Welcome to 'patients at risk,' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard and I'm joined here for part two of our series on physician advocacy by two experts in the field. Dr. Purvi Parikh is an allergist and immunologist practicing in New York. She's also a fellow board member with physicians for patient protection. And we're also joined by Linda Lambert.
She was the executive director for over 20 years of the New York chapter of the American College of Physicians. And she was also a certified lobbyist for quite some time. And she's been the executive director with Physicians for Patient Protection for the last several years to get our organization going. Welcome back, both of you. Thank you so much for joining me again.
Thanks for having us.
One of the things we talk a lot about is the success that nurse practitioners in particular have had at galvanizing their base and gaining independent practice, actually, nearly half the states in the union now allow the independent practice of nurse practitioners without physician supervision, they now have independent practice across
the Veterans Administration. And it's really remarkable when you consider that nurse practitioners are estimated to have about 5% of the training of physicians, at least when they graduate from their training. And yet, in many states, they're practicing independently, when even physicians who may have only a year of residency are not allowed to practice without supervision. So, Purvi, let's
start with you. What are your thoughts on why it is that nurses have been so successful at working together politically?
I really like to give credit where credit is due. And I think that they've done an excellent job of advocating for themselves. And actually, I think we can learn from our nursing colleagues, I have friends in nursing who even tell me the same thing. They said, 'Where are the doctors? We're doing all of these things. Where are you guys?' and the reason is, once I dug deeper into it, it's actually part of
their education. So it is a class in nursing school, in certified registered nurse anesthetist school, on how to advocate for yourself, how to defend your profession, and everything that Linda and I spoke about in part one, that is actually taught in school. So whereas you know, I had to go seek it out, you sought it out, on how the whole process of how a bill becomes a law, how to lobby, what that means. I'm still learning a lot, there's
still so much I don't know. That is all taught as part of their education and their curriculum. Not only that, I found out at national meetings, especially for advanced nursing, like such as nurse practitioners, crna is that part of their meeting is
dedicated to lobbying. So it's very strategic, you know, like, we'll have our annual conference right for allergy immunology and various cities, we talk about medical topics, we present research, but we don't have much on actual - we don't take time out of that meeting and go speak with legislators. That's a whole separate meeting. This is built
into their annual meeting. So all dues from their organizations, a portion goes to advocacy, whatever registration they collect at their annual meeting that goes to advocacy, and then not only that as part of their national national meeting, but they're also learning CME, up to date on new medical topics. Many of those meetings are purposely done in Washington, DC or in state capitals. So advocacy, lobbying,
those meetings can occur. And I think that's genius, because now you're already gathering all of these individuals for continuing their education, rightfully so. And people have taken the time to get there and now they're freed up to be briefed on what issues are affecting them and what to say to legislators. And so I just think it's genius. They're on top of the game. One, it starts with their education right from school, built into
their dues. It's built into their national med, like medical meetings, it's not a separate thing most of the time. And then the other thing is they are already in many different levels of politics. Like I already know in many states, there are nurses that State level politics, federal level politics and they're already, you know, working their way up through administration in hospitals. So that way those large hospital systems also affect politics.
And then even just in locally, they're much better at galvanizing the troops as they say, because even I'm licensed in both New Jersey, New York legislators always say, Well, we've been hearing from the nurses non stop, but you're the first doctor that's contacted us on this or you're the fifth one. So they are very good at just showing up flooding the Capitol, as they say. So I think it's genius. They've actually addressed it multiple level.
When I was writing the book, I interviewed several physicians who were nurse practitioners prior to becoming physicians. And that's the exact thing that they said, they said, when they were in school, they'd have lectures, they'd have specialists come in, lobbyists, and talk to them, they'd have classes on the best way to interact with legislators or aides, and then they would actually bus them. One person told me that it was the day of the final vote for nurse practitioner independence in a
certain state. And they actually bussed the entire nursing class, not just nurse practitioner students, but registered nurse students, which is a lot of people, right. And they bussed them in so that they could have this huge presence, and really make a statement. And it was really impactful on the legislators because you just see all these people, especially in a sea of white coats that really
resonates. So what I'm hearing from you Purvi is that, number one, we probably need more advocacy, training and education, starting in the medical school level, and perhaps even pre med. Who knows. So definitely in medical school and in residency. Secondly, we need to probably talk to our specialty societies and our state societies about incorporating advocacy into all of our meetings. So maybe there needs to be a lecture at each and every meeting, even if it's just, you know, an hour or half
an hour. That's like a training for us to do that. Do you think that's something that would be realistic that organizations would be interested in doing?
I think a lot of the medical organizations are doing that - I can't think of one that doesn't have a legislative day, part of that legislative day is orientation in the morning, I think where it gets sticky - and believe me, we tried to tackle this many, many times - is trying to incorporate anything into the the medical schools education system. The deans are pretty set in what their curriculums are going to
be. In getting that message, we would try to have meetings with the deans, we tried to collectively bring them together to start to stress the importance of going beyond just the science and going into you know, the real life situations that practice brings on these medical students once they're out. So that's a bit of a challenge for us that doesn't exist in in nursing. It's not that way. So we do have some built in barriers that probably have to be addressed as well.
I think unfortunately, though, that lack of adaptability is, is going to end up hurting our profession. I mean, we it already has, I would say to some extent, not only advocacy, but even the business of medicine, I would argue needs to be built into medical education, right? Because anything outside of academics is villainized in a way when you're going through training, and that might be too harsh of a word.
But you're you're just not exposed to direct primary care, right, or private practice, or that there's so many other ways to take care of patients. And I would argue maybe even better, right then out of the larger system, because you can be more adaptable and do more for your patient. So I hoping that some of that flexibility will change when the new guard comes in.
Because unfortunately, I think because nurses are good at being adaptable, in a very dynamic time, they're able to get a lot of things accomplished that we have not.
You know, I think we've always rested on our laurels of the sense of like, well, we don't need to do any of these things. Because we're doctors, and we're so busy doing medicine, and it should be obvious to everyone. I mean, just look at the fact that we feel like we don't have enough time to teach any of this because we're so busy learning and teaching the sciences and the actual practice of medicine, whereas, you know, look at the Doctor of Nursing Practice programs, 85% of them are non
clinical. And if you look at their curriculum, it's like informatics, lobbying, research. I mean, there's nothing clinical there. But yet physicians even just to like Linda said, even just to get like a very brief time to talk about it is not something that many Dean's are necessarily open to that. I think it's funny because when I think back to my med school training, I remember my fourth year having an awful lot of elective time and having some
flexibility. It seems like that could be something that could be incorporated and the business of medicine I think that's so critical, Purvi, you're totally right and it definitely wasn't something that I got a lot of exposure to, either in medical school or even in residency, but maybe the med students today and the residents are a little bit more savvy. I've been really impressed with the young people that I'm meeting how involved and interested they are. I see
them on social media. I see them on on sites like Reddit, they're talking about these things. They're understanding these things so much better than I did when I was at that stage of training.
I can tell you that besides doing the advocacy internship that we mentioned in the first segment, I worked very, very closely with all the program directors in New York State. And there are organizations of program directors in every state, I would do an annual advocacy
conference with them. That's what created the Grand Rounds that I did with students and residents and attendings, so we bridged out, but they built into every one of their annual meetings and advocacy update, and it became pretty much more a part of the program than we ever thought that it would be. But that one on one opportunity to ask questions about what why did
this bill pass? Why are we now mandated to change the work our schedule to something different, they are as interested in advocacy for their own purposes, as you are for PPP. And it's a good thing they just haven't been as exposed to it as the others have been as Purvi said.
Since you brought up PPP. I wonder if you could take the time now, a lot of our supporters have asked us about lobbying. And there's definitely something that people are very interested in, like, how can we actually make an impact on legislators to promote our mission, which is physician led care and truth and transparency among healthcare practitioners? But Linda, you've been a lobbyist and you've explained that it's really not so simple. Can you talk about that?
Every state and federal government have rules and regulations about lobbying. When we speak, we always want to be careful to separate the concept of advocacy, which is representing the healthcare profession and advocating for patient's best interest with lobbying, which, which is actually going before a legislator or writing to regularly or inciting people to write to their legislators and telling them to support or oppose a bill. Any mention of support or opposition to a bill
becomes lobbying. And what happens is, if that is done by an organization, that organization needs to be registered in that state, and they need to be complying with all the reporting requirements in that state. And so that is not a simple process. And it is not standardized in any way, every single state has a different set of rules. So that lobbying across state borders unless you're a large, huge, well funded national organization is extremely
difficult process. I think that there are certain ways that organizations like PPP can help influence those who want to get involved and lobby for themselves as individuals. And that is to provide the resources and the education, doing templates of letters, both in support and in opposition to particular pieces of bills that can be changed and edited to whatever the issue is, but just giving them a basic template of what to write and how to say it and how to approach it.
Organizations like PPP can inform its members of what's happening in states that there's a bill on hepatitis C, or there's a bill on nurse practice, or there's a bill on radiology techs expanding that can be conveyed, but they just have to be careful that they're not saying we as an organization support or oppose, even though they may be behind the scenes and quietly, they're not doing it in an organized way.
So the idea is just once you've crossed that line into lobbying, in other words, I send a letter by from PPP and I say, 'Hey, Everyone, please write your senator, the senator and say vote against it.' That's now lobbying. And so if we do that, we have to actually be registered. And then we have to follow all sorts of rules and file different paperwork. And it could be in a certain municipality, not only do you have to follow the rules of the state, but you have to follow the rules of that
individual area. So what you're saying is, it's a lot to stay on top of, especially if we're trying to navigate different bills across all 50 states.
Exactly. Yep.
And that's probably one of the reasons why it's really useful to work with your local county Medical Society, your State Medical Society, because they do they are registered lobbyists. Most of those organizations have registered lobbyists that know all the ins and outs, right.
And I can say the scope issues are probably the most difficult for many of the state medical societies having worked at one year before ACP and even at ACP, there is a general belief in the team, the healthcare team and so going too far across a line sometimes can create some misgivings on the part of whether it's the organization, the institution or
the individuals. What really matters is that individuals themselves have unlimited ability to lobby an individual is a constituent is a person who is expected to connect with their legislators and give them information. And so that is what we want to be sure people are doing is understanding that just because there are lobbying laws in the state doesn't mean they can't convey the message that they oppose the bill. Are they
support a bill? They absolutely can and should, because that's their right as an individual,
Can both of you address your recommendations on working with national organizations.?You know, there's a lot of pros and cons to working with organizations like the American College of Physicians or the American Medical Association. And we hear a lot on both sides of the spectrum. So what are your thoughts on working with these large organizations?
I think the main thing is to realize which issues are state specific issues and which are federal because this I didn't, I also didn't realize before I got more involved, that not every type of legislation is a national or federal issues, and the national organizations aren't going to be pooling their resources to that, rightfully so. So scope of practice, for example, which you know, all of us are very passionate about is very much a
state to state issue. So there is no real, there's not much federal legislation that affects it there is from time to time. But that is something that you'd want to work with your state societies on. But there are a lot of federal issues, like for example, an insurance landscape with surprise medical bills, or with the Veterans Administration with any issue that happens in the VA, those can all be in the
federal pot. So it's really important to know what to work with national organizations versus state organizations, and every group is different, you I would look to align yourself with, I guess, a national organization that has similar priorities to yourself. And sometimes it is a little bit of trial and error, you know, because some are more
politically correct. And, you know, I've spoken to Linda about this at extent that, you know, whereas I prefer other organizations who I feel like are more proactive, right, on physicians' issues. So it is a little bit nuanced, but both, I think, serve their role. And both are very important.
And I can tell you, I've seen many, many, many times where an individual can help change a national perspective, the resolutions process in every state medical society that then funnels up to the American Medical Association, or the resolutions process within a specialty society is the way an individual can really say I care about this issue. And this is the reason why I care about this issue. And I really think this is something that you should be taking on.
And I have seen where it takes sometimes a little bit of time, but with persistence and the right arguments and the right approach, you can change policy at the federal level, both in Washington and in your specialty, your medical society,
I think you can change policy, but you start with changing hearts and minds, because like you said, you provide the information, as I think about it, the FMA some years ago, I made a resolution. And I want you to talk about writing resolutions in just a second. But I wrote a resolution just about non physician practitioners. And at that meeting, people were like, is
this really an issue? is this even something?' And then the next year, I brought it up again, and they were like, 'Yeah, I heard something about that one time.' And then like a year later, they were like, 'this is a problem.' And then another year later, they were like, 'We need to do something about this now.' And I was like - I was kind of frustrated but also it was exciting to to see that you can, like you said, just consistent education and information and raising
awareness. And then over time, you can start to sway policy, I think you're so right.
I think the important thing and you hit the nail on the head, is to understand the pace at which you can influence policy, because many of us are very - at least I'm very - I'm very impatient. And I'm like, 'Okay, I know, there's this problem, I want it taken care of ASAP.' But it does take exactly what you said. And I went through the same thing, because after my advocacy internship, as I was trying to tell all my friends in residency, and they weren't quite getting it, they weren't
seeing it. And then I just kept talking about it over and over again. And there's only recently now so many of them, who didn't see it as a problem are now reaching out to me and asking how they can get involved. And it's not just on the scope issue on all of these issues. I think it takes a few attempts. But that being said, I was surprised at how easy it is to write a resolution and how easy it is for it to advance, especially when the timing is right.
Because that seemed like another process that was very daunting and overwhelming. But anyone can submit a resolution, you know, and then once it's backed up, that is exactly what is used right for the society's to then target their key priorities.
I wanna jump in, though, just before we go to resolutions, because I know that's what you want to get to Rebekah, but I want to tell you the two quick stories, not only does it take patience on the part of members who really really really are interested in issue, sometimes it takes patience with the legislature. The Clean Indoor Air Act in New York took 14 years to get passed. We had the largest coalition on that bill of any other bill that has ever passed in the New York State
Legislature. We had Cancer, we had Heart We had AARP. We had every constituency out there and everybody wanted the bill but it just took a long time to get the right language. Why? Because of the opposition which you always have to know there was big business who didn't want to have their bowling alleys, unable to have People smoke and bars and liquor stores and things like that, well, that had an impact.
And we had to work through understanding all that opposition getting the right arguments in the right place that took 14 years, there was one It took even longer. And this was one that was so near and dear to physicians' hearts. And it was the Family Healthcare Decisions Act in New York, that took 17 years of very hard work.
And you know, what the physicians never gave up, they had to get the right place, the right time, the right people in the room, the right understanding of the challenges of surrogate decision making of end of life care, palliative care, understanding each and every one of those functions as a part of that bill took time, but we got there. And that took
17 years. So it's not only physicians need to be patient in the process with their national interstate organizations, they have to be patient with the legislature too.
I think you give a very key message is to not give up, right? Because eventually, it got through. And I think we all need to learn I have to remind myself this that it's a marathon, not a sprint, because it is so easy to get frustrated, it is easy to get burned out, feel like you're hitting a wall. But remember that you know, every little thing you're doing, even if it's one step forward, two steps back, you're moving towards that whether it takes 10 years or 17 years, you're still getting
there, right. So I think that's a really good reminder, Linda.
And sometimes a loss can even turn into a win. Because the opioid legislation, which was very slow to get started at states levels and federal levels, from our experience in New York, we fought it for it for it because first of all, it was a mandate on CME hours, you know more, how many more things you're going to parse out, that individual has to take another CME course on, so we fought it before we bought it, it passed against our objections in one of those middle of the night changes in
the back room. But we took that and made lemonade, because we decided, 'Okay, then let's take the bull by the horn,' and hopefully the brass ring and create the education that now is mandated, made some money on it was able to kind of put together a fabulous, ethical smart group that knew what curriculum to put out there. And we created an online program, it was one of the first ones we had 80,000 physicians who took that program, we turned it into lemonade, even though it was a
loss. So sometimes, you know, there's a gift in these packages that you might think are negative,
That's a good way to think of it. Well, let's talk about writing resolutions. So I guess the whole idea of a resolution is it's just a statement or a goal that you have for your organization, which could be to seek legislation for something specific or just to create a policy. Talk about what writing a resolution is about and how we do that.
A resolution can emanate from any kind of an idea, you can be sitting in your practice seeing a patient who suddenly has a rejection from his insurance company over a second opinion or over something that you want to prescribe for them, it suddenly hits you, 'This isn't right, this isn't fair, we need to do something about it.' So maybe your formulary changes - that's a really great example that these insurance companies are changing formularies in the middle of the
year. The patient buys a policy, that's the policy they buy, but yet it changes sometimes halfway through the year. That's a great example, we had somebody write a resolution to say, we need to take up this issue of did your formulary changes that the insurance company does not have the right to change the coverage meet your mid contract. So when an idea hits you, what you really want to do is just capture the purpose because that becomes the opening part of a
resolution. It's the whereas portion is whereas patients are having their formulary changed mid year by insurers, whereas this creates more expenses on the part of the patient that didn't come in their contract, when they bought it, you list all the warehouses and then the result portion of a resolution is what should be done about it. There should be no mid formulary
changes. The resolution itself is kind of structured, but the content is really very purposely based on what the issue is and how to resolve it.
Actually, this was my first year even though I've been involved with advocacy for so long that I actually was involved in the resolution process. Again, I was pleasantly surprised at how easy it was because I think I hadn't participated before because I thought it was something very daunting, because resolution sounds so formal and official, but it's actually one very easy to write. And there's templates from previous resolutions that
makes it very easy. Also, you know, one of our colleagues shared resolutions that they had used at their own state societies on very similar similar topics. So it was basically written for me with a
few tweaks here and there. And then you know, the actual process of when the resolution is discussed is also not as daunting as it seems you make your case and for the most part, sometimes there might be a lukewarm acceptance, but I think right now we're at a tipping point in medicine, where a lot of these issues that many of us has been sounding the alarm on for years people are finally waking up to So actually this year, it was very easy to get all of my resolutions through.
So I had one in truth and transparency, especially with the credentialing and the use of the word doctor in clinical settings, and then another one on the terms residency and fellowship, and what they mean and misappropriation of those terms. Luckily, it was good timing, you know, and it was they were very well received. But yeah, the process is very easy. And anyone can write one medical students were introducing resolutions residents were, you know, I was very, very proud of the future
of medicine. They're very engaged.
Yeah, I think the idea is you just something occurs to you, like Linda was saying, like, for me, the first resolution I ever wrote, I heard that physicians were being forced to supervise non physician practitioners. And even if they didn't think that they were very competent, or very good, it was a condition of their employment. And if they refused to supervise, then they would be fired. So I thought, I don't think that there's any protections for physicians. So I wrote a resolution about that.
And so the idea with writing resolution is it can be you as an individual, as a member of the Medical Society, or it can be you with your delegation, which could be your County Medical Society, your specialty Medical Society, and it could be a combination of different people. And so but it can be you as an individual, and then you write a resolution. And there's guidelines to how you do that. And then the resolution goes before different committees. So it gets assigned to a committee
to review it. And the reference committee is what that's called, looks at that. And they might make some tweaks and some adjustments to your language. And then they'll recommend that the resolution either be adopted or not adopted by the organization. So then after that, they'll hear testimony from people for and against the resolution. And then on the day of the House of Delegates meeting, it's really interesting, because at that point, you can have public testimony from all of the house
on the issue. So your issue may not be accepted, but people have a chance to talk about it and learn about it. And I think for the one I wrote the first year, it wasn't passed that first year. But I was able to stand up, talk about the issue, the whole house of delegates heard the issue. And then maybe they
started thinking about it. And then in the future, they said, 'Oh, you know, this is a problem.' So I think that's what's so interesting is it gives an opportunity for discussion amongst the group and in really healthy discussion, because it's not as scary - when you stand up on the microphone, especially for the first time my heart was pounding like crazy. But people want to hear what you have to say, it's very civil, it's very respectful. Everybody gets a voice, at least in
Florida. And it's such a great experience. So I recommend everyone, if you haven't had a chance to attend one of these meetings, you really should.
And they can be literally on any issue. So there were resolutions on gun control resolutions on women's rights. And you know, it can literally be any prior authorization with insurance companies, which is the bane of everyone's existence, really, you can pick any issue which you think is broken, and healthcare and bring it to light with the resolution. I think that's the beauty of it.
And there are some that just as we were saying, in the first episode, might take forever seems like single payer versus the existing system, there are resolutions in every single session of every single organization I've attended.
And they'll probably never ever, I mean, they're just so big and so huge, like, same with, you know, every year gun control comes up every year, climate change...
...climate change
There's a big discussion about you know, is this even within our scope? And is there something we can even make a difference on? And should we spend our time, you know, and but at least it's an opportunity to talk about these issues.
Exactly. And again, the time will come where it'll be right.
I think you're - that's such a good point. I think that the critical thing about these resolutions is that it is an opportunity for dialogue. This is a time that people learn about issues, you know, we're so isolated a lot n w in our own little silos and o r individual practices or in o r individual hospitals, and e don't always know what's goi g on with other people, or e don't realize that the issu s we're having are the exact sa e issues that others are havin
. So it's such a good opportuni y to explore what's going on a d talk about possible solution . So when you're writing a resolution, you're sometim s asking for legislation so perv , probably on your truth a d transparency. I imagine you gu s were seeking or supporti g legislation to promote tha
Yes, absolutely. And to your point, actually, just the discussion of these issues, and I think involvement and advocacy in general, actually protect physicians against burnout, because we hear this term over and over again. And I think burnout comes from that feeling of helplessness of just being a cog in the wheel of the system, right? And actually being involved in advocacy and writing these resolutions makes you feel like you have some of that power
back, right? Like you're in control or you have a voice to impact these things that seem hopeless, right. So I think in a way, getting involved in these things. may actually help a lot of physicians that are struggling with burnout or who may feel devalued in our current healthcare system.
You're so right, and also keeps us from feeling isolated. Because I think this is the biggest danger to physicians and a huge contributor to burnout is that we don't get together as much. And we start to feel like we're the only person in the world or what are the only person that can't handle these problems and is suffering. And when you talk to other people, when you're involved in advocacy, you start sharing your stories, and, oh, I have the same issue, I have the same problem. And there's
something just so helpful. And you just feel such a sense of relief, when you talk to someone else to know that you're not alone. We need these interactions with our colleagues.
Yeah, I'd like to reference it all going back to the really, really old days where there was a doctor's lounge where you would go in and behind those closed doors, talk about a bad case, a big case of problem and issue a staff nurse or whatever, we're missing that. And the resolutions process, because those kinds of multiple person debates come up does give you kind of a safe haven to have that kind of a discussion.
A problem shared is a problem halved, as they say, right, it just talking about it sometimes makes the load feel lighter.
You're so right. There's another good template that's out there that I know PPP has some of the states and be done to take up the associate physician bills, which are the unmatched graduates of medical school and allowing them to practice under supervision. They have more hours in training than many of the allied health professionals who are seeking
independence. And so taking those kinds of things as a resolution to your State Medical Society saying we need to create legislation in this state, because licensing is state by state, the ability to practice medicine in that state is state by state. This is something that needs to happen within the State Medical Society in the state specialty societies, but we have some great templates at PPP if i that's any help to anyone,
That's a great plug for our organization. We do a lot more than complain. Sometimes people say ' ou guys just complain about the ssues' - not true at all. Yes, e do a little bit of that. But e actually take a lot of action, a lot of education, and we do ha e a ton of resources. In our la t few minutes, do either of y u have any pearls of wisdom or a y other information you'd like o share with our listeners abo t advocac
I would just recap what we already said. One, anyone can make a difference at any level of their training, no matter where you are, you know, what we need is your voice you know just showing up makes the difference. And then the second thing that Linda's point earlier you know don't give up. No matter how long it takes these issues do get through the persistent group of individuals.
And it's so funny you use the term pearls of wisdom because in almost every PowerPoint I ever did a grand rounds with I had two pages of the pearls. And I also have a countdown that would talk about what influences legislators the most starting with knowledge understanding data, as being t e least of the most effective. nd the top one it: 'will g t me reelected?' being you k
ow the first one. so I have ha pearls and all of them is be c nfident in you are the resource you are the person who un erstands health care most. e active, nobody else is going o do this for you. In fact, there are going to be people who are doing it against you and t king away privileges that you've worked so hard to achieve. Be sure that you communica e clearly succinctly know your i sue. Know the people that you' e dealing with. Those are the p arls that I would
That is such great information. Thank you so very much. And to learn more about this topic, of course, we encourage you to get our book. It's called 'patients at risk th rise of the nurse practitione and physician assistant i healthcare.' It's available t Amazon and Barnes and noble.co . Please subscribe to our podca t and our YouTube channel. It s called patients at risk. And f r many more resources like t e ones you've heard about her . Please join our organization.
f you're a physician, it's call d physicians for patie t protection. Our websi e physiciansforpatient protection.org. Thank you bo h so much for joining me a d we'll see all of you on the ext podcast.