Lightning rounds #32: Creating a POCUS system with Leon Chen

Hey everyone, I'm Brandon Odo. And I'm Brian Bowling. And this is Critical Care Scenarios, the podcast where we use clinical cases, narrative storytelling and expert guests to impact how critical care is practiced in the real world. Alright everyone, welcome back. It is Brandon here, back with Brian. Hey everybody. And we have a little lightning rounds and what we wanted to chat about today is point of care ultrasound, something that the majority of us are doing pretty widely now in critical care. And you know, it's starting to get a lot of traction in other fields as well. But that is started to raise a lot of questions, I think, in many centers around issues like not how it's performed clinically, which I think is where we've all focused our attention. But the other issues that surround its use, the infrastructure, the training, things like that, which are kind of part and parcel about integrating a new practice into modern clinical medicine, at least in this country, I don't know, you're practicing in a tense somewhere, maybe not so much of this. But these are kind of the grown-up issues that have to be tackled and a lot of centers that have not done a whole lot of work formalizing these things. And I think they're all starting to realize that it creates challenges. So some places have done very well with it. And to get kind of a perspective on that, we thought we'd chat with our friend Leon Chen, who's a acute care nurse practitioner down at Memorial Sloan Kettering in New York. He works in the ICU there. He's an associate professor at the Columbia School of Nursing as well. And what's your other title down there, you have the... Just a clinical associate professor. Right, yeah. A manager of simulation or something like that. Oh, so yeah, that's a Sloan Kettering clinical program manager of research and simulated learning. It's a mouthful. Yeah, yeah, yeah. Well, I mean, Leon is the perfect person to talk to us about two, two, yeah, whatever, to chat with because he did a lot of work on these exact topics at Sloan Kettering, basically building from the ground up a program for integrating focus into the ICU there. And also, he and I have been working on a project recently developing some guidelines and consensus around a lot of these same things. So it's been on all of our minds and he just wrote a paper describing their program there, which is about to hit press and we'll link it in the show notes here. So I thought we'd just get a look at kind of what they did down there and if we can all learn something from it. If you're finding that your center has not done not just these exact things, but anything to achieve the same ends, then there's probably a good chance that you're going to have to do at some point or that you would benefit if you made some efforts. So yeah, welcome, Leon. Thank you. Thank you for having me. It was good to see you both of you again and since January that we all met in person. Yeah. That's good. Yeah. That's good. At SCC time flies. Well, listen, I thought we just kind of dig through what you guys did there because if I remember right, when you guys started to integrate ultrasound into the ICU, it was kind of not really being done. I don't know. Maybe people were doing it a little bit informally, right? And now you have a kind of a full-fledged program for it. So I thought we'd just look at the different aspects of that. What is happening with training for you? So if you have a new hire who you want to bring up the speed performing ultrasound or if you need to like, you know, grandfather in or, you know, bring a previously hired staff member up the speed, what's the process that you guys have put in place? Yeah. That's obviously involved in lessons where we first started, but right now our system is fairly standardized and what happens is if you're a new hire, we don't actually give you any formal ultrasound training until you're about a year in because we found that when we first started training people, and then if they're only a few months in, they become a new MP or a new PA, putting ultrasound program, this year long program on them in addition to everything else you have to learn, it's a lot. And a lot of people found that to be completely overwhelming and then their clinical aspect of the work kind of get kind of taken a step back because they don't have to do us. Exactly. They had to kind of just dive into all these required readings, modules, the video portfolio they have to complete for progress. So we decided a one year seems to be a good point where they're sort of comfortable to know how to use the computer, they know how to put in orders, and that they know how to look up everything and not be too focused on not making a mistake at that point. They're a little bit more confident as clinicians. So you're talking about the new APP hired to the ICU. Yeah, this is a brand new APP. So they should not be doing any ultrasound their first year? Right. So they don't go into a formal training program. Now, this is for a focus for diagnostic reasons, not the procedural. They will have to use focus for lines, placement, that's a little bit sooner, that would be as soon as they're getting to our system. Do people do it like informally, you know, with one of the intents of it, something like that, or is it like you just don't want them touching a machine of info procedures? No, we don't put a big stop sign in front of them. I'm sure that, you know, especially we have some APP, especially MPs with previous experience in the ERS ER nurses, or ICU nurses, who obviously seen this, and some of them, the nurses, as nurses, they use ultrasound to put in like peripheral IVs, things like that. So they know the knobs, they know the machine, they're familiar with the NASS unit, right? So they will take a machine and kind of do stuff with it. As long as they have adequate supervision from intents events, or somebody who is experienced in focus, we're not really against it, you know, but they're nothing they do will go into the patient's chart, and they don't do anything fancy with it at all. They mostly just limited to the line placement with adequate supervision. Okay. And then what happens at a year, what do they do? So after a year, they start this formal process. So our process takes roughly nine months to a year, and then it's essentially what chest does with their certificate of completion. It's what SECM recommends for ultrasound training. So they go through a about three month period, 17 hours of video modules learning the basics of the physics, the fundamental of ultrasound, basic images, what they look like. Is that a program you guys put together? No, no. If you look at it, it's quite extensive. So we thought about doing it ourselves because obviously we had to pay a third party vendor for these modules, and they could get expensive once you have like 10, 12 trainees at once, but we just the quality of work, the animation, it was just way too much for us. So what's the last one you guys use? It's called C-A-E, and chest uses it. I think the Canadian society of critical care uses it. It used to be an interesting fact. It doesn't stand for anything. I try to look it up for our paper with a C-A-E stand for it. It doesn't actually stand for anything, just C-A-E, and it used to be an aviation company. They make flight simulators for airplanes. So now they venture into healthcare education platforms. So as you can imagine, they're ultrasound animations, the 3D rendering of organs, and then at the various cuts, especially for cardiac, there's no way we could duplicate that. Is it a... It's like for critical care, or is it like a general... No, it's specifically for critical care, and then they have focused ones for like pro-procedures if you're, you know, pulmonology or pulmonary team set that will utilize that. And then they have more advanced echel modules as well. But for us, it's just a general critical care module, encompassing physics, vascular, abdomen, cardiac, and vascular. Okay. So you guys people do this stuff like on their own time? Yeah. Yeah. So we give them a deadline. They have to finish it with every single module, every single topic. They have to take the pre-imposed quiz. That's part of the module, and then they have to get a passing grade before they come move on to the next. So also they have to finish all of the fundamental learning before they move on to the next stage. And the next stage are these asynchronous lectures that may and a couple of other faculty members put together. And then we talk about a little bit more in-depth, the cardiac, more clinical uses of ultrasound for these various organisms and for various pathologies. And then after that, we go through a live, it could be over zoom, but essentially I go through these images that we have of various pathologies and I guide them through interpreting these images. And then it's pretty amazing, just from the beginning of the class to the end of the class, you can see people, even though they went through a lot of module learning, they look at these images, they kind of don't know what to do with it because in that perfect image, they're actual, from actual patients. So then they have to look at it and say, oh, that's the left integral, and oh, that's what the actual, you know, cast-fired bowel looks like, that's what this looked like. And then we kind of go through these images for various systems. And then after that we finish that course, then they go on to collecting images on their own. So they have to collect 105 images of various organ systems on our patients, and they have about four months to complete that. And then a hundred total and like, some different categories, just many examples of it. Exactly. Like 50 cardiac, you know, 30 pulmonary lung images. And then at the end, they take a, they take two tests, a 40-question knowledge-based test that we actually got to be on the computer system. So they can actually see images for some questions. And then it's all about clinical integration, you actually get a clinical veneer, like this patient came in for this, a short of breath. And now you did a lung ultrasound, this is what you saw, and we showed them the actual images. And what would you do next? Right. So there's that. And then there, of course, you know, ultrasound or focus being on such a hands-on tool, they actually have to go through a test, soup, watch by a faculty member, and then they have to get various views and tell me what they're looking at, what different organ system or structures are, and then they get graded on that. So do you usually have multiple people going through this process simultaneously, or is it like you hire a person, and then they go through everything, and you're like doing classes for one person and that kind of thing? We try to cohort them, because as you can imagine, we try to get everybody on the same timeline. And it took a while, but right now we actually got to be a good place where we have about two cohorts going on, not simultaneously, it's consecutively. So one group will start with less than January, the other group will start in June, and then they kind of, as soon as this group finishes the modules, the next group will start certain they'll start there, like let's say image collection. So any given time, we probably have six to 12 people training at the same time, depending on how big the cohorts are, and how many new hires we have. Now for a while, we would have maybe 12 people going at the same time, because, you know, in the newspapers, when nobody is good at focus, or no focus, as you can imagine, we had to try to get a lot of people training at the same time, but now we finally spaced it out, where it's not so overwhelming for the faculty members also. So this is just for the ICU APPs, is it used at all for outside the Department of Critical Care? So our program, we have with the Critical Care Center, which includes intensive care unit, which includes PACU and step down unit. So primarily this program was developed for the ICU folks, right? But now we have a PACU and SGU people, we have a couple of people from those departments kind of interested in this program, and then we kind of had to tailor what program a little bit to what they're going to need and what type of patient they're going to see. So right now we have one or two people from each unit starting this program. Now, there are certain aspects of it that's exactly the same, like the modules and the classes are the same, what we had to kind of adapt to, what they would see is what kind of images are they going to focus on, right? So there are certain PACU patients, there's simply not going to see a lot of TBTs right away, right? So we might have to ask them to do a little bit less vascular studies and focus a little bit more on cardiac. So we try to change it up a little bit based on what we think they were going to see. So what about the physicians? So the physicians, they go through their own program, this is purely for APPs, because for the Critical Care Fellows, they have to have their own training to satisfy the ACG and EU rules, right? We have a, we have a couple of attendings, we're focused on training them during workshops of them and go into the curriculum with them. And then they don't have, as far as I know, for physicians, they don't actually have any like collection of images like the way APPs do. I think they just, the program director had to sign off on their program and saying that they completed a curriculum and was trained in ultrasound. As far as I know, I think that's for physicians, that's what they have to complete to be credential in the next place as attendings. Okay. And then so when someone gets through this training process, you put a stamp on them saying that they're credentialed to use point of care ultrasound? Yes. So when they finish their program within our department, they get hospital privilege, they get hospital credentialing for a portal to ultrasound. So on your privileges list, along with like central lines and suturing, correct? So it says correct diagnostic point of care ultrasound. Yeah. They complete a point of care ultrasound and they're able to independently perform and interpret a point of care ultrasound as a diagnostic tool. Now obviously this is just institutional, right? So it's a, but the good thing about our program is that we actually have a documentation of everything that we complete it. So you're able to see what curriculum they went through, what, how many images they did. And then what kind of class they went through, what topic they went through. So if they want to, you know, if they go to a different institution, they could still take that sheet of training. And if the institution is very, very keen on see exactly what type of training they have in order to promote them or credential them, they could take that sheet and provide proof of what type of training they got through. And does the credentialing, it's just for point of care ultrasound in general or does it specify particular applications? It shows them what, what, what, what type, what kind of exams they learn to perform. And I guess it will be up to the institution that they go to and how, how detail they want to get into, like, you know, what they want to prove them before. If they want to say, uh, are you privileged to do, uh, uh, gallbladder scans, uh, then they will look at our sheet and said, you'd never learn anything about that. So then, but, but I'm sure there are a lot of institutions who, that, that would not get that detail. Yeah. Right. But even for your uses, like the privilege, it just says ultrasound and it's up to people to know what they're trained to do. Right. You could, you could, um, on the privileging, when they look up the hospital system, and see what they're for, they're just in point of care, which is, uh, it won't go into west civic exam training and they, they went through. So what do you do if you hire someone who does have other training and experience? Do you make them go through the same process or will you recognize their existing training or? Well, interesting enough, we actually haven't come across a lot of people, you know, we come across plenty of, uh, if you piece, especially experienced ones, you know, we have several PAs from other institutions, uh, from like the Rookquittical Care Unit, where they actually know a lot about what I can ultrasound, you know, it is even like, uh, cardiac ultrasound and other, uh, vascular imaging. But, um, nobody could produce anything really concrete on what type of training they go through. So, a lot of angels, hey, I took a course, you know, they have to do a third party, uh, society, uh, course, or, you know, I learned from this one attending, uh, who taught me how to do this, you know, how to look at the IPC and this, nobody really presented us with any sheet that would say, like this paper attests to their competency and, and focus, um, and they, so as it was all, everybody have to go through the same program. Uh, you definitely see some, uh, APPs go through the program with much more, uh, uh, confidence because they know how to do a lot of images. And when they collect images to the end, it's, it's much faster than, to complete certain portfolios because they know how to get the images from others. And then it's great because then they can actually, you know, provide a little bit more resource for the other, uh, people in their cohort. But, um, we haven't gotten, we haven't gotten any, uh, APPs so far who come in with, like, vast amount of knowledge in, in focus. Like, have you heard about an option to, like, test out of the process or something? I would imagine I'd be a little annoyed if I came to work there and you're like, well, you can't use ultrasound for a year until you go through this, this, like, slog. Yeah. So I, we, it's funny because, uh, it's, um, we, we, like you said, like I said, before we, we, we haven't gotten that yet. But we certainly have people who are a little bit more annoyed because they just, they just know how to do something, you know, a lot more. And for us, it's, it's about, you know, the standard process and the standardization, which I think is lacking in, uh, focus for, uh, APPs in general, unfortunately. Um, and that's why we, we haven't had many people, I suspect, come in with a sheet that says, this is where I was training and this is what I know how to do. Um, and for us, the standardization is a big thing because we want to be able to provide that. We, we want our, you know, uh, uh, uh, staff members, if they were to leave us, they have something that, to say that, look, this is everything I, I train in. And in fact, that was a big sticking point when, when I was the, uh, when I first started training it as long in focus, because I had a one attending who said, it's okay. I'll just teach you. And then, you know, I'll just say that you're, you're, you're competent in focus. And I thought, you know, that's great. But if I leave you, or if you were to leave, who is there to say that I'm able to do anything, right? So, so, so for me, it was very important to have a piece of paper that document what type of training I went through, how many hours, what type of modules, uh, what exams I was taught, you know, so, um, and going forth, we wanted to have the same process and same documentation for, um, all of our members. And also, you know, for, uh, unfortunately for legal reasons, right? So if something goes wrong, or, you know, I know the first thing they'll ask is like, what type of training you have? You guys have all these APPs going around doing these imaging and then making decisions and, you know, there was no attending, like nobody looked at it, you're doing this by yourself. Now believe it or not, before this program becomes so formalized, um, these are the questions that we get routinely from other, uh, services, um, and other members, the clinical staff, then like, what, like, who says, you know, how to do this? Like, what are we going to do with these images? Now we don't, we don't believe you. Did it come up at all for, I know the, like, in intensivist, for instance, by and large, these days, ultrasound is part of their training programs, but maybe some of the, the older ones who trained some time ago weren't necessarily trained in ultrasound. Did you have to figure out a way of credentialing them or? So we, um, not, not for the attendings day, they kind of go through the same process. We kind of don't get into the, uh, the position credentialing process so much. We, we kind of focus purely on the APP credentialing portion. And then, um, as far as I know, the APP credentialing and physician credentialing is still a little bit different. Uh, I don't know how it is in every institution, but our institution is definitely a separate process. Uh, I would say, uh, the APP, at least for focus credential process seems to be more, uh, thorough even because we have to present a lot more documentation. And then, uh, the, the, um, we have the single FPP that has to be renewed every six months, you know, I, as far as I know, physicians don't go through the same credentialing process. I think, I think there is probably going through yearly, uh, maybe two to three years, um, but, but yeah, they go by a completely different, uh, process than we do. So when you guys are doing studies now, let's say you finished your training program, your privilege to use ultrasound and someone does a clinical study on a patient. Are they routinely saving those images to some kind of system? Uh, yes. So we actually have two different systems, one is for internal training purposes. So for all those, uh, trainees who are going around saving images for their, for the portfolio, we have a separate system, uh, call a viewpoint, uh, I believe it's through GE. And then when they save it, they upload images to this system that does not go into the patient chart. And then they could save these images in a secure, um, storage facility, without facility storage, cloud, or whatever you want to call it, virtual facility. And, uh, these images are, are reviewed for their training purposes and then for their credentialing. Uh, but then when they want to actually save the images to go into patient's chart, so what they do, the process is the first go into the patient's EMR, uh, record, and turn order. And then that order creates this extension number, essentially, it links it, uh, it creates that file on the ultrasound machine. Then you go to the ultrasound machine, access that file and then it opens up, um, the scanning page and then everything that you save will now go to that patient's chart. And then that number, once the, the person completes the exam, the number will link, um, that image with that patient's chart. So later on, if we wanted to QA, if we wanted to go into the patient's chart and look for the, uh, images that, that, that was, collected, uh, we could actually find that on the EMR system. And then, uh, it's great because that if we have to call consoles, if it's a cardiology or the, or the, or the services that want to see what we saw, uh, what we're calling them about, they could just go into the EMR and go into patient's chart and access it anywhere and, and is able to see the images. Yeah, it just shows up the same place as you'd find an X-ray or a CT scan. Yeah, exactly. More or less, you know, it's not packs, but it's a different system, but it's the same idea. Yeah, that's how, um, it's been places that I've been. So if that's for someone who is fully trained and privileged, if it's for training purposes, it goes into a separate system. Is it the same sort of workflow? It just comes off the machine, but it goes into a different cloud. Yeah, you literally click on a different destination when you're, when you're saving. Uh, now the, if your, if a person is training, and is actually scanning the patient and they find something interesting or a final technology that they really want to, you know, uh, save, uh, they could just review the images with a, somebody who is already focused certified or an attending and then say, this is what I think I see, you agree. Okay, I'm going to save it to the patient's chart and then you, uh, when you documenting, you could say that, uh, there's actually an option to say this image was reviewed with so and so and now it's part of the patient's chart and we are making clinical decision based off of that image. Okay. So you, you asked people to basically save and upload every ultrasound study that's done, whether for training purposes to the training system or for clinical purposes to the main chart, but you don't really want people just scanning and then not doing anything with it. Yeah, you know, so I think the, uh, especially doing the, uh, the training process when people are just collecting images to practice, uh, there's actually a big fear of uploading or saving images that's like a little bit subpar. I always tell them, you know, sometimes, you know, just save it, save it, you know, it might be better than you think and also I tell them that, um, focus images are then you're not going to get focus, uh, you're not going to get perfect ones. No, you get what we can see and then honestly, even in the imperfect images, uh, you could get a lot of information from it. You can learn a lot about these patients based on even your imperfect image. So save it. We'll go over a later and see what we can get off of it. Um, and don't be a afraid. Don't be afraid to show off the images that you think are not perfect. Okay, so did the study upload it to one system or the other? Well, okay, so I guess not for training purposes, but if it was a clinical study, does the person then document it in some way? Yes. So in the same patients, uh, uh, e-mar in the chart, uh, when you actually enter a note, a focus note that, uh, it's a pre, um, um, it's a drop down, it's a note with drop down menus and then when you click on certain things, uh, it will, it will kind of create that sentence using certain verbiage that, that, you know, we want people to use. So it will, you know, you won't say that patient has an EF of 30% because that's not part of focus. It was, you get to select the LV function appears hyper dynamic, normal, moderately dysfunctional, severely dysfunctional, right? So so that everybody can use the same languages. Um, and, but we do have the option of free text. So if you look a little bit more advanced, you, you know, how to do certain measurements whatever you always have the option of writing additional information in the, in the free text portion of our e-mar. Okay, so is it, you have multiple templates like that for different types of studies? Yeah. Correct. Correct. We have one for cardiac, we have one for long, we have one for abs and then renal and ask them. And then if someone did a training study, they don't put anything in the chart. Correct. They don't put anything in the chart. The training images never actually, apart from the fact that you're scanning the patient, it never goes near the patient's chart. Okay. So they, they get uploaded and, um, the training studies, you said, get reviewed by someone. Who is that? Is that you or? So in the beginning, uh, when I was, uh, me and this, this attending were the only faculty members for the program. It was just, uh, me and bad attending. As you can imagine, we collectively reviewed, uh, 105 images for 12 trainees. So it was a lot. It was great practice. It was great practice because you got into see so many different images. But now, uh, we actually have, uh, many more faculty members at least reviewing images, uh, the people who got through the program and expressed interest and show, uh, really, um, some talent in teaching focus, uh, they actually are asked to review images. And then this is one way, because, you know, honestly, if you go through a program, you're seeing, uh, let's say 50, 100 focus images, you know, for most people, that would be a lot. But, but now as you're collecting, or as you're reviewing images, you actually look at more and more images and then you actually do build up, like, kind of a, uh, memory bank of various technologies and various, uh, images. So, you know, it's, it's a good practice for all the, uh, these faculty members as well. Are you, the people who are faculty for this program, are you giving them some kind of time to do this work, or is this just stuff they're finding a minute for when they're on shift, or it's just the goodness of their heart? So initially, it was a lot of bribing and, uh, like, offering, like lunch, by, and, and things like that, you know, they were doing it essentially for the kindness of their heart and, you know, for, for people who are, uh, very ambitious and want to teach, uh, who are just interested, they, they, they, they would do that, you know, but now, uh, they actually, uh, we, our institution actually have a clinical ladder program for the APPs, and then, uh, part of that ladder program, uh, to get, to promote it to the next level, or, you know, uh, is mentoring and teaching and, uh, other APPs. So, so this is something that they could use in the fact that they review certain amount of images is something that they could use, uh, to get promoted. So I, I think it's great, because ever since that ladder program came out, uh, I think it went live, I want to say earlier this year, um, the people, all of a sudden, are a lot more willing to, to, to, you know, give us their time to review images, to mentor, and to, to show other people how to, um, uh, get, focus images. So it's still bribery, but, uh, yeah, from, from, from, I was just saying, from the institution, it's a institutional bribery that's much, much less costly on our, you know, individual pockets. Okay. So what about, uh, clinical studies, they get uploaded, does somebody review those routinely, or it's just if someone has a, like, has an actual question about the patient? It's, if somebody has a question about that, or, or if we have to get, uh, for example, uh, for our pericardial tepidat, uh, process, um, we have to involve a cardiologist to review, uh, our images. So, so we usually upload the image once we get a, uh, somebody who is a suspect with pericardial tepidat, uh, it's a part of, uh, our workflow to, to get a cardiologist involved, and who will, overread our images. But really, that's the, more or less the only one. You know, you always have the option, even if you're focused, certified, and you could independently, uh, perform interpret images, uh, it's never about idea if you have a question, or even not sure to run it by somebody, you know, we always have an attending who can look at it, or another experienced focus, uh, clinician or provider, we can also look at it. So there's no, was nobody routinely looking at any, or any portion of these, um, just for, like, QI purposes? So we do have a QI process. So you have to, uh, perform certain amount of images per year to maintain that, uh, uh, privileging, and then those images, the 10 images that you, uh, you actually have to put, uh, patients EMR number, uh, into a sheet, and then at the end of the year, uh, one of the faculty members, right now it's mostly me. I will actually have to go through those images, and look at the images, look at the patient's chart, um, uh, see what your documentation was, and have to see that you did more or less the correct, uh, interpretation. Okay. So you kind of manually go and look at some, yeah, yeah, not, but not, not real time, not every single time. Well, so for the, the training ones, when you're looking at people's like learning studies, what do you, I mean, what are you looking at? And what do you do? I mean, are you like communicating with them about things you saw, ideas? There's some formalized what you do it? Or, so that, uh, I know some institutions, I, I, I want to say like one or two institutions off the top of my mind, they have a, uh, QI, uh, committee. So they actually have a panel of people who will look at, you know, it's a more certain amount of time per week, and you look at the trainees videos, I know, I know certain, a lot of ERs probably do this. They look through all the images together, and then, uh, they have a more formalized way of making, uh, giving like recommendations, giving advice on how to get better images. Right now, uh, for us, it's still a little bit of, uh, uh, and, you know, reviewer dependent, uh, some people will say that this images have to be, you know, uh, some people will say this image is off-axis, some other person will say, no, that looks okay. So we don't have any type of uniform, um, uh, process right now when they're reviewing the training images. That's something that we do want to work on a little bit later, you know, as we have more people, uh, uh, volunteering to be reviewers, and then, uh, everybody maybe gets some more, more institutional driving, we can form a committee to actually look through these images, uh, during the training stage. So if you're like, this one's off-axis, what do you do? Do you like, you like text the guy and say, hey, this is off-axis? Yeah, so that's, that's essentially what we do. Not, not, not texting, but in the review system, when they, when they, uh, look at images, there is a column where you could say, or, well, put in your recommendations. I would say, for example, I would look at somebody's image. I would say, um, too much depth, uh, not enough near-gate, uh, off-axis. Uh, you don't need to see how much apex, you know, that's just an example. Uh, and then next time you work with a person, or, you know, you could just show them how maybe this is what you meant, right? And it's just, it's technical review of the images. There's no review of their interpretation, because they, they didn't document an interpretation. No, no, it's purely technical. It's purely, excuse me, it's purely technical, um, aspect of the image collection. Do you feel like that, that leaves something on the table in? Because that's like a whole aspect of focus that you're not really addressing, right? I mean, it could be a beautiful image, and they, they totally misunderstood what it showed. Yeah, yeah. No, I, that's a, uh, very fair point. So, uh, ideally we'll have some way of doing real-time, uh, clinical review, and I think the problem is just that, um, it's, it's very hard to match up that time with faculty. You know, we don't have anybody who is on 24-7. You know, I know for ER, they, they have ultrasound fellowships, and then these ultrasound fellows, they, their job is, they have no patient care, right? They don't, they don't actually see any patients. Their job is to just scan our day, review images all day, provide feedback all day. So we, unfortunately, don't have anybody like that. Um, so, so we have to do a kind of a, like, a, a synchronous review, um, which is not perfect, but what we do have is that during the testing portion, the knowledge testing, you know, the written portion, uh, so to speak does test a lot of clinical integration. So, so we, we have the clinical being yet. Um, it's not a simple, or we do have one or two questions like, what, what structure is this? You know, what is it near games? We have these type of questions. But more, the test is questions that has a clinical scenario with a patient background with presenting symptoms, and then we show them a image of what you got, you know, uh, and, uh, what would you do about it? Instead of saying, what do you see? We say, what do you do about this? What's happening with billing? Are people, when they're trained, uploading and documenting these things? Are they billing for it in some way, or is somebody billing for it? Yeah, so we actually have, uh, so we, we do bill for it. We do bill for it. I will say that, uh, we have these clinical informatics specialists who did a lot of the, like, the legwork for us. So, you know, I, I, I don't want to go into two technical stuff. I, I don't want to get it wrong. And they'll tell me that that's how we did, you know, right? But, um, but the, uh, as far as my understanding of it, they, they had to go through and, and do the CPT codes, and that's not radiology specific. They have to modify existing codes to make it focus specific. And then, uh, because the documentation, uh, the billing needs a couple of things, you need the effort patient, you need to have an order, the indication, and then what you did for it, and then you have to have the images to go along with that note, uh, for, uh, documentation, and billing purposes, uh, and then that, all, all of those aspects were satisfied. So, that's why everything that we talked about in terms of workflow, creating an order for it, having an extension number for it, the connection between the EMAR, the patient's chart, and then that, that, that image that you performed, that link, all of that is very important for billing. Uh, but I know that our billing department and, uh, the informatics, so, uh, informatics department did have to go do a lot of work within terms of, like, the code and all that stuff. But every single, focused note that we write, uh, after we perform an image, does get built. Wow, it's a big system. Um, I mean, what were the, the bigger challenges that you encountered as you put all this together, which I'm sure must have taken years? Uh, yeah. Uh, it took, I think we first started the training program in 2016, and then that, we, we primarily focused on the, the training aspect that we want to train the APPs, make sure they're able to do these things, um, and then the infrastructure had to come a little bit at a time, uh, afterwards, you know, they will create a billing, you know, the, the, the billing code took a while, the, the building of, uh, the IT system, getting a dedicated Wi-Fi system, even that, you know, that took a little bit of time. So, so that took, uh, what, from 2016, 2017 to now, uh, with, with more or less, uh, perfected without going off, uh, without having errors all the time. That's what seven years, I want to say. So, so it definitely took a long time. Uh, the biggest problems, uh, or some of the things, the things that we kind of anticipated having are the faculty issues, right? A lot of incentives right to lack of qualified faculty members, and uh, uh, once we had that, uh, some of the things that, that we really didn't realize, uh, we're going to be issues at the time, work, with the IT stuff. A lot of it was just IT stuff. You know, we thought we just go and, you know, our institution is fairly financially secure. So we were able to get all these machines, and I know a lot of institutions don't even have, like, machines that have one machine for the unit. If you take it for training, that's it, right? You don't have anything else. So we actually have, uh, any, any given time for machines in the unit. So, so we don't have to worry about, like, taking a couple of training purposes, one is broken, being fixed, and we have nothing left to the unit for patient care. So we have, uh, a lot of machines, uh, but that, you know, securing the funding to get all those machines, uh, was, uh, took a little bit, uh, support, uh, took a lot of, uh, negotiation with, like, the institution. So, so we, we got the machines for it, and then, once we have the machines, uh, setting up the IT system, uh, the, the bioinform, uh, bio, medical department, informatics, all those places, you know, that, they, they ran into a lot of issues, um, later on that, that we didn't realize was an issue. Uh, for example, Wi-Fi capacity. I never even knew that was an issue, but, um, once we started sending a lot of images, uh, we ran into the ship, like, wait, none of these images are going through to the cloud. What's going on? They were found out that, you know, we were overloading the Wi-Fi that, that, that we had. So we had to get, you know, dedicated Wi-Fi, uh, system for our unit. So, so that when we send all these images, uh, it's, it doesn't, like, overburton the system, right? So, so all these technical things that we didn't think we were going to run into. And then, um, so that took a little bit of time. And then another thing that came up in the last couple of years was, um, just people leaving. So that was a big issue. So we had, let's say, uh, 50% or, uh, 60% of people who are trained. So now, we don't have that many more people to train, right? That, that's not a big issue. But, uh, during COVID, I think, um, around the time of, like, from 2020 to 2022-ish, we had about 41% of the people who are already certified in focus or leave. To go to different departments, uh, like go to different institutions, uh, quit healthcare, like, totally, you know, you know, we're not alone in that. But, but, uh, that, that's all of a sudden that we went from, let's say, 90% people certified to 10% certified. You know, so now we have to kind of wrap up training and take time away from clinical care, um, and, and, you know, that, that, that was a lot. I would say in the last couple of years, once the IT system, once the building system, once the notes were created, you know, we thought we were good. And then COVID hit. And then that, that, you know, the staff nutrition became a big problem for us. Was it hard to get institutional buy-in to do a lot of this? Because especially early on when it's just a matter of spending money and finding resources and I, I mean, I, I guess you're, you're billing for it now. So I guess there's some return, but I'm sure early on there wasn't. Yeah, so I think, uh, the, we, I, I was lucky that, um, my boss at the time, uh, she was a real visionary for her focus. You know, she, she knew that this is something that APPs will need at some point. Uh, so, so she actually convinced, uh, the institution, um, leadership to spend resources on me getting me trained and then dedicating time, um, for, like, time off for all these members going through a training process. And then, um, our leadership really, uh, saw that once the first cohort with training was trained, they're like, okay, well, this is actually going to make a difference. So this is actually going to be, um, useful and, you know, improved patient care. So then they actually got us more money and more funding, uh, dedicated time off to do these reviews. So that, that took a lot of institutional support. I, again, you know, every institution is going to be able to do this. I, I was lucky because I had, um, leadership, I told me like, when we're looking at machines, you know, get, uh, I was actually told that, that, listen, just, just tell me which machine you think is good. It's fitting for the department. Like, let me worry about the money. I'll deal with the money, which I heard that I was like, great. That's what I wanted to hear because I, I don't want to deal with the money side of it. So, so, yeah, I, not everybody's able to do that. So I, we were pretty lucky in our institution and it is department to have that. And so the, the workflow you talked about, like for, you know, saving and uploading images to the radiology system, um, documentation and so on, is that something that the, your attendings are also making use of or other departments like the emergency department, which usually is doing a lot of ultrasound or are they all doing different things? So the image uploading and the notes are used by everybody right now. More than just APP, the fellow user, the, uh, the residence user and the attending user. Um, I would say, uh, some people don't upload images as diligently as others, but, but I would say like 80, 90% of the time, you know, everything is compliant. So because especially when buildings involved, you have to have these, uh, key elements for building, you have to have like the notes, you have to have the order, you have to have the images, and then, uh, you have to have documentation and building for, you know, the time document to do and things like that. So otherwise, you know, I'm sure we all get a call and email from building saying like, there's nothing there. Well, it's, it's an impressive system. You know, everywhere that I've been, um, is much less developed. A lot of places where not even, you know, didn't even have systems to allow uploading. Um, now the last couple of places I've worked do at least have some, which may or may not be reliable. Um, not necessarily a policy or even a culture of routinely documenting studies. I mean, maybe informally, like mentioning something you found in a progress note or something, but, you know, not like, you see a patient, you do a study, you do a note with some standardized way. I've been trying to do that just because it seems like a good practice. But, um, and training by and large has been informal and although there's been talk on and off, um, not really any formal process for credentialing. Well, how are things for you guys, Brian? Where are you fall in this spectrum? I feel like, uh, Leon's kind of a 10. I, like, I can't imagine anyone that's got much more of a developed system than this. Probably other places are equal. Uh, and then I guess a zero would be like, nothing. Where are you guys? For sure. Yeah. We're not there. Um, I will, I will say we talked earlier, um, about some folks in Cincinnati, um, that are doing some really good stuff like this too. But, and when I talked to them, I talked to them about a year or two ago, I guess about all this and, um, yeah, we're, we're nowhere near that. We don't have any kind of formal credentialing process. You can just go pick up an ultrasound and go scan people. Um, I mean, there's nobody to say that, you know, what you're doing other than, you know, hopefully you know your limitations. Um, you know, as APPs, we're, we're not totally independent, right? We work with a, with an attending. So, you know, I don't know that there's a formal thing in place. Uh, I certainly, you know, when I was first learning, would run everything by, you know, like, okay, come look at this. This is what I think am I right here. Um, you know, I, I will still do that a lot of times before I take major action, right? If I go ultrasound somebody and I'm going to be like completely changed the, of course, the plan of care based on what I found. I'll run that by my attending and say this is what, and nine times out of 10, they don't even necessarily come look at the images. They'll go, yeah, no, it sounds right. You know, you've done enough of these, you know, what you're doing. Um, one thing I think we've found in our place is we have a lot of self selection for this, right? A lot of people, they just go, I don't know what I'm doing. So I'm not even going to pick up the probe. Um, and so we, we found we don't have a lot of people who are going to be out there doing images and making decisions that have to have oversight because they, everybody kind of realizes their own limitations. There's a big demand right now for this when I'm on a hospital wide education committee looking at providing some sort of uniform ultrasound training for all our APPs because there's a huge demand for it. But, um, I think right now that's that's sort of where we are with limitations and stuff. Yeah, I mean, one of the implications with the having the process is also that it's an expectation, right? It's not like if you are into ultrasound, then you do it, but if not, then you don't. You, Leon, I mean, tell me if I'm wrong, but if you hire a new PA or NPE or something a year from now, they, they, they're doing this, right? It's not opt out. No, no, that's, um, uh, in the beginning, we prioritized the people who self-selected, right? Because we thought that those people will probably go through the program the fastest. Uh, those people will go through the program, um, uh, without a hitch and that's we, that's what we need it. We need it. We need it. The program to succeed. So we will pick the people who would think was, you know, support the program and champion the program. So that right now, uh, we got into the stage where it's a requirement. It's a, it's a job requirement. So, so during interview process, um, part of the interview committee, um, when we interview people, the new APP, your perspective to APPs, uh, we will tell them that one aspect of the training program, uh, once you get off orientation, once you get to feeway, once you look at what's comfortable, you will go through this extensive program and we'll tell you ahead of time. But we made it, um, easy enough for you to access, you know, the modules you can do at home. Uh, you do get some time off. Uh, you look at the, uh, the lectures, um, and, and you will, um, uh, but you will have to put in the work because it is your job requirement. And this is part of every, um, modern, critical care providers repertoire, so to speak. Yeah. Well, that was going to be my next question is if you got pushed back from people because I've had, you know, like I said, we're, we're looking at this coming up with a way to do it house wide because we have a lot of people who are like, I want to learn this. I don't know how to do it. But I've had a lot of people say, listen, I'm not going to learn that, um, you know, I've been, I've been an MP for 20 years, um, and I've been doing just fine. Um, you know, what do you do with that? I mean, you're new hires. You say that's an expectation. What do you do with your experienced people who say, like, hey, listen, I've been doing this for 20 years and I don't, I'm too old to learn a new trick. So, uh, a lot of, uh, um, so it's, you could copy back up, right? I, I'm never the backup. I always say that, you know, I have no power over anybody. I, I, I'm just going to strongly convince you, look, this isn't, you're going to need this. This is going to be good for you. You're going to need this. And for your patient care, it's good for the patient. Uh, and then I sometimes I say, look, these people who are newer providers, the junior providers, they're going to know how to do this more than you. So, so sometimes if you bring out the competitive nature, you know, go with them into doing it. But ultimately, uh, we, we have, uh, management leadership, I would say, so that wouldn't say, look, this is a new job expectation. You have to do this. You know, this is going to go into evaluation and stuff like that. I imagine billing is an incentive too. So we don't currently have a system place to bill. Our IT people, I talked to them six months ago or so and they're working on it really hard, uh, to get it in place. Um, but currently we don't. So I go out and do a study. It's just like you said, it's, in my mind, it's what's right for the patient and helps me make a decision. But that's the end of it. Uh, I imagine, especially if you're in a place where your pay is either tied to your billing or there's some sort of like bonus structure or incentive for, you know, you're not meeting certain targets, etc. Then if you can bill for this study, that becomes a huge incentive to say, okay, well, I've survived 20 years without it, but maybe I should've learned it now. Yeah, I think, you know, different people obviously will have different motivations. And then we, uh, luckily we didn't have too many people. We had, I'm not going to say we had none, but we definitely had those people who were like you said, like, why am I going to learn this when I've been very good at my job for X amount of years, right? So, um, you know, honestly, we sometimes have to point out to them that's not always the case, right? No, we have plenty of people who say they're very good at certain things without ultrasound. But really, when you show the data behind it, are you, are you actually, right? Yeah, yeah, was that patient actually, actually, you know, like, or did they have a massive tab enough, right? So, so, those are the things that we have a conversation about. But at the end of the day, if, you know, these type of talks that didn't work, we do need like somebody just sit down with them like, look, this is part of the evaluation, this is part of the job requirement, you're just going to have to do this, right? And then we provide them as much support as possible, you know, if they need a little bit extra time to, to look at the, uh, get collected images, if they need more personalized attention from a, uh, faculty, uh, slash mentor, we will provide them, we'll care them somebody, uh, with somebody who will have extra time to show them images, uh, Larry, put your hand on their hand and show them how to collect these images, right? That, that's totally fine. We'll work with you, you know, if you need a day off for lecture, I, I, I've spent plenty of time just doing one on one because somebody can't make a group lecture or something like that. We, we will make it happen. But, but the bottom line is you will have to do it. Like, I, you know, it might take a little bit longer, but you, you, you have to do it. This is part of critical care now. Yeah. Well, I think focus is an interesting case, I guess, in that, depending on how you look at it, it can be just part of the physical exam, right? Like, a lot of times that's how we think of it. It's, it's the stethoscope of the 21st century, but I have students, like N.P. students who will sort of, you know, their eyes glaze over and focus lectures and they'll, yeah, they'll go through the motions, but they're clearly not interested in it, which I think is interesting because you, you couldn't get away with that by saying, like, listen, I'm not interested in learning how to use a stethoscope. Um, I'll just figure it out, right? Well, plenty of people are not, but we make them. Right, yeah, sure. But then, but there's, there's, uh, we treat it as differently, though, like, you know, in that, I don't have to be credentialed to use a stethoscope. That's taken for granted, and I know how to do that. Um, yeah. Do you think they're, we're getting to a point? Is there a day coming? And if so, in our lifetimes or our careers where this will just be considered part in parcel of your training? Um, I think so. I like, because if you look at the trend of, like, medical school, I've, I've got the exact number. I think it's somewhere around like 60% of medical school students are exposed to some type of poor to care ultrasound curriculum or some type of training, right? I know some of the New York City mess schools, the California mess schools, they, they, the mess students doing their internal medicine, the rotation, or clerkship, they are provided with like the portable ultrasound of the, the pocket scanners, and then, you know, so to put them to perform physical exam, uh, certain mess school require that their students know how to perform certain images by the time they graduate, right? But if you look at, uh, residency of fellowship apart from critical care, which requires, uh, focus learning, uh, the other residency or specialty is EM, right? Emergency medicine, they require the residents to complete a certain amount of images by the time they finish residency. So, uh, I, I don't think many PA programs do that, and I know for sure, and P programs do not want to do that, even though the, the recommendation from credentialing agencies and educational societies for, uh, and educational, uh, I guess, organizations for MP schools, they, they will say that, uh, acute care MPs should be, like, proficient in diagnostic procedures, diagnostic, uh, uh, tools, like ultrasound, and things like that, but, uh, the language is just not clear, but, um, I think it's important to actually expose students in school, uh, you know, whether it's grab program or mess school, right? Because at some point, the places pressure are, um, practicing clinicians, even not proficient in these tools, the new tools, you're going to see, best students come in and do things that you have no idea how they do, and, you know, you, you're, you're kind of, are pushed to kind of keep up with the times, right? So, um, I, I'm hoping that MP school and PA schools, uh, we'll, we'll kind of catch onto that wave. You don't want to be left behind on that. So, so, um, they're going to have to be more and more, uh, push from educational organizations, regulatory societies, professional societies, to make that push, right? To kind of, um, at some point, hopefully we'll get to that point where, um, the organizations say every single MP school to be credentialed for acute care programs, you have to do these, you'll have some type of curriculum, right? Like, you know, we always joke that nobody would do until you make them do it. Like, I'm hoping it won't get to that point, or I don't know when that's going to be the point, but I'm hoping that at some point that the, um, these organizations will have to say that, look, you want to be credentialed, you want to continue to stay in business, your acute care program, have to have these, uh, training, at least some curriculum, you know, to provide patients, uh, students with the focus learning. So then, um, with that, it won't be like less, like, it won't be like foreign to students. So, and then they know that this is going to be an expectation. So they will seek out any type of training opportunities. Well, look, I mean, like I said, I think your program there is one of the more developed ones. So I think a lot of people listening are going to say, we're not, we're not doing a lot of these things. I, I'm just kind of using ultrasound. I was trained on it informally, maybe, um, but, but I am, I think competent and it is useful to me the way that we're doing it. What's the benefit from adding on all the rest of this, um, formalization to the process? I think I could see a lot of people saying, well, it's, it's useful to be able to save an upload images, like a show of other people, you know, maybe when I choose to, not necessarily requiring me to, but most of the rest of this, um, is not much benefit to me. I could see the benefit to the institution, medically, the ability to bill, standardizing training and so on. But for me, it's just, it's just more headache because it doesn't, I'm already using the tool. Um, I, I don't really want to need more oversight or standardization or requirements for how I go about it. Um, what would you say to that? I mean, do you think that's true? I mean, it might just be the case that is good for the institution and not necessarily for the individuals, but I, I think at the end of the day, we can't make people do what they don't want to do, right? Because that, that's, that unless the institution mandates it, right? So, so each institution will have to decide how much of mandate they're going to do. Um, you're always going to have people who are like more adaptive, like they welcome these types of changes, they welcome these new technology, they welcome these new tools. You can have that. Um, and for those people, I think as much standardization, as much documentation is needed, it's, it's good. Um, but we, we also have to accept the fact that some institution would never do something like this. You know, our program, like I said, many times, we're very fortunate we have the resources to do something elaborate like this, you know, something very, very, uh, uh, structured, right? So it took time, it took dedication, it took funding, it took resources, right? But if you look at SCCM and other professional society recommendations for ultrasound, they, they take into account that not every institution is going to be able to afford certain things like this. You know, not every institution can have an infrastructure for something like this. So, so they, they will tell you that do what you can with right? They, they tell you, they tell you, do what you can and, you know, hopefully you have some type of learning curriculum, some, you have certain type of, uh, somewhere where you can store the device, you know, some, uh, somewhere where you can store the images and some way to recall that images or the, or the funding that you had for patient care, right? So, so there is a lot of variability, there is a lot of flexibility, uh, what the recommendation is. Uh, I think our institutions, process is a template and certainly you could take various parts of it and, you know, try to apply an institution, right? But I, I don't foresee every single institution being able to enforce or, you know, uh, it's to something like what we have because I, you know, I'm not like unrealistic, you know, I understand what we have, I understand what not every institution is going to be able to do that. But, um, I'm hoping that a lot of institution will kind of gravitate towards some type of standardization, some type of structure. Um, it, I just don't see, uh, and we've all done this, you know, I, I just don't see taking several videos of a, uh, scan and sending over texts to a supervisor, uh, physician or, or a different team as the ideal weight of for patient care, right? So also, as long as you have some type of structure, um, you know, it's better than not. Well, and I think, you know, getting back to what you were saying about what's the benefit to me, the individual provider, you know, hearing like what you said, when you, when you, when you said, you had an attending who was like, I'll teach you how to do that, right? I mean, that's sort of how I learned it. And I'm thinking right now, like when I was in school, I was interested in potentially pursuing first assist in the OR. And I had a professor who said, you know, listen, there's two ways you can go about this. One, you go work for a surgeon who will teach you what you need to know. Uh, don't do that. Go do a formal training course, get certification, because like you said, what do you do when you go work for the surgeon and he teaches you how to do stuff? And then he retires or you move to California or whatever and you go, yeah, no, I know what I'm doing. And they go, but how do we know you know what you're doing? Or it turns out you don't know what you're doing because all you know is, you know, I taught you one way to do a procedure is the way he liked to do it, right? So get formal training and I feel a little hypocritical when I tell students, yeah, I think you should get formal training and certification, because I don't have it. Um, but you know, for me at this point, it is a huge headache, right? Because it's more than just, okay, can I sit down and take a test and show you that I know what I'm doing? No, I got to take this big course and I got to do this. I got to travel in some cases, uh, two places to do hands-on stuff and it becomes a big obstacle for somebody who's experienced. I think that's a natural progression. Like a lot of things go through this where it starts out more informal and then becomes more widespread and formalized. And I think often there's an acceptance of that and you kind of maybe grandfathering people who have been around and um, it's kind of just accepting the practicalities of it. But that's what I'm looking for. A grandfather procedure where I can just demonstrate that I know what I'm doing. Grandpa Brian, yeah. Listen, see the gray hair in me right now. I'm already feeling a grandpa, but you know, priorities are obviously always to be safe. Um, and yeah, then probably I think a second or maybe third priority is not to make a process that takes ultrasound away from people needlessly. Because the people are using it and benefiting from it. And even when they're doing it in a somewhat unstructured way, um, I think they're probably providing better care and it's safer care than if they didn't have it. Um, now, you know, obviously if they're the training and credentialing and all these processes were more formal, then the safety could be a little more consistent or provable or reliable or whatever. But um, I'm always kind of wary about saying, well, everyone really should be doing x, y, and z. And if you're not doing this, don't do ultrasound because I, I think that's, that's not a net win, you know. Yeah. Yeah. No, I think, you know, I agree, you know, the, uh, for our trainees who haven't been formally certified that the fear is also, you know, a lot of them come in with fears already. They say, I don't know whether what I'm doing. I don't want to touch an ultrasound flow. And we really don't want to perpetuate that by saying, well, it's a scary thing. Don't touch it until you went through the training process. So they, they do have a conditional, uh, uh, credentialing to an ultrasound. So they couldn't use the alert as long as you have to, there was somebody. We just don't want you to do it by yourself without structured teaching and, you know, mentoring, so to speak. So, so I think anybody who, like, we're plenty of people who come out and very, very excited to learn. And, um, we, our institution have a quick, okay, fellowship for our APPs. Um, and honestly, uh, when we have students and, uh, prospective, uh, trainees come and learn about our fellowship, um, I get to speak with a lot of them and it's a big draw. So a lot of people aren't, you know, interested in doing focus. A lot of people do want to learn focused training. And, uh, some people even said, they, you know, if they didn't get into our program, if they didn't get higher or slow, some people were willing to pay at a pocket, you know, to, to take the third party certification courses, like, you know, chance or study possible medicine. And, you know, it's the expensive, you know, so, so they did, but they willing to do it because that's just how much they want to learn. So I think in terms of recruitment for us for both the fellowship and the, uh, formal ICU unit, uh, I actually think it's a point of pride for us. And it's a drawing point for it. It's, you know, it's a point where we really advertise to prospective trainees and students and pro e's also. So, um, and I, I do think it brings people in. You know, there's always been this tension of, is focus, like we said, more like a physical exam maneuver or more like a special skill or radiology test. Um, and it's kind of gone back and forth on it. We were saying maybe one day it'll be more like a physical exam where the, the knowledge of it is so widespread that it doesn't need a lot of special attention into how it's done. But I think it's going to go the other way before it ever gets to that point, you know, this more formalization and standardization of how it's being done is kind of a inevitable trajectory that we're on right now. People that have been doing it in a more grassroots way, which is how most of us started. Um, it's probably not going to last except in much more low resource settings where there just isn't the possibility of more infrastructure. It's going to be harder and harder to defend that kind of practice. Um, so, you know, I think we're all inevitably going this direction, at least in the short to medium term. So worth giving some thought to for all of our systems, I think, but Leon is a great chat. We're glad to have you. Um, we'll, uh, put a link to your paper in, uh, in the show notes here. And I hope people check it out because you go into a lot more detail, I think, on your system there. Um, maybe we'll talk to you soon.