 relationships with any commercial interests related to this activity. Those of you seeking continuing medical education, you should have received two pieces of paper on the way in. The small one is for you to fill out and leave at the registration table. The larger piece is for you to take with you and remember in two to four weeks to look at the information on that piece of paper and go online to claim your credit. For the rest of you, we do care about your feedback and there is a link, an electronic link on the back of the program which you can use with your smart phone and you can go online and fill out a survey and tell us how you felt about this presentation today. Now, a few words about Dr. Frank Bryant for whom our lecture is named. Dr. Bryant was a much-loved family physician and a community leader in San Antonio until his premature death in 1999. He's among the first African American students to graduate from the University of Texas Medical Branch in Galveston and he went on to become an important advocate for the medically underserved living on San Antonio's east side. He co-founded the Ella Austin Health Clinic where he was the first medical director and he also co-developed the East San Antonio Medical Center. He served as the first African American president of the Bear County Medical Society and the first president of the C.A. Whittier Medical Society. I also want to say a couple of words about our topic today. Dialogue about race is a charged subject in our country. It is challenging and it has rocked our cities and our universities with renewed energy over the last several years. None of the underlying issues are new but when we fail for centuries to acknowledge and address certain biases, these internal prejudices find destructive ways of externalizing themselves. Today, April 19th is the anniversary of the death of Freddie Gray. He was a 25 year old black man in Baltimore, arrested for the possession of a switchblade. He died after what was called a rough ride to police headquarters. The cause of death was injury to the spinal cord. The officers involved were charged with second degree depraved heart murder, assault, manslaughter by a vehicle, misconduct in office and reckless endangerment. Many of you know that the city of Baltimore rose up as a result in an ongoing series of major protests against racism and police brutality. Civil disorder looting, burning, and a state of emergency in Baltimore ensued. This is something that happened not 200 years ago. This happened last year and it's just one example. I bring up this story from our history, our recent history, to remind us that when we bury painful truths, like our intrinsic mistrust of people whom we perceive to be different from ourselves, when we bury disturbing truths down in the recesses of our consciousness, they inevitably resurge and manifest themselves in ways that cause great harm. Not only to individual lives, but to the very fabric of our society. If we don't choose to disturb ourselves to discern our disease and try to cure it, the disease rises up. It undermines our human civilization. Today's Frank Bryant Memorial lecturer, Dr. Damon Tweedy, has faced many manifestations of intrinsic bias, both personally and professionally. We are grateful to Dr. Tweedy, a learned psychiatrist from Duke University, and author of Black Man in a White Coat, A Doctor's Reflections on Race and Medicine, for his willingness to speak out and to educate us about how racism impacts not only our practice of medicine, but the way in which we recruit and educate future health professionals, and the way we deliver health care to Americans. Dr. Frank Bryant would have agreed with Dr. Tweedy, who has said, being black can be bad for your health. And Dr. Bryant was a San Antonio hero who tried to do something about that. He lived his life in a way that said health care would be available to everyone, regardless of their socio-economic status, and regardless of the color of their skin. Please help me welcome Dr. Damon Tweedy. So thanks for that wonderful introduction. And it's really an honor, I had a chance to read a little bit about Dr. Bryant before coming here today and seeing his family. It's an honor to be here and to see some of the previous speakers who come to participate in this lecture. It's really an honor to be part of this larger tradition now that you have here. So the reason why I'm here is that last fall I published a book, as you see here, Black Man in a White Coat. So it came out in September and it was published a lot more. Initially, and I will get into this more later, I thought it would be a really sort of small project, wouldn't get a much attention at all. And in some ways it's been a complete option of that. And so it's allowed me a platform that I never really envisioned having. And so certainly it's just a tremendous honor. And what I wanted to do with the time I have today is to tell you a little bit about the book and about my experiences that sort of informed the book. But also with my own stories and individual sort of means to this larger kind of dialogue about race and medicine. So let's start with the title. So the title is Black Man in a White Coat. So actually I came with the title myself and I was in the shower one day. And normally when I'm in the shower I just sing really bad songs off key. But this one particular day I had some inspiration I guess you could say. And the White Coat was hanging up on a little rack there and I got out the shower, got dressed, and it sort of just kind of came to me, this whole idea of black man in a white coat. I can't really grasp it any other way. And so there's a literal meaning to it, like the physical manifestation of being a black man in a white coat. But then there's also a symbolism. This idea of having two identities. This idea of being a young black man in the American society and all the things that that entails. But also being a white coat, being a member of the medical profession. And so these are two very different identities. And so much of the book really talks about the ways in which these identities merge and clash. And so that's really at the heart of the stories I tell. So the book is really two stories in one. Two stories in one. So the one story is a story that you talked about with Dr. Bryant of the challenges of African-American patients. The challenges that we face in the country and also within the health care system. It's like one integral part of the story. And what I do in the story, a lot of it's known about these issues. But what I try and do is personalize it. To use the stories of real people to illustrate how these problems are impacting people in the real world. These larger issues. It's also a story about my own journey as a young African-American going through the medical training process. And the ways in which my experiences were very unique from others. So it's really these two stories melded into one. So I know there's a CME requirement here. So I'm going to kind of guide you through that. I call this the MD version of my slides because it's often for medical audiences. And so you can see that the goals here there's several goals. So one is that you're going to get a better sense of the health disparities that are impactful in the primary care and mental health. Those are the fields that I know most about. But the truth is that these issues are relevant in all areas of medicine. It's just that these are the areas that I've had most personal experience with. I'm in psychiatry myself. My wife is in primary care. So these are the areas that we know the most about. But they inform all areas of medicine. And then I'm going to take you through some slides and look at numbers. And I think this will be pretty interesting. You'll look at some of the disparities in terms of the patient populations, in terms of the demographics of the communities where people where doctors are being trained. So you'll see the differences between the numbers of doctors that are minorities and the numbers of the patients that they're serving. And I'll show you some interesting data points about that and what the implications of those are. And then here we'll look at some issues about the role of minority physicians and some of the African-American patient populations as well. So this is just sort of the nuts and bolts part about what the books about. Why did I write it? What did I learn? Where did we go from here? And I think this last part is particularly interesting because I'm going to give you some idea. The book's been out in the world now about seven months. And I want to give you a sense of some of the feedback that I've received. In some ways it informs where we've come in terms of progress but also some of the limitations of that progress. There'll be some really uncomfortable things that you'll see that have been said to me about some of the things that I've written. So I think that's also interesting because it tells about this larger story as well. So the idea of the book, if someone were... the way it all sort of came about for me was I was interested in medical books, medical stories. I was always interested in those kind of books. There's some famous authors from this university here as well that I learned about today. And these medical stories, while I really enjoyed them, there was a part that was missing. They weren't talking about this experience of the minority patient, the African American patient in particular, the challenge they were facing, but also the challenge of African American providers. It was almost like a story that wasn't being told and I wanted to contribute to that larger dialogue. It was almost like I wanted to write a story that in some ways spoke to this larger problem. And so that was sort of the idea which I started with an interest in writing and it became something more than that. And so that's sort of how the book evolved itself. So let me just kind of advance a few slides here. So these are some of the books. So again, some of these books, they're all really well-written books, but I wanted to sort of tell a story that contributed in my own way to this larger conversation. Now when I started medical school, I wasn't someone that 20 years ago, I started medical school, 1996. It's hard to believe it's been that long. I wouldn't have been someone that you would have imagined one day 20 years later being the person here writing this book. So I grew up in a lower middle class African American community, 1% African American, and I clearly was aware of the challenges that came with that. But I was, in some ways, I'd always had my head down, did well in school, and kind of felt like I was in some ways transcending these problems that were inherent in society. That was sort of the mindset that I came to medical school with. I wanted to become a cardiologist and the thought was that I was going to unclog arteries and an artery is the same no matter on the inside, no matter what you look like on the outside. That was sort of this kind of frame of mind, this sort of post-racial kind of exploration that I had when I started medical school. But several things happened when I got to medical school, both in terms of what I learned in the classroom as well as what happened to me in personal life. I began to sort of change my perspective and sort of got me on the path to where I am today. So as a first year medical student, so Duke, we do this strange curriculum where you do everything in one year in terms of the classroom. It's pretty kind of strange. I think we were the only school that does it that way. There's good and bad with that. So what happens is that they really compress everything into that first year in terms of all the lectures on diseases, et cetera, et cetera. So we kind of get through everything really quickly. You go through things really fast. When we learn about diseases, say common things like high blood pressure or diabetes, right? So you start with the physiology, how it affected the body, this sort of thing. But then they would always kind of eventually, in the lecture, they would go to the sort of the social implications, like one of the demographic factors. Who's affected more? Men or women, young or old. And so whenever that conversation would drift towards race and ethnicity, there would be this sort of refrain, this sort of ugly refrain that would always come up. It would always be that the disease was more, so disease, as I say, was more common in blacks than in whites. And then even if the disease was uncommon in African Americans, they would say, well, after Americans who get this disease have a worse course and it would be this sort of refrain over and over again. But there wasn't any context to put to that. It was just sort of like disease, race was a risk factor for disease. But there was no understanding as to why or what that meant or what could be done about it. And that was sort of the story that was happening over and over and over again. And so, and this is the next slide to sort of illustrate some of the examples. You know, the truth of the matter is that basically any area you look at in medicine, you see these same sort of stories play out. Whether it was the beginning of life or the end of life and everything in between. And so these are just some examples of these problems. So one of the things that was in some ways troubling to me was this whole framing of the discussion between black and white. And that's sort of how it was framed. And so it still continues to be framed that way. And so that was problematic to me. But then beyond sort of the thought, so this is sort of how I interpreted what they were saying. Because there was no context to it, right? So being black is somehow bad for your health. But what does that mean? And where can we go from here? What can we do about it, right? So that was a part of me that was really troubling. Because I would be in a class, it wasn't quite this large, but I was in a classroom and I would be one of the few minority students looking around a classroom, wondering what the classmates around me were thinking about these issues. Was it something that even registered on their radar? Was it just in one area, out the other? Was it just a box to check off? What did it matter? Well, it mattered to me quite a bit from an intellectual standpoint, but it also mattered from a personal standpoint. And the next couple slides will illustrate that. How it came more than just something that was an academic sort of exercise. So this is a picture of my maternal grandmother. So this is in the last couple years of her life. So she's actually the only grandparent that I knew. So my dad was the youngest of, well, the ninth of ten children. So by the time he was around, his parents were up in age. And so I never got a chance to meet my grandparents on my dad's side. But on my mom's side, this is the, my mom was raised by a single mother. And so this is my grandparent that I knew. And so, you know, we, she lived in Washington, D.C. area. And after church on Sundays, we visited her and she tells us about life, you know, growing up and those sorts of things. And so from a health standpoint, she had a long history of high blood pressure, hypertension. I knew that. But during the senior year of college, she started to develop complications. So she had a couple strokes. And the last one caused physical and mental sort of impairments. And it was pretty, pretty noticeable. And so there was a clear decline. During the summer before I started college, started medical school, she developed heart failure. And that rapidly progressed. And she died in my first year of medical school. Right before I was getting ready to start my gross anatomy lab, I remember that pretty vividly. And so, hypertension, strokes and heart failure. You see, they're all diseases that are more common among African-Americans and have a worse course. So this was, that narrative I was hearing about in the classroom was playing out in my own personal life. And the story became more personal several months later. So this is me as a first year medical student. I can't find any picture of me being happy as a medical student. I don't know what that... I don't know. I tried and tried. I just couldn't find one. I don't know what that says. So anyway, this is me as a first year medical student. And as you can see, my sense of attire was a little off too. I had on a black coat, blue pants, and I actually had on brown shoes. So it was a little bit off. I've come a little ways thanks to my wife now. So about six months after, you know, that first after my grandmother passed away. So those of you who are physicians in the morning snow or nurses or whatever, you know that when you learn the basics of clinical skills, checking blood pressure, drunk blood, you learn by practicing on one another. And that's what we did. And so one day a classmate of mine was checking my blood pressure. And it was really high. But she was brand new to measuring blood pressure. So she didn't know what she was doing. She rechecked it. It was high again. And then we boarded in the supervisor, the faculty, the doctor. And he said, yeah, you know, I think you should go to the student health clinic and get this checked out. So I went a few days later. And when you have high blood pressure, the first things that a clinic will do is they'll draw blood, get a urine sample, make sure there's not anything else going on. So what they found when they did that was that I also had some early signs of kidney disease that went along with that, which is a known outcome or complication of high blood pressure, right? One that's more common among African Americans that has the worst course. So for me, this was really striking. I was 23 years old. I was 15, 20 pounds lighter than I am now. I had played college basketball. I really thought I was in great shape, very robust and all this sort of thing. And here I'm being told that I have this health problem as well. The same problems that I'm learning about in the classroom were then sort of affecting me in a very personal way. So that sort of kind of led me on this whole kind of reformulation of what I wanted to do in medicine and where I wanted to go. And so trying to solve these problems. And so that's sort of the foundation of how we got here today. So, you know, what I would say for the next few slides, and these are things that you guys are going to be pretty familiar with, I'm just going to kind of try and talk through them. So, because I want to get to the other part, which I think is more interesting to you guys. So there are basically all sorts of factors at work that are accounting for this why. The question is why are there these differences, right? So there are huge structural systemic issues in place that really impact health in ways that was not apparent to me when I started medical school. So when you're in medical school, you know, they're focusing just on the sort of the science, you know, these are the facts, these are the facts, without that sort of social context, right? And so the way that I sort of learned about this, and so even though I grew up in a lower middle class background, my mom worked, my dad worked for a grocery store. I'm not sure what the grocery store is in Texas. I don't know what the main one is, but sort of like a safe way or just whatever standard grocery store is. He worked in the meat department at a store like that. My dad did not attend college. My mom worked as like an administrative person in an office, you know, sort of in that world. She finished high school, did not go to college. And so they had, you know, what you call a working class, blue college jobs, but they were able to sort of carve out a, they had health insurance. And so I was under this sort of misconception that when you have health insurance, you know, if you don't have health insurance, that means that you're unemployed and all these other sorts of, you know, just sort of really binary black and white kind of thinking that I just didn't understand, wasn't being taught about in medical school. So early in medical school, I got the chance to go to a clinic that was about an hour and a half from campus. And in that clinic, the town was half black, half white, and the town did not have any physicians. And so Duke established this relationship with the town where students would go out there and rotate once a month to this clinic and sort of provide care to people and sort of really kind of really suboptimal way. It was basically like a trailer and this time it was actually a one room house back then and now it's a trailer. And you're just delivering sort of piecemeal care to people. And it was, I was struck by several people that I write about in the book, people who are quote unquote doing things the American way, you know, they have jobs and married, et cetera, et cetera, and continuing to just fall through the cracks. And it was really eye-opening to me how complicated these issues were and how problematic and how much what was happening on the outside was impacting, you know, what we could do as a doctor. It was just, it was distracting to me. It wasn't something we were getting in school but I had to learn kind of on my own. And so these are just examples of all the things that impact health. Do you have health insurance? If you do, what type do you have? Where do you live? Where do you go to school? These are all factors that are just tremendously, you can never overstate how important these things are. So I'm in the mental health field and these issues are even, some ways even worse than they are in the general medical field. So I want to give you, so these slides give you some information but I want to give you a kind of vivid illustration of how that might play out. So one night I was in an emergency room as a psychiatry resident and there were two women that came into the emergency room with very similar problems, very similar problems. They both needed to be hospitalized, at least in the short term, to kind of get them over the crisis that they were in. Very similar stories. So the first person was able to go upstairs to our university hospital unit which is, you know, generally, as far as mental health care was nice. You know, it had small numbers of patients, more staff, etc., etc. The other person, however, because she didn't have insurance, had to go to the state hospital, which is a very different experience. I worked in both settings. So the state hospital is a setting where people are much more aggressive, maybe they have criminal issues, not a place for the kind of problems that this woman had, but this is the only place that she could go because of these logistics of insurance. And so to make the complicated matters worse, further, because it was a separate hospital, we had to go through this process where she had to be transported by police. So she had to, this is her first encounter with the mental health system and she had to go in a police car, you know, treated basically like a criminal for having a mental health problem, right? And so you can imagine how that informs how someone then follows up with mental health moving forward, right? And all too often that kind of example, I mean, it was really striking because there were back to back patients. And so even though it wasn't strictly a race thing in per se, it was playing out along racial lines. These class differences were playing out along racial lines all too often. And so it was just really striking. And these sort of slides, this information sort of gives voice to that, the idea of how African-Americans are more likely to receive care in these suboptimal settings and the implications of that in terms of health problems and health outcomes. So I think that's a really important piece to the puzzle. There's another important piece, obviously, the doctor-patient relationship and how that can go awry. So we have a long history, obviously, in our country. And sometimes people are tempted to think that this is a distant past that has no present day implications, but it certainly does of mistreatment at the hands of the healthcare system. And so that informs not only the way providers see patients now, but also the way that patients in turn see the healthcare system in providers, right? It kind of can go both ways. So I'll give you a couple examples. So in the book, I talk about a couple ways in which this plays out. There's one story near about an African-American man who's kind of blue collar background, comes to the hospital with a physical problem, chest pain. He doesn't have a heart attack. We do all the usual medical stuff. But what comes out of that is that the doctors, so when they have this discussion, when he's ready to leave the hospital, there's a back and forth about how to manage his blood pressure, his high blood pressure. He wants to lose weight. He'd better die. Very sensible things. The doctors are fixed on this idea that he's got to take medicines and that he can't, he's not capable of doing these other things. I mean, that was more or less what it came out to be. And so when we left the room, the discussion became not about his medical issues, but about what was wrong with this guy. How could he know so much about these lifestyle things and how could he know so much about this? And they ended up giving him a mental health label, which was just astonishing to me and just so troubling to me. Another example I can give you an example is a more personal one. So I was a, so in my early 30s, I was, so I had played basketball in college, injured my knee, and several years later I re-injured playing tennis, but it wasn't nearly as severe. And then I was at home one day in the yard, working my yard. It was really bothering me. And I think I said, I need to get this checked out. So I went to an urgent care clinic. So not an emergency room, but an urgent care clinic. Now it wasn't that busy that day. And the nurse there was very nice. Spending nurses in the room. This nurse was very nice. But then, so then the doctor comes into the room. And so the doctor looks at me, well, actually doesn't look at me. He looks at my leg, my knee, and then sort of looks at the computer like this. And then just sort of says, well, stand up, sit down. Never really looks at me at all. And then just says, well, okay, you're fine. You're okay to go. But kind of like sort of just pushing me out, pushing me along. Now I'm not someone who normally, where is the label of being a doctor? I'm not someone who goes into the room. The first thing I'm going to tell you when you meet me is that I'm a doctor. I went to Duke and all this sort of. That's not the way that I sort of project myself. But in this case, I felt like, gee, this is not right. I should say something. This is not cool. And so I did it initially subtly by giving him some sort of medical references, medical terminology. I didn't sales a doctor, right? But here's the thing. So here's the deal, though. But then he looked at me and he's like, well, are you an X-ray tech or something? So that was his first reaction to me. It was still this way of sort of limiting who I could be and what I could be, right? And so then I said, no, I'm actually a physician. And then once I did that, the whole interaction between us completely changed in ways that were just mind boggling. People have heard that maybe doctors get, maybe you can get a sooner appointment for the colleague or something like that. But this is completely different care. So what this guy ended up doing was, he looked at me first and then he started a conversation. The first time he actually looked at me in the eye, as like a real person. And then we had this exchange and he was suddenly interested in me, right? Before he wasn't. And then he examines my knee. So this is the thing, first he didn't do that. So then he examines my knee, says, oh, we need to get an X-ray. We need to do this. We need to do that. And so it was like getting two different levels of care and being two different people, right? And so the first person was just me as this guy, random person coming from my community who knows what he may have thought of me. I had sweatpants on. I had tennis shoes. I was not dressed like this. And then once I became this medical person, I was suddenly a different, everything completely changed. So you can imagine how those dynamics play out in the real world when doctors see patients. And I certainly have seen many examples of that play out. But I thought that was a really vivid illustration of how that could play out as being two people as one. And one person being two different people in one setting. So this next slide will look at some kind of, this is looking at some of the I probably need to update this slide, but this is looking at some of the history of the perceptions and ways in which doctors might perceive patients. There's a recent study that came out from the University of Virginia. People may be familiar with it. It was about pain control and this idea that African-Americans are somehow immune to pain or their nerve endings are more resistant. And this was the study that came out of the University of Virginia just a few months ago and they surveyed medical students, right? And a large number of students were still having these beliefs. So these things are not, these things are still persisting and are very troubling. And so one of the things that I tell people is that what it speaks to is this idea that there's a sense that somehow doctors are magical and they have this great education and they're somehow different than the rest of society. But you know, we grew up in the same society and are informed by the same beliefs and problems that the rest of the society is. So these are things that really need to be addressed within the medical school curriculum. So the flip side of that I wanted to just briefly touch on is this idea here. This idea that we have this history of bias and mistreatment and how that informs how people then perceive the healthcare system. So what often will happen to me as being one of the only African-American providers in a clinical setting is that I would go in there and the medical team would sort of have all the sort of appropriate treatments presented to the patient. But the patient wouldn't, they wouldn't believe it. They wouldn't, they would honestly think that the doctors were somehow lying to them or trying to experiment on them. All these other sorts of things you would hear people say. And so the habit of putting this role was like a mediator or a translator it will. And it was really an awkward thing to always sort of be put in that position. But trying to assure the patient that indeed this doctor did have the best intention and was actually trying to do things right. So it was a role that I kind of would find myself in quite a bit as well. So this is certainly a really important huge piece to the puzzle. I'm going to kind of skip through part of this but I think one important part I want to mention was I told you in the beginning that I had blood pressure. I think it was kind of important for it to tie up. So one of the couple points I wanted to bring up about that I think were interesting. So I was 23 years old really healthy at least I thought. I had come from a community where people didn't excel, African-American men in particular. So I had several neighbors, one guy across the street from me who had been incarcerated a couple years old of me and then he got murdered in prison and a couple other people in my neighborhood who had similar kinds of stories where they got incarcerated for different things. And that was sort of kind of the trajectory. So the success that I've had was something that was certainly unique to the kind of community that I grew up in. There's an interesting term, may or may not be familiar with but I wanted to mention to the audience. There's a term called John Henryism. There's this idea of African-American. It's a famous folk legend of an African-American man in the early 1800s who was so proficient at drilling spikes in the railroad that he was better than a steam machine. So he succeeded in facing these great obstacles but then he died. He dropped dead suddenly. The whole point of that story is that there's been research suggesting that the African-American people who can succeed in the environments that I grew up in actually have, there's a health toll that kind of comes with that, which is interesting. So typically we think of people who do better in society being more well-off is having better health but there's sort of this paradox often that African-American people who are succeeding often are not healthy than the people who are not as well-off as them. So it's a really interesting paradox. And so this study here kind of plays out to some extent that point. So Meharry is an African-American medical school in Nashville, Tennessee. And so there was a doctor there who was sort of collecting data on his medical students back in the 50s and 60s and these are all African-American medical students. This is back in the days when it was basically all men in medical school. And then Johns Hopkins had a similar study that they were sort of doing as well and eventually these two investigators sort of paired up and compared data between the two institutions. Things are really fascinating study. And they found that the African-American physicians did have more health problems, both at baseline and over time. And I think part of that is this idea of people in society may look at well, you're both at the same level you're both doctors, you're both whatever, but then it doesn't account for the extra challenges the journey, the extra stresses that are involved and tailed in that. So I think that's just an interesting point. So for me it was really difficult to make health changes. I was so focused on trying to succeed and get through and prove that I belong there and all this kind of thing that I sort of neglected my health in a way. But then it was also this other challenge for me as an African-American coming from a lower income community, trying to adopt healthier lifestyle because it felt like it was somehow giving up something for myself, for my community. And so it was kind of a challenge that I've seen a lot of patients that I see over the years deal with and talk about. So I have very candid discussions with patients about this. And I think so being a doctor who can understand that issue and be able to relate to patients with that issue is a really important thing as well. So I think that's the lesson there. So the post-good for me is that I took blood pressure medicines for a few years, four or five years probably, but I was able eventually to work with my diet and things and I've had normal blood pressures for several years now. So it's a lesson that I like to impart to the patients that I see over time. So I wanted to switch gears. So this is the other part of the story of my book about what it's like to be an African-American doctor, a medical student and doctor and what that experience is like and how that experience can be different in many ways from the other students that are in your course. So I had a chance this morning to talk to some of the medical students here at this institution. And I was, you know, some of the things that I talk about here are things that are still going on. And so it's always, you know, troubling in some ways, but it also informs the relevance of this story. It's not just my own personal story, but it's a larger story. So it's all about perception. So someone sees me and what do they think of me instantly, right? So this is some of the ways in which I've been perceived and I'll talk you through some of these, right? So as a first year medical student, I was at a lecture hall one day early in the year and I was coming into the lecture hall and then there was a break and then came back in the lecture, like after a back and came back into the lecture hall for the second lecture. The professor was up here to pull him in and came all the way across the classroom in front of me, asked me, are you here to fix the lights? Okay, so my first response was to think, you know, maybe he misheard me. I mean, maybe he was thinking about someone else. Maybe I looked around and said, was there someone else here? You know, is it me sort of thing? And then I said, no. And then he sort of amplified. He said, well, I called you last week about this. Why haven't you done this? I didn't realize I had a twin at the medical school, but I must have, right? And so that was his response. And I was like, you know, no, I'm not here for that. And then he said, many of his response was, why are you here in my classroom? And so it was a very sort of confrontational exchange, right? And it was sort of, I was already feeling insecure about being at Duke. Coming from the back when I did, me and my classmates were very well off. Parents were very successful. And so that was a very uncomfortable experience. And the first chapter of the book sort of talks you through sort of the mental challenges of that, because you wanted, who do you share that story with? What do you do? Do you confront the professor? Do you tell administrators who's going to understand you? Are they going to think that you're just trying to cause problems? You know, it's such a complicated dynamic. And so many students go through these sorts of issues. So years later as an intern, a medical intern, so this is when you have the MP behind your name, but you don't really feel like a doctor yet, I was in the hospital one night and an elderly white gentleman came in and this is what he said. So it happened, so I don't want to you know, inward doctor. It turns out there were actually, I was the only African American doctor, which is not an uncommon experience for me. And there were several medical teams in the hospital and they just so happened I was the only, he happened to be assigned to the team with the only African American doctor sort of thing. So whether that's karma or whatever you want to call it, that's what happened. And this is what he said. And his daughter was one, so it was in North Carolina, and she had the shirt with the confederate flag all across it. And then another family member had a tattoo confederate flag which I thought was, I'd never seen that before. And so my first thought was, gee, this is really not going to work out, right? So because you can imagine their negative energy towards me, but you can also imagine I had a lot of negative energy towards them, right? And so it's a flip side of that. So the story ends up having a better ending than you might expect, but again it speaks to this unique sort of aspect of the experience of being an African American man. And so these are some other things that people have said. You know, people have sort of mistaken me for or thought I was. Now the basketball thing, okay, so I'm really tall, right? That's well and good. And sometimes it's fine. You know, I did play basketball. It's nothing to be ashamed of. But what we're troubling was that there would be some patients who would think that that was the only thing that you were capable of doing. And so at one time a patient said, well gee, he actually said this. He said, you know, a black with long arms and long legs should only be playing basketball and nothing else. Like wow, really? Is that, I mean so, and so his daughter was so dismayed and embarrassed and she like cursed him out. And so I'm glad she did that, so I didn't have to. But so that was, so there were all sorts of experiences like that that were problematic, right? Really problematic. And so this is just the tip of the iceberg. So I've had so many emails and calls and letters from physicians. This is not just like, so some people have tended to think, well, this is Duke. Duke has some kind of racist institution. That's just the Duke thing. Or you're in the south. This is North Carolina. It's the southern thing. Hey doctors from every corner of the country share these exact same stories, many much, much worse than what I experienced. So this is just the tip of the iceberg in terms of this larger problem or challenge that we face. Now on the flip side, there is the obvious sort of experience I've had where African-Americans are really happy to see someone like me. And then there are these sort of situations where you're not sure what to make of it. In some case I think people might be well-meaning. It's a difficult conversation to have. They don't know what to say and they really mean well. And then there are other cases where people really think they're really low of African-Americans to sort of see this. They just can't believe it. And so it kind of, it's flip side to it, right? And so that's sort of some of the challenges of my experience that I've had. There's this other piece that sort of emanates throughout the entire book. This idea of sort of having dual identities. I went back to getting this symbolism of being a black man in a white coat. So the community I grew up in was very, the pages we would see were very similar to my own family members in the community that I grew up in. But yet I was part of this other medical world where the people tended to be much well off, much more struggling. And so there was this struggle to sort of figure out where I fit within that, within those two worlds. And this is a photo of a W.E.B. Du Bois who's a famous African-American philosopher from the early 20th century. He coined this term double consciousness. This idea of sort of being in two worlds and sort of going through life sort of perceiving yourself, sort of seeing how you are perceived by two different, both groups. I'm really doing him justice. He's probably turning over in his grave now. But you know, sort of seeing how the immigrant community is perceiving you at the same time you're concerned about the white community perceiving you. Sort of this dual identity and all the sort of mental energy and strain that goes along with that. So this is an interesting point. So part of the reason why people look at me so strangely is because in some ways I do, I am sort of an isolated kind of breed in a way within the medical world. So this is an interesting point. This came out in August. So right before my book came out. It's from the AAMC, which is an organization that sort of, they represent, and they put out consciousness about academic medicine. And so they represent all the academic medical institutions. This is their refining. So there are slightly fewer black men applying to and getting into medical school in 2014 than in 1978. Wow, right? 36 year time period. A lot's changed in that period of time. So the U.S. population has gone up a lot in 36 years. The population of physicians has gone up a lot in 36 years. And in most subgroups of physicians, the population has gone up a lot. There are a lot more Latino physicians, a lot more Asian physicians. There are actually a lot more African American women physicians than there are now than there were then. But among African American men, we have this sort of unique picture. And so what you'll see in medical schools almost everywhere you go, you'll see medical school classes where there are three or four African American women for every one African American man. And so the question is, what is that all about? I have my thoughts about it. I'm curious about if people have their input as well from the audience. I can talk a little faster. I have a couple thoughts about that. So I think there's this perception game, this idea, there's external perceptions of what it means to be an African American man. There's perceptions of threat and violence and criminality. And then there's also these perceptions of sort of success through sports and athletics. And so I think that narrows the lane in which people, African Americans, can see themselves, particularly men. And so I think of myself as a young man growing up in a community I grew up in. 13, 14 years old, I would never have imagined the idea of being a physician. This wouldn't have even been something that could have been imaginable to me. The first time I ever saw an African American doctor, I was a male doctor. I'd seen African American women that never seen an African American male doctor. I was 17. I had a back injury from playing basketball. It was an older guy. And so I was thinking, wow, that's pretty cool, you know, an African American doctor. He must have gone through all kinds of things to get where he was, but he was much older. So I couldn't totally relate to him in the way that I would have liked with. He was in his 30s. He was a cardiologist. And, you know, he had trained in emergency Maryland and Johns Hopkins and everywhere. And it was like completely eye-opening. This is a guy who sort of had a similar background to me, kind of looked like me. And he was actually in this place where he was succeeding and people were looking him in this different way. And it was amazing to me. And that was really the first time that I ever considered becoming a physician. I mean, honestly, so just the idea of having someone who looks like you, you can see in that role how important that could be and how profound that could be. Even though I was good in school, I had no concept of what I could actually achieve. Because excitation was just so limited and so narrow to what it meant. So I think that's a really important point. I think in some ways it plays out even more for African American men. But it's even more so than African American women, even though it's important there as well. The next couple slides I'll go through, I'll try to go through quickly. Look at some demographic data, which I think is really important here. So just to kind of quickly go through these. So African American population is about 13% U.S. And you can see as the numbers go down from medical school to trainee to practicing doctor, the numbers continue to go down. So about 4% of African American, 4% of practicing doctors are African American. Now what would happen for me a lot of times is I would come to a clinic and I was in a psychiatric clinic and I was the only African American provider there. And the clinic served a population that was half African American. And so I would get all these requests constantly to sort of see African American patients. Now whether it was coming from the patient, sometimes it was, sometimes it was coming from the providers themselves who were saying, we think this is best for the patient. It would work both ways. But I was one person and I would find myself just sort of getting all these referrals and having this sense of like, I didn't have like two or three times as many patients as my colleagues. And sort of feeling like that was somehow unfair and I'm still trying to learn my craft, why is it that all this is happening to me sort of thing. But it speaks to this numbers game which I'm going to sort of play out before you. So this is some demographic data here. The red is African American. You see in the U.S. population it's 12 or 13 percent. In North Carolina it's about 22 percent. So it's higher as most southern states are. And then in Durham, North Carolina it's in the high 30s, about 39 percent. So about three times the national rate in terms of the African American population. This is how it looks, but that pattern and notice the busy slab, this is a really important one. So look at this. So you see how Durham is 38 percent African American. Well, look at these other cities. These are all cities with several major medical schools. And you see the same pattern play out replicated nationally. And so even in the cities where there's a lower, relatively lower African American population, the numbers are still considerably higher than the national average. So you have this pattern nationwide of schools where young doctors are being trained, where these prestigious medical centers are existing, that are situated in these communities that are lower income, often large African American populations, often there's a tension between the communities and the universities. So you see this play out, this sort of mistrust and things play out often. And so it's replicated nationwide. It's certainly not something specific to my own experience. So we showed the slide already. This is just a couple of some data on the mental health field, which I think is interesting, because mental health, this is my area of course. This is an area where you're really talking about the most important and intimate issues in your life. And a lot of times patients would come in wanting to go into marital therapy. And I have requests. They say I'd want an African American provider. There wasn't one to define. It was this common pattern that I would see a lot. We can kind of go through these slides. I'll brush these because I want to leave time for questions. The point here of these slides is that there's a body of research that suggests that not only African American providers are more likely to serve in underserved communities. That's been established, particularly in the primary care and mental health fields. But there's also some perception, there's also a perception among many patients that this in some way provides a more comforting medical environment for them to be seen. So we'll just kind of skip through those. So I wanted to finally kind of conclude with this. I think this is really interesting. This is the perception of how the book has really been received in the world. I think in some ways it speaks to these issues in a way in which me giving a lecture maybe can't. So when I first sort of sent the book out into the world, this is the literary world takes place in New York City. And these are the labels that many of the people who are in that industry would put on themselves. This is not me sort of, this is the labels they would sort of self-describe as. And so when I first sort of put out there, these are a couple of samples of how people would receive the book. So this first person here, and this is actually, there were several people who felt this way. They said, wow, I've never heard there were anything such as racial differences in health. This is really interesting. This is amazing. It was almost as if I like uncovered some secret, you know, I cured Alzheimer's or I solved the mystery of candy. It was amazing. It was like this is readily available information. And I don't say it to sort of be negative about those folks, but it sort of speaks to this idea that these are going to be very well-meaning people who can live in a world in which they can be totally separate from these issues that are so important to a large segment of the population. And so what that told me was that there was a real important piece of the book just in terms of education informing people about these larger problems because you can't really address problems until you really know that they even exist, right? And so that was a really big piece there. Now there were some who didn't receive it the same way. This person was a former journalist and they said, well, I'd done a couple stories about this and I talked to some doctors and they said that all this is really just a behavior of the black people, of black people in the community. And she said, I talked to some doctors. I wonder who those doctors were that she talked to, right? And I'll have some more about that in a little bit. And so I figured this might not, we probably wouldn't work well together. And then this is the third one. I don't think people would find this useful or interesting. So a lot of people wanted me to strictly talk, you mentioned pretty great. So a lot of people thought that I should only talk about race and criminal justice and I thought, well, there are a lot of people out there who have written really good books about that sort of subject. There's a really important story to tell about medicine and health care and these challenges. And that's the field that I know. And so that sort of spurred me on. Now whenever you write about these issues of race and medicine, you know you can't make everyone happy, right? So there are going to be some people, so I'll give you a sense of that. And this is really important. So you guys have all seen online where you write articles and there's comments to articles and comments to be very malicious. People will say things they probably would never say to you face to face. So I've certainly had plenty of that. But what I've also had which is more interesting and maybe troubling is I've had emails from people expressing their views. Now it's one thing if you're just sort of a random citizen who doesn't, who's not in a role where you can actually do anything about this. But then I had several emails from physicians, practicing doctors who had really negative things to say about what I wrote. And I thought that was really interesting. So I wanted to share some of those with you. And I don't do this to sort of bum you out or anything because this is definitely the minority of people. But I wanted to just sort of illustrate some of the challenges that we still face. So one doctor said it's all about class. You're seeing a racial problem that doesn't exist. And then he kind of goes on about me being a Duke professor. So race is a certain, class is certainly a big part of this puzzle. There's no doubt social class is a big part. Teasing that out, class and race are so often still intertwined in our society. So I reject the idea that it's strictly class and race has nothing to do with it. I don't think that's the case. But the point is taken. But here's the next comment. You are grossly mistaken. The day when race or ethnicity had to do with the quality of patient care has been a relic for decades. So this doctor is saying that at some point that was the case maybe but now everything is completely different. I thought that was interesting because he mentioned being working in a community clinic where he saw a lot of lower income patients. And he stated that he himself was not biased, which would very well only be true. But he knew for a fact that the patients themselves had no concerns about these issues at all in terms of seeing providers who weren't like them. And I thought that was interesting that he could sort of read their minds and know what they were thinking in that way. I'm going to say kind of because I know that you can't read people's minds. I'll just tell you that. And so I thought that was interesting. Now this person said, the next one said you did the entire population of non-black doctors a disservice by trying to convince the public of your misguided thoughts. So you know actually some of the best feedback I've gotten from the book has actually been from people who are not African-Americans, women doctors, Jewish doctors, Asian doctors, people from other fields. I might have other perspectives who can sort of, my experience can inform some of the experiences that they've had, right, in some way. There's parts of my story that are relevant to their own story. And so I think that I certainly would object to that characterization because I think I've written about it from my own lens through race and medicine and this applies to so many other lenses as well. And then the final one I think is the most troubling one. The health problems of black people are solely the fault of black people. So here's the thing. So here's the point about that. So if you're a doctor and you already, a patient comes to your room and you already believe that before you ever even talk to the patient, imagine what that, how that impacts everything that proceeds from there and files from there, right? Just imagine if you already had that in your mind that this is what's going to happen. And so I think that's a particularly kind of troubling commentary and it shows some of the, you know, challenges that we still face. Now on the flip side, on a more optimistic note, the vast majority of my feedback has been positive. Now I anticipated when I wrote the book that the younger group of medical students and doctors would be able to relate to my story. But then I've also had other things that I've really appreciated. There have been many African-American patients who have said that they've sort of valued my sort of self-empowerment measures about taking better care of your health, using my own story as an illustration of that. And then I had many readers, I say white readers here, but it's in many, many other groups of folks who've really been able to sort of tap into my story. So I've had several classmates from medical school. People that I knew, we went through the same classes, same rotations together who've contacted me since the books come out. And they were all just so amazed. They were like, they had no idea that these things were happening. They had, they had, they had like just different experiences in so many ways. You know, we went to the same schools, same hospitals, et cetera, et cetera. And so I think that was also telling as well. But most of them were very, you know, they were most of very troubled and very positive about how they perceived things. Now, I think at Duke, so this book came out last year, I started at Duke in 1996. I don't think that in 1996 Duke would have received the book very well at all. I think things have changed in some ways quite a bit. And so in some ways that's a testament to progress because when I first started at medical school at Duke, there had never been a senior person in any leisure position at Duke who was not, you know, who was a woman or a minority, never. And so since that time, things have changed a lot. And some of them have made a really concerned effort to sort of bring these issues to the table and to talk about these issues. So I think, you know, this is just sort of summarizing what we already talked about. So I think what I would say to this is that, you know, these are huge issues that we're talking about. There's system, there's so many ways to tackle these problems. There's so many ways. So for me, writing was my way to sort of put the story out there to give people to talk about these issues. There's so many ways. People tell me, what do we go from here? What do we do? In the book in the end, I talk about some of the challenges, like I talk about how healthcare system, how the healthcare, we spend in healthcare, but we still have it in some ways and all the sort of politics of how the politics of healthcare have kind of really messed things up and are still disproportionately impacting the minority community. So I talk about these issues, where do we go? So sometimes people might think that some people have this message of feeling kind of powerless in some ways and I want to always, I always like to end with this sort of point. So there are obviously a lot of system-level political issues that need to take place and need to be involved with and I'm happy to talk more about that. But there's never discount the role of the individual in what you can do as an individual person as well. And so while certainly African-American providers like Prince of Dr. Brian and many others have played a great role in that, it's not solely up to the responsibility of African-Americans about doctors to solve this problem. And so I really want people to not lose that message and this idea of like, what can you do? So I'd say it's a little story about my own personal background. It's not medicine, but it's related to this story. So when I was in eighth grade, I went to a middle school that was what would be called a low-performing school. It was 98% African-American. And a middle-aged white teacher, she's in her 40s probably, she said, you know, you've done well in our math class. Maybe you should try and test into this magnet program. So it was just like a separate school that I would have to go into for high school. Now no one in our school had done that and no African-Americans had done that. My first inclination was to say that no, that wouldn't be something I would do. I told her no basically. And so she persisted and she got my mom involved which I guess is the way to make it work, right? So you got my mom involved and then I went through this test and to my surprise, I had really, internalized all this sort of negative self-belief about what it meant to be an African-American man. People don't realize how powerful those external messages are and I internalized a lot of that. And so I'd never thought that I would do all this test and I did on a whim and I got into this program and that really changed my trajectory in terms of beginning to change my trajectory in terms of where I can see myself as being. And so I think we should never lose sight of the role that we can be as individuals in this larger problem. Even if we can't fix everything and there's a lot of work to do at the big level, we as individuals all still have the tremendous power to make a difference in folks' lives. So I think I'd like to conclude my remarks here and if there are any time for questions, I'd love to answer. Okay, okay. All right, ladies and gentlemen, we had a technical problem with our microphones today. They were causing a lot of feedback and screeching. Consequently, we don't have the floor mics that we usually have for Q&A, but we believe we can do Q&A anyway. It just requires that if you have a question, we'll call on you. Please stand up, project your voice, and be succinct with your questions. Please, though, the floor is open for questions for Dr. Tweedy. And I see Tati McAllister, so I'm going to call on her first. So I was hoping I could have the mic and walk around like those talk show folks and... Oh, well. One thing that would help, though, is if you would repeat the question so everybody can hear it. Oh, yeah, thank you. Yeah, you know, she said, how do I attribute my equanimity? Nice big word. What do I attribute that to, right? Was I born that way? So there were times in my life where I was very angry about the things that were happening, very angry about some of these experiences. Looking back, I think that, you know, me having this high blood pressure, my blood pressure was really high. It was like 160, you know, 90, 100. It was really over 100. It was really high. And I was wondering if maybe some of this, remember I mentioned about this old John-Hemianism thing about sort of fighting and fighting, and was that taking a toll on my health. And so I think I started to realize I had to sort of try to let go of some of these things and take a different tack. I was angry, but I wasn't really getting anywhere. I mean, I was just sitting for myself, and just being angry with him wasn't helping me. You know, in some ways it was probably hurting me in some ways. And so I think I let go a lot of that. So I think if I had written this book 15 years ago, it might have been a different sort of book in some ways. Yeah, so I don't think it was, I wasn't always that way. I certainly felt the unfairness. I felt the anger, the hurt, all those sorts of things. But I tried to come to a different place in my life. You know, so that's sort of how I would answer that question. There had to be more questions. Come on, it wasn't. I didn't thank you for volunteering. Oh, a couple. Okay. Yes. Okay. So his question was whether the Tuskegee experiment had any impact on African-Americans being willing to see positions. So just to kind of briefly the Tuskegee experiment, for those of you aren't familiar with it, basically it was a U.S. public health service study conducted from the 1934 to 1972. It's testing the natural course of syphilis in African-American men. Even though treatment was available towards the early part of the study, didn't offer treatment, didn't let the men know they had syphilis. It was a really egregious misuse of justice, power, everything. So what's the impact of that? What's the legacy of that? In some ways, it's the tip of the iceberg. There's a lot of other stories that are as well known that have similar problems. So one of the challenges of teaching that story is a really important lesson to learn. We need to know about it. A lot of times nowadays people say, oh well, we would never do something like that. So if we're not to that extreme, then of course then we can't have any problems at all. If I'm not that racist, then I can't be racist at all. It's sort of this extreme, so it can kind of be used in a way that can often in some ways maybe not be as helpful as it is. The truth of the matter is that there's certainly that legacy, that old history that's passed down. Even though I didn't know about Tuskegee when I was younger growing up, I still knew this old history of how some of my relatives would go to doctors and be mistreated or misdiagnosed. So Tuskegee is sort of like the tip of the iceberg. Does that impact the way people perceive the healthcare system? Absolutely. And so there are doctors, there are patients, I have several patients who would come in and use these words, I don't want to be experimented upon. Am I getting pig? I'm gonna hear these things over and over again and that's certainly part of the legacy of those studies and many other things. And you hear these terms over and over again and you know when they're saying what they mean I know someone else had a hand up. Actually a few, wow. You mean like the ones where they're more negative comments? Which quotes you mean? The question was were the quotes that were put up there were they all for men? Now the ones that were from physicians did happen to all the male physicians. They were all somewhat older physicians so there's a lot of other things that work. Over 60. So there's a lot of factors that work there. Yeah, so that was the case. I hadn't really thought about that in that sort of way. Yeah, there could be something to that. Yeah, certainly. Yes ma'am? I sort of described what? Imposter. Yes. Yes. Yeah, the question is how did you overcome? So is this idea of being an imposter, the affirmative action and people perceiving that you don't belong and you're not qualified and all those sorts of things? Yeah, it took a while because those are the things that you think about. So for me being able to succeed was one way to validate that but even once you succeed in one form when you get to the next stage it still kind of comes up again and so it was still kind of continued to be there. I got to the point where I realized that some people were always some people that were going to think that's an idea of me and I couldn't control and this is part of the anger of letting go of things. I couldn't control what everyone thought of me. I'd have to pick my battles and so that sort of would work for me because there are students that I knew who sort of let this consumer to the degree where they were not able to kind of move forward and so I didn't want to find myself in that situation because I mean so that's sort of how it worked for me. There's a better answer in there somewhere but I can't seem to dig it out. I think I might come back to that one then. I'll try though. How has what changed my view of what now? Oh, that's a great question, right? Yeah, so part of that was because I remember I mentioned that I was one of those folks who would not have been likely to write this sort of book when I started medical school. Even as I got through my training there was a part of me that was sort of feeling like I got through things and I had a successful life, etc. Maybe it was feeling like I was getting too distant from my past in some ways. So in some ways this book was an effort for me to try and reconnect to that and to recognize the importance of some of those other folks that played. Like I mentioned that doctor and how important he was in me becoming a doctor and sort of trying to find a way in which I could kind of give back in a way. I mean people always use that term but it really felt like I was in a place where I wanted to sort of be more involved and more engaged in that way. So I found myself talking. You may have noticed this. I'm not a natural public speaker and the idea of being in front of a large audience is actually like my first start I called it exposure therapy because I'm a very introverted person and so putting myself out there is not natural to me but I felt like there was this important part that I needed to do and I couldn't just be successful just for my own self in my own way, in my own cocoon and so I've been reaching out to younger African Americans, particularly African American men which I could be even more effective in that way. So that certainly changed my thoughts in that way, the way the receptionist took the book. Yes, sir. And I'll get you next, man. That is an incredible question. He says, what advice would I give to a second year medical student about the start to clerkships about uncovering their own biases and taking care of patients? Wow. Great question. Because some of it, a lot of it varies. It's not one blanket set of advice that's going to necessarily work for everyone. I do think that not isolating yourself, some people often see this when my African American students are isolating themselves and that would be very problematic, so not isolate yourself to be able to bounce things off of people, have a group of people that you can bounce things off of I think is really important. I mean, really important. Not losing sight of what your goals are is also really important. As far as this idea of bias, everyone has that bias. I always like to say that everyone's been, in our country, and everyone in some ways has been poisoned by it. Some of us have been affected more than others, but everyone's been poisoned in some way by it. And so having that, starting with that framework and then realizing the ways in which that could inform how you see patients is really important. Like, as I mentioned, that one family with the Confederate flag. So I have certain clear biases against folks from a certain part of the world. And so how do I not let that cause harm to that person? How do I work through that? This is a book where I talk about the challenges that are inherent to that. But starting with that framework, they're all fallible in that way. I think it's a really good starting point. All too often I would see doctors who have the sense of infallibility, which is so problematic. This idea that you've gotten to this MD or PhD and you're in this residency and that somehow you're immune to these problems. So starting with that framework is so problematic. So I think that's the first step, to have a little humility in that way. Okay, so the question was he's a book lover and she asked if there's another book that I might want to write. So, great question. I've been thinking about that. This book mainly talks about my experiences in medical school and my internship medical year and very little about psychiatry. So one thought that I've had is that write a book that explores some of these issues through the mental health lens. Because in some ways they're even more troubling and I haven't quite crystallized it but I think I want to write something more specifically to the mental health field and the challenges that come from that. It looks like the speaker has told me that the music is playing in the background that can show us the time to be quiet. Thank you again. Let's applaud. Thank you so much Dr. Tweedy for your message to the audience. There is a reception in the Holly Auditorium Lobby as you exit. And there is also an opportunity to purchase Dr. Tweedy's book and he will be here for a brief period of time to sign the books. And thank you very much for attending our Frank Bryant lecture. We're adjourned.