The job requirements of a physician are so much more than what’s learned in medical school. In this modern, connected technological environment, skillsets must include digital know-how, emotional intelligence, data management, and even the basic concepts behind software development. While the electronic health records (EHR) environment has led to a massive increase of data, learning and understanding what to do with that information can be the biggest day-to-day challenge of clinicians. All too often, knowledge gaps can persist and even widen without innovation and education, a dynamic that has exponentially increased since 2020.
On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, chats with Lalita Abhyankar, MD, family physician and clinic medical director at Carbon Health. They discuss her medical background, the evolving mission of Carbon Health, and her journey in understanding change management. They also discuss the emotions behind clinical care, the similarities and differences between primary care and urgent care, and how doctors can think more like engineers while still maintaining and growing relationships with their patients.
Listen here:
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Want to hear more from Dr. Joseph? Order a copy of his book, Designing for Health.
Show Notes:
[00:00] Intros
[01:25] Dr. Abhyankar’s background
[07:05] The mission of Carbon Health
[08:45] The overlaps between primary and urgent care
[14:05] Working with software developers and engineers in healthcare
[21:20] Learning about change management
[24:18] Drinking from the firehose of data and technology
[28:06] Relationship building
[33:10] Things that are so well designed, they bring Dr. Abhyankar joy
Transcript:
Dr. Craig Joseph: Welcome, Dr. Abhyankar, to the pod.
Dr. Lalita Abhyankar: Thank you so much for having me.
Dr. Craig Joseph: We I’m super excited to talk with you today because you are at the crossroads of where a lot of physician designer technologists want to be. So, you work for a private company called Carbon Health, and you all are in the middle of flying this plane as you design it, I believe, Correct? Very much so, yeah. Tell us a little bit about your background. I know that you're a family physician. How did you end up at Carbon Health?
Dr. Lalita Abhyankar: Well, that’s an interesting story. So, I graduated from residency in 2017 and I started working at a federally qualified health center in Brooklyn, in New York. I probably developed my clinical chops there in a way that in an urban environment, I was seeing all sorts of patients, regardless of age, regardless of background, mental health issues. I was seeing prenatal care like it was really lovely to be able to build out my outpatient chops in that way. Then the pandemic hit. Brooklyn, of course, was one of the hardest hit in terms of the entire country. I carried a lot of grief for a really long time. For that whole summer, I would say it was really challenging to practice and be there for patients who had loved ones in the hospital who were getting sick, who I was trying to keep out of the hospital, my colleagues and I have stories of trying to diurese patients over Zoom who should not have been right ... they should probably have been admitted. But we were trying so hard to keep people out of the hospital as primary care doctors that it became this huge burden. And ultimately, I think I realized I had maybe known this a year before, that I wanted to be involved in helping people design the tools that we use to take care of our patients. And I think historically, physicians have really had that influence. A lot of people have designed their own tools for the things that they needed in the past. And electronic health records are a tool that we use every single day that don't really have that much physician input or influence because you can't learn unless you have that engineering or software development background. And most people kind of pick one and not the other. So, there's not a lot of that kind of flying by the seat of your pants, making these tools in order, like making a stethoscope or something like that. It's not as tangible in that way. So I had known that I had wanted to get involved in something creative like that for a while. And the pandemic kind of derailed that. But I also learned a lot about technology. We moved over to telehealth within a week, and that taught me a lot about like what you can do and how you can actually offer services from a virtual perspective. Like you can diurese patients over Zoom. It's possible. You can make sure that you're setting them up with the infusions that they need without actually having to go to the hospital. I had a couple of patients who, desperately needed either it was chemotherapy or iron infusions, and I was able to get those things done. It's not an ideal state. And so, I was really curious to see who was out there, who was kind of making changes and setting up a system where you're allowing yourself to use technology in a way that can actually help patients. So, at some point I decided that, you know, I was really trying to look for opportunities that allowed me to kind of expand that knowledge base as well. Like, how do you talk to designers? How do you talk to engineers? Like, what are people looking for? What kind of clinical input do people need when they're actually building out these tools? Do they even have clinical input in a lot of situations? I got a really cool project actually at the FQHC we got a grant to help support geriatric care at our practice. We had like a multi practice company in Manhattan, Brooklyn and the Mid-Hudson River Valley, and we had received this grant to do geriatric care. And the I had been partnered with a geriatrician, also a family doc, who was very into like, how do we build education around geriatric care? And my thought was, well, it's part of it is, yes, like lecture series making sure that the residents know what they're doing, making sure that attendings and other people who are providing the care know what they're doing. But in order to make it sustainable, having that decision-making tool somehow embedded into the EHR is going to be far more effective longitudinally than not. And so, we worked with our CMIO and some of the social workers actually, to identify pain points within geriatric care. So, like durable medical equipment, that's a huge one. So how do you streamline that? How do you allow a clinician to find all of the information that they actually need in order to take care of somebody who has multiple chronic conditions and who you need to be able to assess for physical and mental deterioration? And so we were able to create like a snapshot within EPIC, which is the EHR that we were using at the time. And that really whetted my appetite for like, cool, this is a way that you can actually help people take care of patients more effectively. And so when I left that practice, I was really looking for, you know, the idea of a startup was fascinating to me. And so, I was looking for different places that were trying to be innovative within primary care. And Carbon, I think, provided me the most support in terms of the skills that I wanted to build. And so that's, that's why Carbon.
Dr. Craig Joseph: So, what does so first of all, carbon health, I believe, is principally located in a different ocean. Were you aware that it was a different ocean from the Atlantic to the Pacific?
Dr. Lalita Abhyankar: Yes, I was aware that someone told me that. Someone did.
Dr. Craig Joseph: Tell me about that.
Dr. Lalita Abhyankar: Yes, I had to fly across the country in order to start my job here. That I think some of that was also pandemic decision making. My family lives in Arizona. Getting back here during the pandemic was really challenging. And so, my 12-hour driving radius was kind the thing that I wanted to make sure that I had. And I think, you know, New York is a really transitory city. And as much as I love it, I think it was time. It wasn't New York. I think that San Francisco was the other option for me. So, I'm in the Bay now and yeah, and really, really falling in love with the Bay in different ways also.
Dr. Craig Joseph: So, what does carbon health do? I as I understand it, when you first started, it was focused mostly on kind of episodic urgent care.
Dr. Lalita Abhyankar: Yeah. So, they have, you know, Carbon has been an urgent care practice primarily, and I think we introduced primary care into the practices about two years ago, maybe a little bit more than that, 2 to 3, three years ago. Since then, I think that has been a challenge of its own. Like how do you take primarily urgent care practice and build in successful primary care? it's been, it's been interesting and fun.
Dr. Craig Joseph: And what are the, what are the big differences between primary care and and urgent care? Right. They overlap a lot more than I would have thought, actually. Pre-pandemic.
Dr. Lalita Abhyankar: Oh yeah? How so I'm curious.
Dr. Craig Joseph: Well, you know, I used to think of them as having very little overlap. You know, urgent care was. Yeah. You know, I, my kids got an ear, or my kid might have an ear infection, or I have this rash or I'm having a cough and I might have pneumonia or exacerbation of my asthma, which, which is, you know, certainly episodic, but it's usually kind of in my mind, self-limited diseases and primary care. Again, I have my focus as a pediatrician has always been a little different than, you know, for adults. But most of what I did to I'd say maybe half was certainly that kind of episodic care. But the other half was, you know, your traditional, hey, how is this child developing and what are all the things that they're not here to tell me about that I have to figure out on my own, because they're purposefully not going to tell me or they're just not aware that, you know, that the child's development is off or there's, you know, there's something there. And to me, those were different things. But boy, urgent care is really kind of become, hey, as long as you don't need to be admitted, we're going to we're going to try and handle it.
Dr. Lalita Abhyankar: I honestly think that urgent care only exists in this country because we don't have good primary care. It exists because we have a gap, because we have a lack of supply when it comes to primary care, because everybody wants to go to their own doctor when they're not feeling well. Everybody wants that person to check out their ear if they're feeling like they're having an ear infection so that they can also talk about, you know, like you connect the dots in a different way. I think we were talking about before where it is relationship building. And you want the relationship that you have built to be the person who's taking care of your episodic care as well. That's what ideal primary care. That's what that small-town doctor ideal, Norman Rockwell painting, is about. Urgent care takes over what primary care doesn't currently have space for, but it's all the same like I was trained in, you know, I did an urgent care shift recently and I had a kid who came in with a dislocated elbow and I was able to snap it back into place. But I've done that in my primary care practice as well before. And so those little things, I think really overlap. And in my case, if I have a patient who comes in on the primary care side who has, you know, maybe they have some acute complaint, I'm able to get their preventative care done at the same time. And so that I think that’s to me, urgent care is really just an offshoot of primary care.
Dr. Craig Joseph: Love it. No, I think it's a hot take. And I would argue it's absolutely spot on. So, what are some of the struggles? I'm assuming there are struggles as Carbon Health kind of moves from traditionally just urgent care and then starts in the last two or three years adding primary care. Do they speak your language? Are you kind of showing them new and different ways of thinking as you’re helping them move?
Dr. Lalita Abhyankar: Yeah, I mean, there's a number of us who are doing primary care here in different capacities. I think that everybody has their own input. And yeah, it definitely is a language. There's a translation component for sure, especially when you have people who are trained in emergency medicine on the clinical side who are kind of running things, to make sure that that longitudinal care outlook is something that's supported and evaluated and prioritized, especially as we're building out primary care like that. That definitely does lead to some really interesting discussions. Not to say that, you know, I think that there is something to be said about like if you really, truly want to provide care in an innovative way, you have to be able to think outside of the box and outside of like traditional clinical hierarchies. And also, those clinical hierarchies exist for a reason. We've been trained, and we're so entrenched in them that that kind of moving or shifting away from that sort of thought process sometimes becomes like, you can't teach people who have been ingrained in that system new tricks because that's just not what how they've built their intuition on things. So that's also something that's really interesting that I've experienced, especially talking to designers and engineers at Carbon who are building out the EHR. Who really wants to redesign things to make them look pretty? And I’m like, no, no, like blood pressure has to come first, then heart rate has to come after that. And that's just how we're used to reading it. Don't mess it up, which I think can be sometimes, you know, really constraining. Yeah.
Dr. Craig Joseph: Constraining for you?
Dr. Lalita Abhyankar: Constraining for the training for them, I think.
Dr. Craig Joseph: Yeah, so let me pick on that a little bit. So, you're, you're dealing with, with software developers and engineers who are used to often living in, you know, a black and white world and you're now kind of exposing that to some extent, some of the gray where, hey, this is not exactly right. And I know that we're violating your design rule by making this look a little ugly and data-intense. But in day-to-day, you know, come hang out with me, and you'll see how many minutes I have to see this patient and move on to the next patient. And I can't be, you know, flipping around a nice screen. So how do you kind of handle that communication? Is there is there a secret to speaking engineer that we all should know?
Dr. Lalita Abhyankar: That is the crux of what I’m learning. I think there are times where one of the serious philosophical questions I had over the last six months was how do you tell someone that their baby is ugly in a way that doesn't shut them down and make them feel like you hate them? And I think that that's the skill that I'm trying to hone, is that how do you give feedback in a way that is constructive and kind and thoughtful and also appreciates the other person for what they've done? Because a lot of times people have poured a lot of time and energy into some of these features that for me, on the clinical side are completely useless and I could use the word useless and then I don't want to, but at the same time, like how are we going to make something that actually is useful? And that's something that I'm really learning and is a big skill. I was just talking to somebody who was a physician on our design team recently about like how traditional design tells you to drill down the problem to the narrowest that it can be. And to solve that problem and to then build up from that. And I have learned how to do that definitely over the last two years. That it's sometimes I don't come in with solutions. I don't come in hot with solutions anymore, even though that that's how I've been trained. And that's kind of what you do in medicine, is that you're taught to, you know, stick to your diagnosis like you might be wrong, but stick to it, convince me in this case, I think that I try to give as much information as I can so that I'm very, very, very, very clear about what the problem is. And so that's been a change in terms of how I talk about it. And so, one of the ways to give that feedback, I think, is to make sure that like, cool, this is great, and this is what I actually need it to do. And the people that you're talking to are usually smart enough to put two and two together that they're like, this is completely useless for her. And also, the other piece of is that in a clinical setting, sometimes you can drill down to one parameter, but it's really important to have like an orthogonal parameter included as well so that you're building out from multiple use cases. Because otherwise you end up creating something that's too narrow of a solution.
Dr. Craig Joseph: Sure, so empathy seems to be a big player.
Dr. Lalita Abhyankar: They talk about that, like, designers talk about empathy all the time.
Dr. Craig Joseph: Yeah. Well, I mean, I think I was asking you a question I knew there was no great answer. Yeah. You know, how do you kind of convince them that, hey, this is this is what I need and it's not as pretty and it's kind of basic, but it's really going to get the job done. And to that end, do you have do you host a lot of developers and engineers in your clinics? How do they learn what you need?
Dr. Lalita Abhyankar: Yeah, I think up until recently, I’m working on it. It’s not a great answer, but I think that there is a push to make sure that they’re involved in clinics and that they’re, you know, following and shadowing people. I know that designers in the past who have been here have been really mindful about doing that. I know that there's people on the team that I'm able to reach out to who are very open and really responsive when it comes to the concerns that I have, even if it is like, yes, we thought about this and this is why we did that, right? That's also the two-way street that a good designer, when they're talking to somebody with a clinical background, needs to be able to do, that often appeases a lot of those like hot and bothered feelings. Yeah, like why is this happening? Oh, this is why this is happening. So, you had to make a decision between this feature and that feature, and you decided to go with this one. And I understand why, and I'll make it work, I am, you know, as clinicians, as physicians, I think especially you learn how to make it work in suboptimal settings. If you know residency, you learn sick and not sick and you learn how to make sure that things get done. So, I think that that sort of two-way communication is, is integral when you're building out something that's creative and interesting.
Dr. Craig Joseph: Yeah, it's, it's a truism. I once went when I was on the vendor side, I went to a go-live and this, this nurse said, hey look what happens when I click this very specific set of, you know, this specific workflow. And I'm like, that's clearly a mistake. I will go and then see if I can fix that. And it turned out it was not. It was it was kind of like, no, that's a design feature. And when I went talk to the developer, when I went back to the to the mothership and talked to the developer and he said, well, we know how to fix that. It's on our list, but it's been a low priority. And I said, You're going to come with me to the next go-live. I want you to sit next to me to look when that nurse looks at you like you don't have any idea what you're doing. And then I want you to tell them that, yeah, we know about this, but it's been it's a low priority. So sometimes, you know, I need them to feel the pain that I'm feeling and that you’re feeling and that the users are feeling just. It often can change their priorities or what they think is important. They don't have unlimited time. So, you were just, you were mentioning being a resident and, and learning how to focus and get things done. Change management. I'm pivoting but I'm not really. Change management is something that you learn how to do as a physician in training. We are constantly trying to manage change of our patients. Hey, you know, all of those foods that you're eating are not helping your diabetes or your hypercholesterolemia or those kinds of things you've said that you've undergone, I think in this job and maybe your previous one, a fellowship of change, which I love. I would hate to see the board questions that you must have done when you did this fellowship of change. But what is this fellowship of change? What have you learned about change management that maybe helps you deal not only with your patients, but also with your peers?
Dr. Lalita Abhyankar: Yeah, I just said this again at a meeting this morning where I was like, yeah, this has been a two-year fellowship in change management. So as a startup, being a part of a startup you have, there's a number of decisions that are made, there's a rapidness to it that doesn't actually exist within most kind of legacy institutions, especially in healthcare. You learn change management in residency in order to ... maybe you're a senior and you're trying to teach someone you know how to do things. Maybe there's rapid change happening with the patient, right? Like you're trying to convince, perhaps there's like an ICU situation and you have to convince the family that it's time to let go. There's a lot of different change conversations that you end up having in the clinical setting when the company makes decisions or when there is new rollouts or new workflows, or just, I think in this economic environment, in order to survive, there have been some really challenging decisions that we've had to go through. And how do you make sure that the team is along for the ride, that you're being honest and open and able to kind of talk to your colleagues about how to navigate these changes and the emotions that come up? I think, you know, at Carbon we've talked a lot about how to make sure that you’re kind of emotionally on the same page and that it's okay to be in that kind of anger, apathy, because that happens with change. Also, like, you're going through the five stages of grief any time any change happens. And so really, how do you use that framework to continue? And at the end of the day, it's also like there's a financial piece to it. I hate saying this from like this altruistic clinical, somewhat of a philosopher background. You still have to keep your doors open and your business running. And so how do you reconcile all of that is really what I have been learning over the last two years. And it's been really remarkable to see, to be more patient. I thought that nothing would faze me after residency and like, no, things really still did.
And, you know, much less, I think fazes me now after having been at a startup for two years.
Dr. Craig Joseph: So, I'm hearing you're recommending that all physicians do some startup training. Maybe it's not a bad idea.
Dr. Lalita Abhyankar: It's not for everyone.
Dr. Craig Joseph: Well, that's fair. Whether you work at a startup or not, though, you're using technology. If you're in healthcare for sure in the United States. And yeah, and a lot of the big countries. You've mentioned about drinking from a fire hose of technology.
Dr. Lalita Abhyankar: Yes.
Dr. Craig Joseph: And that's a quote I love because we don't really think about it. It's an expectation we have of physicians and clinicians nowadays that. Well, this is how you do your job. You still might have a stethoscope and a reflex hammer and surgeons still have scalpels, but none of them can do their jobs without putting in orders or prescribing medications or looking at lab results. And all of that requires the firehose of technology. So, I think my question is, how does a physician figure out what's the most important thing? Because when I'm drinking from that firehose, I'm clearly not getting everything. I'm not I can't swallow all that water. And so, some of it's going to go in in one ear and out the other ear. How is one to prioritize or what suggestions do you have that you use?
Dr. Lalita Abhyankar: It’s not just technology, but there's like a deluge of data and I mean, I have a lot of patients, especially being in the Bay Area where I'm practicing, who are obsessed with data. And a lot of times I have to be like, what's the point? Like, what are we actually looking for here? What decision are we making with this data? Is this helpful data, or are you just looking at data for data’s sake? Similarly, I think, you know, technological interventions like we've wanted for a long time, oh why can't I just get my node done magically based on like what I'm talking about with the patient? And that's happening now, right? We're seeing natural language processing; we’re seeing artificial intelligence or machine learning based programs that are helping to create notes and helping to mine information in charts and helping to kind of add on and really optimize what somebody can do in a patient room. I'm interested in this stuff and it's so hard for me to stay on top of it. I admire people who are able to just really entrench themselves in the technology space and understand all of the background and the drama and, you know, whatever else exists with what's being developed in order to help with healthcare. I think from the firehose, what my hope and intention is that if we get more practicing people on board to actually have those conversations about what's necessary and what's not and why, maybe minds can change in both directions. And so you have a lot of people who are building out technology without clinical input. You have a lot of clinicians who are really just choosing to take that luddite path, which I can understand. You don't want to deal with any of it. How do you create that dialog and that platform so that the firehose doesn't seem as intimidating? I think that's the best answer that I have. I don't know what you drink and what you don't.
Dr. Craig Joseph: I was just hoping you would tell me what to drink, but yeah ...
Dr. Lalita Abhyankar: Not the Kool-aid.
Dr. Craig Joseph: Yeah, sometimes it's not so much important to know what to drink but what not to drink. Don't drink the Kool-Aid. All right, I'm totally down. I'm totally down with that. So, another thing that, you know, you and I, when we were preparing for this podcast were talking about was relationship building. And you had said something that I thought was incredibly wise. Which was that the number one job of any physician is relationship building, especially in primary care. So can you talk a little bit about that and how you came to that conclusion?
Dr. Lalita Abhyankar: Yeah, I know that people have been talking about this, especially like what is the skill set of physicians as we have all of these technological tools that are being built out? I think it is at the end of the day, it’s a relationship. If you are going to build primary care, the number one thing that needs to be optimized for is that relationship. I think the example that I had used with you was have a patient of mine who recently was a new patient, his physician of 30 years, had retired. He came in, I was doing just a basic exam on him, and I heard his heart, and he had a really, really loud murmur. And I asked him about it and he said, you know, I, I have had this murmur for a very long time. And I was like, it sounds particularly loud and harsh, I don't have a prior echo on you. Like, I feel like it's time. If it's been more than like 3 to 5 years, which it probably has because of the pandemic, I want you to go get another echo. And so we sent him back to a cardiologist who had all of his stuff. And it turns out that his aorta was so stenosed at that point that he needed a replacement. The magic of that was not that I caught this or anything like that. I think it was really as he was in that decision making process because he's an older gentleman. There's a lot going on in his life right now. And they were like trying to do renovations. And also, there was business decisions and financials, there is so much going that this felt like it was not necessarily a priority at the time. And so, I actually was able to have multiple visits, like he would just come in and ask, what do you think? What should I do? And I'm not going to be the one doing the replacement in any way, shape or form. But I am a guide and a counselor, and I have been in the system for long enough to be able to knowledgeably talk about what I have seen in a way that hopefully I try not to be like, this is how it is, don't do this, do this. I think my job is really to serve as somebody who is laying out the pieces and trying to figure out what that best choice for that patient actually is. And it may be something that I wouldn't do. And that's okay. But that relationship, without that kind of back and forth, I mean, ultimately everything worked out. Like his blood pressure is now well-controlled, his murmur isn't really loud anymore, and he ended up getting it done. But it was because we had those, like, really candid conversations that now when he comes back, I'm able to talk to him about so much more. Anytime you have that right, the cardiologist or, you know, a surgeon isn't necessarily going to have that longitudinal relationship. They're not necessarily, even if they know or if they've studied that open heart surgery, for example, is more likely to lead to feeling like loss of purpose and depression. They're not the ones who are going to be able to counsel and talk to them before or after about those kinds of things. And that's where primary care really comes into play.
Dr. Craig Joseph: Yeah, I love that story because, you know, the idea that this person goes and sees several specialists, perchance they saw a cardiologist and then a surgeon who are both telling them like, hey, you need to do this thing. And yet who do they go back to? That's you, the person with the least experience in terms of replacing cardiac valves. And, you know, I've had that experience, too. You're asking me? I sent you to the smart people, let the smart people tell you, but they do want to hear from you because they trust you and they've got this long-term relationship with you and the cardiologist. Maybe they've seen once or twice and the surgeon only once for sure. But it's hard to judge that. How do you measure that? If I'm running a big healthcare system, how do I know which of my doctors have good relationships with their patients? It's hard to know. I can potentially know which ones have patients who are getting their colonoscopies regularly.
Dr. Lalita Abhyankar: What you can do, a friend of mine is in an informaticist and family doc in Texas and she was talking about how there are docs who are able to get their patients to do the colonoscopy, what's the magic sauce that they have? There are docs who tell people to do their colon cancer screenings and their kit is never returned and the colonoscopy is never scheduled. So, what is that secret sauce like? That's where I think we should really be digging into what that is because that is what primary care is about.
Dr. Craig Joseph: Yep. Hallelujah is what is what I say to you. Well, on this high note, let me, you know, start to kind of start at the ending. One of the things we love to do on this podcast is ask folks to describe to us one or two things that are so well-designed that they bring them joy. And often this has absolutely nothing to do with healthcare or medicine or technology. Sometimes it does. So, what are those things? Are there one or two things that you think are just amazingly well-designed?
Dr. Lalita Abhyankar: I mean, okay, so when you said bring me joy, that's like a different parameter. And I would say that Golden Gate Park, which is what I live next to now, is one of the best-designed parks. And this is somebody who lived in New York for seven years. And it brings me a lot of joy. I think it's like designed in this way that is wild and beautiful. And there's always more to find and more to get lost in. The other example, and this is from being in New York for seven years, is that the subway system is ... it doesn't bring me joy. So, I think that's why I changed my answer. But it is the great equalizer in a way that I think healthcare and primary care could be as well. You see people who are you know, it's the fastest way sometimes to get from point A to point B, faster than a car, faster than walking. And so, you see people who are suited and booted and probably sometimes worth millions of dollars next to people who slept in the shelter last night. Everybody is on equal footing, and everybody uses the subway. And it is functional for the most part, almost always. Sometimes. And also, it is you know, it is something that is kind of like the lifeblood of the city. And so that is the other thing that I think has been well designed. It serves its purpose, I think, which is a different parameter for design, I think, than just joy.
Dr. Craig Joseph: That's great. I love the idea about the well-designed park and sometimes that sounds like part of the thing that you love, and sparks joy is that there are areas where it's just not designed, right? It's kind of just wild and ...
Dr. Lalita Abhyankar: But it's curated in a way. So, there's redwoods there. It's also curated in a way that feels like you're going on a hike, but guaranteed some Parks and Rec person knows every single one of those paths and you know, has cut every single one of those bushes or something like that just so that they, they feel that way.
Dr. Craig Joseph: Yeah, that's awesome. Well, what a pleasure it has been to speak with you. Really appreciate it. I've certainly learned a lot and I'm thankful to you and I look forward to all the great things that you're going to do and that Carbon's going to do with you.
Dr. Lalita Abhyankar: Thank you. I appreciate that. It's been really lovely speaking with you as well.