think also, you know, statistically speaking, 60 percent of the population is overweight or obese, and about half of doctors are overweight or obese.
So if a heavy patient walks into a doctor's office and that patient looks like the doctor, the doctor may not see them as actually having a weight problem, and so they may not actually be diagnosing it. And as we heard from the doctor earlier on the phone call, a lot of patients' charts don't actually have BMI or body mass index included, so it may not be a red flag to doctors to say this particular patient has a weight problem.
CONAN: Thanks very much for being with us today, very interesting.
BLEICH: Thank you for having me.
CONAN: Sara Bleich, an assistant professor at the Bloomberg School of Public Health at Johns Hopkins, lead author of a study titled "Impact of Physician BMI on Obesity Care and Beliefs," published this year in the journal Obesity.
We're talking about doctors and the conversations they have or don't have with their patients about weight, exercise, smoking and other lifestyle issues. Patients: What does your doctor say to you about your lifestyle? 800-989-8255. Email us: email@example.com. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION, from NPR News.
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CONAN: This is TALK OF THE NATION, from NPR News. I'm Neal Conan. In June, U.S. Preventive Services Task Force recommended that doctors screen all adult patients for obesity. And as Kaiser Health News reported at the time, those found to be obese should be offered at least 12 weeks of intensive counseling about lifestyle changes.
That's not an always easy - always an easy conversation to have, whether you're the doctor or the patient. So we want to hear from patients today. What does your doctor say to you about your lifestyle? 800-989-8255. Email us: firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org.
Our guest is Dr. Ranit Mishori, a family physician who practices here in Washington. She also serves as an associate professor in the Department of Family Medicine at Georgetown University School of Medicine. And we got this tweet from user47: I'm morbidly obese. I know this because WebMD says so. My doctor has never once said anything about it. Our system is clearly broken.
And Dr. Mishori, are doctors trained to have this conversation? Isn't this vital?
MISHORI: Well, I could count on one hand the number of hours during my medical education - both in medical school and residency - that were specifically focused on how to talk to patients about behavior change. There are different approaches out there to help patients with behavior change, but they need to be taught and they need to be practiced. And we don't really do a very good job in teaching our learners, our students, our future doctors, how to do that. I didn't learn how to do that until I decided that I needed to teach others.
So once you learn some of the skills, some of the tools that are out there, it takes a long time to practice them. And then, you know, there are those of us who never - are never exposed to these tools.
So, you know, so in addition to not having enough time to do it, and if you don't know how to do it, there is no incentive to even try to talk to the patient about it.
CONAN: As we've heard, many doctors say they don't have the time or the tools, as just mentioned, to really help their patients with these lifestyle changes. Eileen O'Grady is a certified nurse practitioner who, after 20 years in primary care, wanted to find a better way to talk to patients, and she joins us here in Studio 3A. Nice to have you with us.
EILEEN O'GRADY: Thanks, Neal.
CONAN: And I know you spent 20 years in traditional primary care practice. You've been listening as the conversation's gone on. These complications must sound awfully familiar.
O'GRADY: Yes. And my experience was handing out fistfuls of prescriptions and really nobody getting well or whole, nobody really losing weight or quitting smoking. I didn't have any effective tools. And when your only tool is a hammer, you treat everything the same.
And so I was trying to find a community of people who felt the same way I did. How can we actually get people well? And so I discovered the coaching world, and it all stems from human resources and the science of motivation, how to get people to move forward.
And it's not education. What I learned in my traditional nurse practitioner programs was patient education, and that's hugely important, but that's all that's needed. It's something different. It's moving people forward, motivating them to make some very deep decisions.
CONAN: So - and it's more than just a fragment of the eight to 15 minutes a doctor or a nurse practitioner can spend with a patient.
O'GRADY: Yes. But it's also a skill set that could be done very quickly. And I think the caller - you know, it was heartbreaking to hear Ruth describing, you know, being shamed. And what that physician is doing is moving her deeper into resistance instead of working with her and asking her what she wants and why is she overweight, I mean, those fundamental questions, what's getting in the way, what are her obstacles and really getting underneath them.
It's not a long conversation. Most people can tell you in two sentences why they're overweight.
CONAN: In two sentences?
O'GRADY: Yes. Oftentimes they're nighttime binging, or they're eating to emotions. And so that's the solution. And if we're eating for any reason other than physiological hunger, we'll never be thin.
CONAN: And it's interesting: You do your counseling on the phone.
O'GRADY: Yes, coaching. My practice is all over the country. I coach only over the phone. And studies have shown that people are more candid when there's no eye contact, and they'll start being more honest and tell you what's really in the way when there's no eye contact. And so that moves people forward. It's the beginning of the change process.
CONAN: And how do you measure success?
O'GRADY: By excavating their goals and what they want and them attaining them. So we start with baby goals, small steps. And I have a patient, a client I'm working with who his first goal was to discover if he had workout clothes that fit him. And then six months later, he's running 10-mile races and lost 40 pounds.
So it's these - I don't let anyone commit to a goal unless they have a seven out of 10 chance of achieving it.
CONAN: So success is - reinforces success...
CONAN: ...and down the road. And, obviously, the goals escalate over time?
O'GRADY: Yes, get bigger and bolder as we move forward, as the confidence and self-efficacy increases.
CONAN: And in your experience, you obviously worked in a practice, but most medical professionals don't have these skills, or they don't study these things.
O'GRADY: Yes. I would say that's for sure, that the toolsets aren't there. And there's a lot from this coaching world that needs to be deposited into the curriculum of medical education and nursing programs for sure, without question.
CONAN: Let's get some more callers in on the conversation: 800-989-8255. Email is email@example.com. And James is on the line with us, calling from Fruitland in Maryland.
JAMES: Hi, how's it going?
CONAN: Good, thanks.
JAMES: Well, so, about seven years ago, I was about 360 pounds or so, and over - you know, I had sleep apnea, couldn't walk up stairs, couldn't walk a block to Camden Yards in Baltimore, typical. But I cut out fast food, soft drinks, that kind of thing, and eventually dropped to about 300.
When we moved out here to Delmarva, my doctor basically sat me down for a half-an-hour reading of the riot act and just basically made me cry after half-an-hour of yelling at me. And he just told me that I was going to leave my wife and my newborn daughter, you know, a widow and an orphan and got me to take it seriously for once. And I, you know, got a - five years later, I'm down to 190, and I'm healthy.
CONAN: So in your case, reading the riot act really worked.
JAMES: I guess I was just at that point in time where I needed to hear that.
CONAN: It's interesting. Dr. Mishori, as you're hearing these different approaches, practical matters. What do you think is effective?
MISHORI: I think for very few people, reading the riot act is something that works. Generally - but this caller was also saying he was - he must have been ready. You have to be ready to hear what your doctor is telling you. There are stages of change. It's one of the approaches to behavior changes, recognizing where the patient is and their ability or willingness to change.
And if they're not ready, you can read the riot act until they're blue in the face, and nothing is going to happen. So you have to work individually with each patient to see where they are, as - and how much work they're willing to put in to change these lifestyle issues.
CONAN: And readiness, Eileen O'Grady, they're hiring you. Presumably, they're ready.
O'GRADY: Generally, or they're really stuck. They're in resistance. Most of the nation that's in an unhealthy pattern, that's stuck in some place, are in ambivalence, that they're in contemplation, they want to, but they don't feel that they can. And it's helping tip that decisional balance. And it sounds like the caller was in that situation where he was ready to make a change.
And, in fact, he might have needed information. He might have not known how destructive this lifestyle was to him. So there is some role for information, but he was already on the evidence-based track to change. He was already moving.
CONAN: And James, we hear so much about the difficulty of keeping the weight off even after losing it. How are you doing on that?
JAMES: It fluctuates. I think I got down to, like, 185. And I'm kind of like 190, 195. And like for the past year and a half, two years, I've managed to stay around there. So it's working well. I mean, I eat less. I, you know, watch what I eat. I exercise more, like, you know, and, you know, it's - every single day is a different day.
CONAN: All right, well, stay with it. Congratulations.
JAMES: Thank you very much, sir.
CONAN: Appreciate it. Let's go next to - this is Sherry(ph), and Sherry's with us from Glasgow, Kentucky.
SHERRY: Yes, I'm a family medicine physician who practices in a rural area of about 6,000 people. And I graduated from UNC Chapel Hill. So prevention was very much a focus. And I tell all of my patients you must - you know, we can't replace all of your vessels. We have to prevent the damage.
My concern, specifically, or one concern, is the patient-centered medical home, which is the new - it's a phenomenon where clinics can get special qualifications where if their patients are meeting certain criteria, then, you know, that determines reimbursement.
And my concern is that doctors may cherry-pick patients based on their ability to perform to the doctors' desires and the doctors' needs, as opposed to, you know, understanding that everybody is where they're at and they move at different goals - or different spaces, anyway.
CONAN: So, in other words, to qualify for these reimbursements, they would not take patients who were obese?
SHERRY: Basically, if you - you are not reimbursed as much if your patients are not meeting criteria. For example, diabetes - diabetic patients who have a hemoglobin A1C or a 3-month sugar measure greater than what it should be, you know, you're kind of dinged on that.
And, you know, it's my worry that - you know, I really am very much a fan of Obamacare. I think we all should be - you know, we are servants, as doctors, and we should be taking care of our patients. But I think sometimes punishing the doctor is almost like punishing the patient: Neither one is going to be effective.
CONAN: Dr. Mishori, I wonder: Is this a phenomenon you've been seeing?
MISHORI: Well, I've certainly heard about places that try to discourage obese patients from attending. You mentioned the woman - the doctor in Massachusetts. There are a few cases in Florida where basically some practices decided that they won't - weren't going to take obese patients anymore.
Beyond the reimbursement issue, I mean as a system and as an office, we have to adjust certain things to accommodate people, specifically obese patients, where it's the physical environment that needs to change. So maybe some physicians' offices don't want to spend the money on a sturdier exam table or on new furniture that may make obese patients feel more comfortable sitting there and not have the armrest kind of constricting them.
So as a medical system, we have to adjust to the reality of having a lot of obese patients. And I think some of the people who feel not welcome in physicians' offices is not just because the doctor says I don't want to treat obese patients or I don't want to have to deal with it, but also the environment itself is not welcoming. You know, maybe you have to be weighed in a public area and you're embarrassed. You don't want to have to do that.
So there are a lot of small changes that we can make, but all these changes cost money. And some people may not want to spend that money to - and welcome obese patients to their practices.
CONAN: Eileen O'Grady, I wanted to hear you on this. Are your clients meeting this kind of resistance?
O'GRADY: Well, in terms of the health care homeroom, the purpose of it was to fix the fragmented and fractured health care system that we have. And I guess I would say rather than the 10-minute visit that we typically give, what are we doing to really get people's hemoglobin A1C normal, their blood sugars normalized, and their weight off?
I mean, these Preventive Services Task Force recommendations recommend a 12-week intensive program. So I think it's more of a call to change what we're doing and expand the primary care team and have more targeted resources, more evidence-based, effective resources, and particularly doing it in groups and moving away from this Marcus Welby model where it's all one-on-one and we're having the same conversation over and over.
CONAN: Sherry, thanks very much for the call.
SHERRY: Thank you. And what we're doing actually in groups is we actually do have a patient educator, and I think that's going to be a really positive thing. It's more than information. It's about motivation. Thank you.
CONAN: All right. We're talking today about the conversation that's between the doctor and the patient, mostly about obesity. Our guests, Dr. Ranit Mishori, a family physician who practices here in Washington, also an associate professor in the Department of Family Medicine at Georgetown. And also with us, Eileen O'Grady, certified nurse practitioner and a wellness coach. You're listening to TALK OF THE NATION, coming to you from NPR News.
And let's get Veronique(ph) on the line, with us from - Columbus?
CONAN: Go ahead, please.
VERONIQUE: I'm also a family doctor in Columbus, Ohio. I also practiced in Kentucky as well. And my husband actually has a story sort of similar to James', where he was up to 260 pounds, and he was able to get down to 185 and is now, you know, around 190 and, you know, is now running marathons and doing triathlons.
And that's been a really helpful story to have for patients, to tell them, yes, you can do this and use it as an example and just to try to break it down for patients into little steps. And like the study showed, if you can be a positive role model for your patients, they're more likely to believe you. And I've had a lot of patients who said, you know, your husband's story really inspired me, and they've, you know, started working in the right direction.
CONAN: So the story is a classic - Eileen O'Grady, the story is a classic motivational device.
O'GRADY: Absolutely, yeah. And really finding out what people want, what do they want, and help them get there.
CONAN: And Dr. Mishori, I wonder, the role model part of this, is that a doctor's obligation too? Is that something physicians need to think about?
MISHORI: I think being a role model absolutely is very, very important. And I always try to find - to have the patients find role models either in myself or other people in our practice or some of their family members or friends. You know, finding somebody that you look up to or finding somebody to go through this process with you is extremely important, and there are studies that show that, you know, you can't do it on your own. You have to do it in the context of the family, in the context of the community. And so absolutely it's very important.
CONAN: Here's an email from Jane in Winslow, Arkansas: When I met with my gynecologist this past year, she asked me if there was anything I would like to discuss during my exam. I mentioned that while I'm active and a pretty good - have a pretty good diet, I seem to be slowly gaining weight. She asked me if I've changed my diet and exercise routine over the past few years. I told her I haven't. She said, well, you're in your early 30s now. Perhaps it's time you did. I think she's dead-on, and I appreciate her blunt and accurate observation.
We also have this from Bob in Anchorage: When I changed doctors a few years ago, he wouldn't even take me unless I was willing to take on a weight loss program. I was a little surprised since I was only about 15 pounds overweight. He insisted I join the clinic's weight watchers program. I did. It was great. It taught me how to eat well. I still dine out two or three times a week. All the patients at this very large Anchorage clinic must participate, and this makes a lot of sense since obesity is one of the biggest contributors to poor health. It really makes the patients actively participate in their own health outcomes. These days I work out five days a week, and I'm within two or three pounds of ideal weight.
Is that kind of a solution, Dr. Mishori, to require your patients if they're overweight to enter a program?
MISHORI: I think incentives work, but to an extent, and doctors are finding different ways to incentivize their patients, either to join groups in their practice or to join groups outside of the practice. I think it can work, but for a certain group of people.
As I mentioned, you know, poor people have a whole different issue here because they - I don't think they can do triathlons. Maybe they can, but not a lot of them can because they don't have the money to spend. They don't have the environment to exercise in.
So we have to be very careful when we talk about all of these interventions, that we don't marginalize a whole set of the population. As you know, there are many people who have the wherewithal and the level of education to understand that, and then you need to have the desire and the resources. But many of us, many Americans, do not have the resources despite the fact that they would love to shed some pounds and start an exercise routine.
CONAN: And I wanted to finish up with you, Eileen O'Grady, by asking - you brought some of the principles of coaching into this field. I wonder if you're getting pushback.
O'GRADY: No, not so much. People seem to be really interested and engaged. And what I'm finding on this topic of eating - and the recent caller just saying that he just learned how to eat better. And so he was not in the category of emotional eating. He wasn't eating to bad feelings.
O'GRADY: So his remedy matched his situation. So what I find is that people are often hungry for something and they use food as something else, and food is a terrible mitigator to loneliness or stress or unhappy, meaningless work or any of these other things. So you really have to coach the person and their environment. And if any of the listeners out there are feeling stuck in any way in some self-defeating pattern, there's absolutely no reason for you ever to feel that way.
CONAN: Eileen O'Grady, thanks very much for your time today, appreciate it. And our thanks as well to Dr. Ranit Mishori, who joined us from Minneapolis, and appreciate your time.
MISHORI: Thank you very much.
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