 I think I will start colleagues. It's an honor and a pleasure to welcome Dr. Marshall chin, as our speaker today in the series on ethics and the covered 19 pandemic medical social and political issues. As you can see from the slide. Professor chin is the Richard Parillo family professor of health care ethics, as well as the associate director of the McLean Center and a senior faculty scholar at the Bucksbaum Institute. Dr. Chin, a practicing general internist and health service researcher has dedicated his career to reducing health care disparities through interventions at individual organizational community and policy levels. Dr. Chin is elucidated practical approaches to improving the care of diverse individual patients and addressing systemic structural drivers of disparities in the health care system through the Robert Wood Johnson foundations program advancing health equity, which Dr. Chin co directs. He collaborates with teams of state Medicaid agencies, Medicaid managed Medicaid managed care organizations and frontline health care organizations to implement payment reforms to support and incentivize care transformations that advance health equity. Marshall chin also partners with the eight urban and rural communities to integrate medical and social care to reduce diabetes disparities to the foundation bridging the gap program. Dr. Chin evaluates the importance of the federally qualified health care centers improves diabetes outcomes on the Chicago South side to health care and community interventions and improves shared decision making among clinicians and LGBTQ persons of color. Marshall also applies ethical principles to reforms that reduce health disparities discussions about a culture of equity, and what it means for health professionals to both care and advocate for their patients. Dr. Chin's most recent project uses improvisation and stand up comedy storytelling and theater to improve the training of students in caring for diverse patients and engaging in constructive discussions around systemic racism and social privilege. And this this has been well published by Marshall and the Bucksbaum Institute has joined. We hope other institutes in in supporting this program of improvisation and comedy and storytelling. Dr. Chin and his team created the roadmap to reduce disparities cited in centers for Medicare and Medicaid services reports. Marshall is a member of the National Advisory Council of the National Institute on Minority Health and Health disparities, and is a former president of the Society of General internal medicine. He was elected to Harvard College and the University of California San Francisco School of Medicine, Marshall completed his residency in fellowship in general medicine at the Brigham and women's hospital at Harvard. He has been entering awards from the Society of General internal medicine, the University of Chicago, and was elected to the National Academy of Medicine in 2017, and currently as a member of the National Academy of medicines committee on the future of nursing from 2030. Today, as you can see from the slide, Marshall we speaking on COVID-19 inequities, a culture of equity and healthcare policy reforms. It's a great honor to welcome Marshall to our program and as our speaker today. Dr. Chin, please. Thank you very much, Mark. So I have an ambitious agenda for us over the next 60 to 90 minutes, 60 minutes of roughly the lecture and then 30 minutes for discussion and question and answers. Three main learning objectives. First, to identify equity concerns with general COVID-19 health system funding. This is separate from targeted specific COVID-19 funding. So for example, we've had talks in the series about vaccination and funding for vaccination. I will not cover that since other speakers have done such a great job with those specific topics. The general COVID-19 funding refers to general federal government funding provided to the healthcare system during this period of COVID-19 in the context of COVID-19. And we'll see that there are major equity issues have been raised by this type of funding. I'll segue into the second learning objective discussing then principles of fundamental policy reforms to advance health equity. So we want to move beyond a problematic system that leads to these types of inequities in COVID-19 health policy. How do we move beyond that with general principles. And then third, I will highlight the importance of creating a culture of equity to implement policy reforms and transform systems. I think if I gave this talk about a year ago, I would be heavy on more of the technical aspects in terms of policies and levers and in the process of change. I think I've learned over time and even more so over the past year that having a, I would call it culture of equity is equally important as to the technical aspects. And one without the other just won't work. So in words, we could have a culture of equity, we won't go very far unless we develop specific reforms with payment and with care transformation. Similarly, we have policies regarding payment and quality improvement with advanced equity. But if we don't truly have a culture of equity in practice, we're going to have limited success implementing those technical solutions. Here's the agenda. I'm going to first give an example of a cultural and structural problem that has received a lot of attention in the past two weeks. Second, I'll then segue into some ways a preview of the take home message and overview of the conceptual model for advancing health equity. Third, I'll talk about then the COVID specific policy so COVID-19 cares that provider relief fund. I'll then go into more detail regarding these principles for advancing health equity, really focusing upon culture and a roadmap to advance health equity. And I'll end with a discussion trying to place all of these discussions within the context of the current partisan divide we see in our country and populations living in alternative realities. So how do we we deal with our current context, given these major problems with inequities. And my talk is based upon my own research. So Mark mentioned a variety of research, which ranges from patient studies to policy studies, and then disparities intervention literature. We are now in year eight of the University of Chicago's equity initiative. And so we've learned a lot. We have a long way to go, but we've learned a lot at the same time regarding practical on the ground lessons. And then I'm involved in a lot of meetings nationally committees regarding equity. So I have a fairly good pulse in terms of the national discussion. And here are the take home messages. First, we need to be intentional about advancing equity. Second, strongly advocate using a roadmap to advance health equity, which emphasizes a culture of equity, as well as discrete systematic processes for care transformation and payment. And then we need to be flexible amidst the reality flexible for opportunities, both in the short term and the long term. The other thing I try to do is really take the all of you to what I consider to be the forefront of the equities issues that I've used this lecture to try to assemble thoughts of like where I think that the current big issues are in some thoughts about how we may approach them. And one of the big ones that I think we're all aware of is that we've had a rise in public attention and recognition of systemic racism over the past year. COVID-19 police brutality, increase in importance and recognition of systemic racism. And it's starting to come out now in a variety of institutions. The Commonwealth Fund just came out with a new initiative that's goal is to dismantle systemic racism in healthcare policy and practice. The CEO of the Robert Johnson Foundation at Richard Besser. He had a recent statement that says that dismantling structural racism must become America's ultimate public health intervention. And just as a minority health disparities within NIH, at the fall of 2020 they approved a structural racism research concept. And these research concepts become the basis then for eventual call for proposals and request for applications. And with a Biden administration, I anticipate that we'll start seeing NIH coming up with structural racism RFAs probably over the next year or so. Here's the initial example. So, JAMA has a podcast series. And at the end of February, they came up with a 16 minute podcast on structural racism. And here's the accompanying tweet from JAMA, which, which advertises the podcast. No physician is racist. So how can there be structural racism in healthcare. And the definition of the idea by doctors for doctors in this user friendly podcast from a great Dr. Mitch Katz, who's the CEO of the New York City Health and Hospitals. System Corporation, basically the group that runs New York City's public health system, and Dr. Ed Livingston, who was one of the JAMA editors. I think that Dr. Katz and Dr. Livingston are well intentioned, and they really do care about reducing inequities. What has happened though is that this particular tweet and some elements of the podcast have been painful for many. And they convey and exemplify some of the major problems that anyone that's trying to advance equity will need to address in their solutions. In terms of this example, the focus to be more on the objective issues raised by the example that then become factors that must be addressed for any solution to reduce inequities to work. So this was billed as like structural racism for skeptics. And in the preamble to the interview in the podcast, Dr. Livingston said that given that racism is illegal. How can it be so embedded in society that is considered structural. It's a child in the 60s. I didn't get it. I'm a racist. I grew up in a family where racism was reviled. So I grew up kind of anti racist just never ever even think of a person's race or ethnicity, when you're evaluating them. And I think I'm being told I'm a racist in the modern era, because of this whole thing about structural racism. As Dr. Cass responded, you are not a racist. And also we are not going to end structural racism by focusing on individual people's attitudes. We're going to end structural racism by changing policies that keep people down. I think one of the mistakes good people make is thinking that we need to tell people how to think that is not going to succeed. You cannot tell people how to think what you can create. Dr. Livingston then stated personally, I think taking racism out of the conversation would help. Many people like myself are offended with implication that we are somehow racist. When many of us grew up in an era where there had been racism, and much progress had been made in ameliorating racism, the dramatic legislation that was passed in the 1960s. So over the past two weeks, Twitter blew up, and there was a lot of pushback against the tweet and elements of the podcast, and the response from AMA and JAMA was fast. Here's a CEO, James Madera, formerly of the University of Chicago. The AMA's House of Delgates passed policy stating that racism is structural, systemic, cultural and interpersonal. And we are deeply disturbed and angered by a recent JAMA podcast that questioned the existence of structural racism and the affiliate tweet that promoted the podcast and stated, no physician is racist. So how can there be structural racism and healthcare. Dr. Madera continues, JAMA has editorial independence from AMA, but this tweet and podcasts are inconsistent with the policies and views of AMA. And I'm concerned about and acknowledge the harms they have caused structural racism and healthcare in our society exists and is incumbent on all of us to fix it. I'm James Madera, JAMA Editor-in-Chief Howard Buckner, MD. The language of the tweet, as well as portions of the podcast, do not reflect my commitment as an editorial leader of JAMA and JAMA network to call out and discuss the adverse effects of injustice and equity and racism in medicine and society, as JAMA has done for many years. I sincerely apologize for both the lapses and the harm caused by both the tweet and some aspects of the podcast. JAMA will schedule a podcast in the future to further discuss issues of structural racism and health and to address concerns raised about the podcast. So recently, AMA hired a chief equity officer, Dr. Alifa Maybank. So she set out a series of tweets. The podcast slash tweet are were wrong. Absolutely appalling. And it's very core is a demonstration of structural and institutional racism. I am furious. It is harmful for everyone, the field of medicine, and even more so for my black, indigenous Latinx Asian and other historically marginalized colleagues, friends and families. It is harmful for my team and all the other folks within the AMA who have been fighting hard and daily against racism and white supremacy to change culture structures and norms. I knew Falwell that coming to this space to lead this work was in no way going to be easy, just only necessary. I believe this impacts the credibility of AMA and the Center for Health Equity. Please know I am not silent ever. We all deserve better and way more than pulling up a tweet. I deeply appreciate and acknowledge the ongoing accountability provided by many of you over the last 24 hours and over the years towards AMA and JAMA. Please keep it up. I hear, see and feel you. Later, there's a press release statement by Mitch Katz, Katz, March 4. Systemic interpersonal racism both still exists in our country. They must be rooted out. I do not share the JAMA host belief doing away with the word racism will help us be more successful in inequities that exists across racial and ethnic lines. I believe that we will only produce an equitable society when social and political structures do not continue to produce and perpetuate disparate results based on social race and ethnicity. Therefore, I firmly believe that both interpersonal and structural racism still exists in our country, and it is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it. So it's a lot to digest in these statements in this dialogue back and forth, and we'll have time during the question answers and discussion to dive into more depth. Throughout my talk, I'll refer back to different parts of these statements. Because again, I think they, they crystallize some of the key challenges and barriers that solutions will need to address to work in today's real world. This is the slide the Robert Johnson Foundation uses to demonstrate the difference between equality, where everyone gets the exact same bite versus equity, people get the bite that fits them. Many of you seen this slide which shows a similar idea that equality one box equity you give the men the size boxes in the game. The reality is some people are born to privilege. In this slide if you remove the fence just designed to represent structural barriers structural inequities structural racism, then you have that barrier removed. So here's the part where I give you like some ways that the take home message up front. Back at the end of 2020 I was invited by BMJ quality and safety to write an editorial. I asked to for the patient safety world to give a quick sort of, here's the state of the art regarding what we know about reducing disparities, advancing health equity. So you start the very top that really core to everything really is to commit to the mission of advancing health equity, and then being intentional about it that we have to be intentional about advancing health equity. In this split. So the creation of the culture equity is involving both understanding personal biases. And so why I would argue that probably all of us are implicit racial biases, as well as then for our organizations identifying the systemic structures and biases that can then discriminate against an oppressed marginalized populations. I gave this example of JAMA, but you know my guess is that most of not all of the organizations that were part of, you know, we have it also so you know it's not just JAMA. We have implemented the roadmap to reduce disparities, identify disparities, doing a root cause analysis, why disparities exist, designing implementing cured inventions. You see in between is where the rubber hits the road that every worker, whether they're the frontline with the CEO, they know how to to operationalize advancing health equity in their daily jobs. On the right you have some of the big policy issues payment reform that supports and incentivizes care transformation that advances help equity, and then cross sector partnerships to address medical and social drivers of health, both individual drivers and structural drivers, the bottom improving individual population health, ultimately also also improving health and health care equity. So my attempt on one slide to basically summarize really the key aspects of advancing health equity. So, Mark, you've organized a great seminar series has really been sort of a wonderful set of lectures and experts and discussions. And there's been a lot of discussion about COVID-19 racial disparities. To summarize that from the talks we know that there are higher comorbidities which I think minorities higher exposures from essential work crowded housing. Vaccine hesitancy issues and mistrust from discrimination access barriers such as transportation or access to employer based health insurance. And I put up here just to represent Monica and Govan. The talks and Govans talk from last week was a great example where, again and again govans mentioned the actual policies for vaccine vaccine distribution. Do not intentionally advanced health equity they were intentionally designed to advance health equity example after example state after state. It's a common theme. Not to like the COVID-19 specific part of my talk and this is the CARES Act Provider Relief Fund. On the right there that's one of my colleagues Colin Grogan from the School of Social Services Administration professor there was one of the national leaders in this particular area. And I'm going to give like general principles and I'm going to refer you to three of Colleen's works for a deeper dive of the issues. One is on the left she has a paper and press the Journal of Health Politics Policy and Law empirical piece that shows data regarding the inequities that I'll be talking about. Great detail regarding some of the financing mechanisms for hospitals. So it's a great read in terms of like getting inside the black box. On the right she has already out there now and press or actually, you know, online, a editorial in the American Journal of Public Health on these issues of health equity and this Provider Relief Fund. And back in the fall, she had a lecture on these issues. So now on YouTube, you can search on the School of Social Services Administration website Michael Davis lecture. So thank you Colleen for your leadership in this area. I was involved in the spring of 2020 I got an email from a reporter from Newsweek asked me to comment upon the legislation that was being passed to respond to health care systems financial predicament because of COVID-19. And so this is the quote they picked from our interview. Dr. Marshall Chen, Professor of Health care ethics at the University of Chicago, proper medicine told Newsweek that CMS is so Medicare medical case formulas appear to be designed to ensure that hospitals and large healthcare systems can maintain their bottom lines, rather than guarantee if the facilities and wish vulnerable Americans to pen and keep their doors open. And then holds in terms of what was happening at that particular time. I say that as the program went on during the course of 2020. It was more this. And so little context of spring 2020 there was great economic hardship for two hospitals closing mostly rural hospitals, March 2020 42,000 healthcare workers lose their jobs. April one month later, 1.4 million healthcare workers lose their jobs. So major problem. And we know like hospitals the University of Chicago for example one of the issues is that we lost elected procedures no elected procedures, and for privately insured population. It's a lot of elected procedures that bring in a lot of the money. So, possibly lose money that way. Safe than hospitals. They were taking care of disproportionate number of COVID-19 patients. The cost then of the equipment supplies for COVID and then labor costs went up during this time as there was more demand for a limited supply of labor to care for patients and COVID patients. So financial crunch. Federal government passes the Cures Act provider relief fund, which purpose was designed to provide an influx of money to hospitals and other healthcare entities to help them respond to the pandemic. Congress said that funds could be used offset cost related to treating COVID patients, or to reimburse for lost revenue. So it was the first initial intent. So there was in the general distribution of funds faces 123 so phase one was the biggest phase $50 billion. So April, right around that time of turbulence with a lot of the job loss. $30 billion in grants was distributed to eligible hospitals, physician practices and other providers in portion to their Medicare fee for service billings in 2019. So based upon Medicare 65 and older population. April $20 billion was allocated to nearly 15,000 providers based on their share of net patient revenue net patient revenue that's all patient revenue, not necessarily like vulnerable populations at risk populations, but net patient revenue. So you see them that these, these regulations prioritize revenues lost over COVID need. So net patient revenue, Medicare fee for service billings. So you probably been sort of connecting the dots, the problem here. So this is the New York Times headline from July, you're saying actually may so may 25th headline is wealthiest hospitals got billions. And this bailout for struggling health providers 20 large change received more than $5 billion in federal grants, even while sitting on more than $100 billion in cash. The funding criteria weren't based upon need, not care of uninsured, not Medicaid, not the Medicare Advantage program managed care, not children's hospitals. No accounting for existing money and resources my financial resources so if you have presented a lot of money in the bank that wasn't accounted for it. May Kaiser Family Foundation study, they have empirical data, they conclude hospitals with the lowest share of private insurance revenue, receive less than half as much funding for each hospital bed, compared to hospitals with the greatest share of revenue from private insurance hospitals with more market power can command higher reimbursement rates from private insurers. They are more patients for private insurance, they can charge relatively high rates. So we haven't seen this issue of like the system rewards those with power in the system. And if the system is not set up to advance health equity, then you got problems. The de facto result was that wealthy hospitals with private insurance patients were prioritized over safety hospitals with uninsured and public insurance patients. So de facto hospitals with white patients were prioritized over hospitals, the black and brown patients. So one of the possible reasons why prioritize revenue lost was the, the big priority over COVID need. One issue was speed, both in terms of saving system and getting the money out. So Seema Verma who had a Medicare at that time said the first priority is we want to get this money out fast. Using Medicare based on the systems that were used to distribute Medicare money using Medicare was the fastest we are in the data sets and data systems. Also then of course they were powerful stakeholders that benefited from this plan and the hospital lobbying groups were very active during this period, and a lot of possibilities that equity was not a priority. So I'm going to sort of have a digression here of this issue like being flexible and the question of fundamental reform versus seize the opportunity. The take on this just being that advanced health equity is not necessarily a linear process and go where there are opportunities. You're going to see as we get into the meat of like my principles for best health equity. However, there are opportunities for a shorter term to then advanced equity and to give you an example. Right around that time, I guess it's the spring time era as I was involved in a number of calls with some of the consumer patient advocacy groups, and they were trying to determine well, you know, we know that the regulations may written for these legislation. What do we try to put under the plate to try to get into regulation. So that then more money would flow towards the providers institutions that care for these at risk populations. And so, I would say that none of the suggestions dealt with fundamental reform. And the reason why is that that was not going to be part of the regulations that it had to be things that could be. So into regulation and rulemaking quickly, and that meant that could be built into existing programs. So almost all the suggestions were more money for existing programs, imperfect as they were. Phase two and phase three smaller amounts from the 50 billion expand to Medicaid provide providers, Medicaid managed care, as well as steal the Medicare. And then over time, later than the spring period there was target distribution to try to work on equity issues. You notice these are all smaller numbers from the general funding. So you'll get the hotspot code the new areas rural sites, safe net providers, tribal facilities, for example. So it helped over time, not to the same extent as the magnitude of the general funding. So I'm not going to go to the part where I go into more details with some of these principles for advancing equity. So you see this major problem with the way that the COVID on it was distributed largely because the current system is set up and then that equity was just not enough of a priority. So I'm going to really focus more seriously on the middle part of the diagram, but both the cultural equity part and then the implementing roadmap part. And so here are the five lessons I give when I give my sort of standard talk on advancing equity, there's no magic bullet solution, achieving equity is a process and what we'll focus on for this talk is the culture and roadmap technical processes. We need to address social determinants, we need to address the payment incentives, and then, you know, it's just like the purpose of the McLean Center, but I think too few times clinicians and health care folks do not frame equity as a more or less social justice issue. I'm not quite sure why we talk about joint discussions, but we do better at that in terms of this framing. So I think one big problem is what I call magical thinking. I can't tell you how many times when I talked to various health care leaders about vessel equity, and they say, basically, don't worry, we got to cover. And they basically one of the variation one of the three statements here, we're already doing quality improvement. The statement organization is who we are the shift from fee for service payment, the value based payment and alternative payment models or fix things. So this is the assumption that these things inherently will lead to the addressing of the problem is that's not how the invisible hand works so basically you assume if the invisible hand of alternative payment models or the invisible hand of back the end of safety and provider, or the invisible hand of Addis Smith the free market will naturally lead to a good result. She has this cartoon from a daily cost where the tears in the invisible hand are drowning the little man down there. So this is a variant of like a rising tide does not necessarily lift all boats so a, a one size fits all solution doesn't really work as well for equity. And that can be negative unintended consequences so like the most common one or one of the most constant ones is that it's oftentimes easier to basically share a healthy patients and erect barriers to adverse populations so for example, creating rules where you don't want your clinic from seeing Medicaid patients. That's often an easier fix than trying to improve the current outcomes of adverse patients, unless there's more intentionality with the rules and incentive systems. So Mark mentioned this Robert Johnson Foundation program where again we're going to seven teams, a team consists of a state Medicaid agency, a Medicaid managed care organization and frontline healthcare organizations. And the magic sauce we're trying for is payment reform that supports and incentivizes care transformation advances health equity. So no it's not payment reform for payment reform state, a payment reform that supports and incentivizes these care delivery transformations that can advance health equity. So now I'm going to do a quick view over you have some of the technical aspects of roadmap is identifying disparities I'll spend more time on root cause analysis analysis. So here's a common mistake that people will look at and try to figure out what why do we have disparities. They basically don't do the work of like involving patients and communities in the discussions and solutions and there's no substitute talking with the effective patients and communities. Let me share an example with you. One of our early grantees was a Medicaid health plan in the state of Rhode Island. They said that their Hispanic patients had worse depression outcomes than their white patients. And so they decided to get together for a focus group other Latin next providers so they're Latin next doctors, nurses, social workers, educators, and ask them, why are there these depression disparities, and the Latin next providers said well, you know, we think it's for a couple reasons. One is that they're basically our transportation issues and things like the child here at home and so that it's really hard for some Hispanic patient population to come in to visit. So if we do a telephone intervention, that's going to be great. It's convenient. We don't have the transportation issues, childcare issues. This is the solution. Sounded great in theory, they roll out the intervention and they found out that huge help plan, they had trouble involving more than 12 patients. And in retrospect, the reasons were obvious. It turns out that most of their patients had cell phones, but they had the pay by the minute cell phone plans as opposed to probably most people on this webinar have the unlimited plan minute plans. So it would be very expensive rapidly. You were doing a telephone intervention that we were paying by the minute, then also at the time the governor of the state was starting to do a crackdown on immigrant workers so it's not a good timing and all. So my guess is that if the instead the, the, the help plan had got us focused with 12 Hispanic patients. My guess is they would have found this and save a lot of time and effort and designing a better intervention. There's a lot of themes about what works to reduce disparities, the best we've come up with reviewing like over 400 interventions was multifactorial interventions that attack different levers, culturally tailored approaches better than generic team based care, often strong willful nurses, evolving families and community partners, robust literature on community health workers, patient navigators lay health workers, interactive skill space trainings what we'll do in 30 minutes when we do the discussion as opposed to when doing now lecturing. Here on the slide that left you have a person who lives in the community. If they have access to cure they become a patient interacting with the provider a health organization. Above it you have policy where money is the big hammer. So you can have interventions at any of these different levels at any of these different sort of no sigh. So I talked about this in terms of like social needs, both individual and online social drivers. This is a cool diagram by a constituency in our back. Sometimes you hit this upstream downstream terminology downstream is our health care workers what we do in terms of you know what's preferred downstream upstream is for example addressing underlying poverty or underlying problems educational system. And as an example so you know Monica peak and I we co direct this work foundation version to get a program. So we've done like a couple site visits to La Clinica, which is a fairly qualified health center in Washington DC that serves a mostly El Salvadoran immigrant organization. And they are truly a committed organization socially justice oriented that they do it right in terms of addressing the whole patient. And social factors and many other patients have a variety of legal issues. So one example is they partner with a legal partnership is literally two blocks away. They have case rounds, we make a legal case rounds where they will bring together medical legal staff and talk about the variety of the patients clients and jointly discussed in the medical and legal issues basic coordinating care. The sad thing is that there is currently little funding stream for the social parties so they are grant making machine that help your system page for the health part, and then they are grant making machine in terms of grants that apply pay for addressing So payment here. So those here really are explicitly designing quality parent policies to achieve equity holding the healthcare system accountable to public monitoring evaluation and supporting with adequate resources. So I'm going to stick at the level of principles because you're going to hear about this again again in the literature and the papers as this becomes more prominent. So I want to give you some primer so that when you do come across more detailed descriptions, you have a foundation for your further learning and application. So purpose of this talk I'm going to find value based payment as both payment systems are designed to reward high quality care health outcomes, promote value and cost efficiency. They frequently incorporate bad as payment principles at present many still use fee for service inside as the internal chassis to distribute resources. So these could provide effective mechanisms and incentives to fund infrastructure to address social terms of health and vessel equity, i.e. the clinical problem. So this is maybe the key slide here you might think about payment terms upfront payment and retrospective payment upfront payment or prospective payment could cover infrastructure and workforce interventions so for example, if a fee for service generally does not cover for community health workers, you could use upfront funding to pay for community health workers or team based care so it's an issue for a university cargo, how do you fund team based care, for example, change the information technology system to track equity retrospective payment, you could use retrospective payment to reward incentivize reducing disparities vessel equity. So those organizations have done well with reducing disparities, give them more money. I talked a lot about this already slipped to the bottom here so one example, especially for like our search goal and will be joining colleagues, a hybrid of upfront and retrospective based payment would be example be a maternity bundle payment that covers prenatal care, the cost of delivery postnatal care that also includes a quality withheld for a healthy birth weight baby, even additional money, if they have a good health outcome. And then again, keep saying a little principles. When you're reading these talk or these plans and about payment, you might ask these questions. What is being incentivized or what is that financial risk. Some systems for example just incentivize outpatient care inpatient care or total cost to cure very different incentives. Let's get into the incentive with the amount of money at risk. What patients with populations are you responsible for, what are the data and like paid list you have or don't have to do the analytical work for this. If you have savings, do you have to meet certain quality metrics to get that savings, what the appropriate payment targets to advance equity is it, obtaining an absolute level of quality is it relative attainment compared to a benchmark. Is it improvement so you may be starting at a low level but you improve you get paid should you reward incentivize paying for these disparities relative combinations of these. So again, general principles keep in mind to refer to over time. So, you know, this is lesson two so you know most of my talks I usually give like the talk about like integration equity and culture and technical, but it makes more sense this talk to basically now come back to culture and start coming back to some of those Java examples and now watching the discussion. So, yeah, back to that slide there. And so many of you heard the famous quote from Peter Drucker businessman culture each strategy for breakfast, his point being that it's experienced business world where you can have wonderful business tactics, wonderful business strategies, but it doesn't fit the culture organization, it's not going to happen or it's not going to happen well. I gave the money slides here though why is the cultural equity so important what why am I spending so much time on this talk compared to like a year ago. Well I've come to realization that effective equity and then interventions won't occur or be sustained unless equity is truly prioritized in an organization. Just like so academics here, you can do a one off so you may get funded to do an equity intervention, you get buying in the little neck of the woods or whatever your project is. But if the wider organization is behind it. This is a high chance that it won't be sustained and that will basically wither and die after the grant money goes away. The other sort of recognition here and gets in the second one about buying across the organization won't occur unless equities understood valued and prioritize both individual behavior of the organization and then organizational structures. So one of the things that I kind of realizes that for sustainable change for an involves payment and quality and care transformation is the whole organization. You can just work with quality improvement folks, or the payment folks, or the equity folks, you got to involve, for example, it get involved patient experience, you got to involve the strategic planning folks, you got to involve the front line of people. It's everything there's no shortcut around it. For example, like we work with like state Medicaid agencies, you can't just work with like the equity division you got to work with the actuarial people you got to work with the strategic planners you got to work with the IT division within the state making agency, it really is the whole shebang. And so this really got to be the buy in across the whole organization. And then, and here's where it gets back to John podcast. I've come to conclusion that organizations won't address the key drivers, unless the hard discussions occur. Well, many organizations won't address structural racism, unless they gone through the hard discussion, which involves you know how are they defining racism how are they finding equity. You know, internally in terms of individual biases the hard luck internally a well, what how have we structured certain things that any place clean versus cargo that are basically our structure racist ways of sending things up. Do we really value health equity or we're giving lip service are intentional. So part of our mission statement does the reward and incentive system for example for the senior leadership is a built in that you they were working for incentives for equity or it produced inequities is a part training the interpersonal and the structural. I will skip the original example. I want to do more time for discussion and you've already heard my initial example, another talks probably. I'm going to share the state Medicaid example. Recently. So in the past month. We had two hours with the senior executive leadership team of one of the state Medicaid programs were working with this like the senior leadership. So they got a version of this talk cut down version, as well as the key part was probably like half time in breakouts designed organized by the way they're structured. And I noticed that it was a real eye opener that they hadn't quite thought of wasn't mean to apply an equity lens to unit X within the agency, for example. So this whole idea like what does it mean to apply equity lens to the work. And this is issue of like every working worker knowing how to operationalize the best equity in their daily jobs. I've mentioned that. I'll skip the universal example. We'll come back to this during discussion Monica. I do want to mention this that you haven't seen it so Monica peak Bella and I, we had a paper come out the end of 2020 and academic medicine was basically title something like practical lessons about teaching about race and racism. I think it's one of the articles that we're proud of some in terms of like bringing together some of our practical experience and what we've learned from others. There are like 12 lessons. What I want to point out here is the upper right here start with stories, not numbers, start with stories, not numbers. The way Monica peak is said is that we start a lecture with numbers. It's almost giving people an excuse to tune out as opposed to starting with stories and examples. Keep that in mind during the rest of my talk. Well, fearless conversations. And so these are conversations about structural racism, colonialism and social privilege. One of the transformative events for me in the past decade was I spent a summer in a tarot in New Zealand, working on a paper of what the two countries were doing to advance health equity. But to slide her on my left, these three co-authors are Maori, the indigenous peoples of our tarot in New Zealand. And so we have literally dozens of these hard conversations and in fact this phrase about free frankness, free frank and free frankness comes from mum. And then they put it in, you know, they really pushed for it to be in the article we wrote together and I'm glad that it became part of that article. And what they basically explained to me during these dozens of difficult conversations is the lived experience of being Maori and how the rules and regulations baked into the private and public sector in New Zealand basically had put the Maori at a disadvantage. They were also the folks that introduced me to this concept of white fragility and they introduced me to the work of Robin D'Angelo. You may remember this was a book that got a lot of press about a year ago, a white fragility defined as racial stress that can lead to defensive emotions and behaviors in whites such as anger, fear, guilt, argument, silence, withdrawal, or statements such as, you know, I find it offensive that someone would consider me to be a racist. And again, the way the Maori colleagues described to me was, and this was quite impactful when they explained it to me, discomfort cannot be a reason to avoid dialogue, for then white fragility would in essence be a tool to perpetuate inequities in the power structure. And I said, oh, we can't discuss racism. Well, basically you're basically then baking in the current system, which has been sort of these structural racist aspects. I gave NSTs a grand round recently and someone asked me, well, you know, are we particularly bad health care in terms of this racism. And my answer was, well, you know, sad stories that probably every other field is similarly bad. For example, so there's a little Rooney rule where I wish I think minority can eat coaching candidates. So some of you may know the story so Jacksonville Jaguars they hired Urban Meyer to be their football coach recently. And one of the key hires after that becomes the strength and conditioning coach the guy that's going to basically get the team to shape. The guy was hired was going to Chris Doyle who used to be the strength and conditioning coach at the University of Iowa. And he left Iowa because he had been accused of being racist against the African American players, as well as bullying the white players who had learning disabilities. And so the first public alliance which advocates for fear hiring executive directors. I had this quote, which says that this reflects the good old boy network that is precisely the reason why there's such a disparity in employment opportunities for black coaches. There's a quote after her Meyer when there was pushback, he said, well, you know, I can vouch for Chris Doyle. He's an upstanding guy, you know, he's a man of highest, you know, caliber. And I have no doubt that Chris Doyle, you know, treats urban Meyer well, but that is not necessarily then the live experience then for example the University of Iowa football players. New York Times a month ago, Nashville notorious for being very male dominated and white dominated. So Morgan Wallin is one of the big stars now and he was caught on video saying some racist language. And he's the only African American woman hired to sign to a major label. So she sort of tweeted out, you know, assistant to the same thing where in the past, the country at music established and basically swept it on the rug. And actually there was pushback where his songs were pulled from the radius for a while he wasn't eligible for the music awards that type of thing. The New York Times that trial has quotes from a couple of women and people color who in the country music business. We see Palmer and the female experience you understand what it is to be the underdog to come into situations mostly white male driven and try to assert yourself. Men of shires assume a lot of males aren't speaking out because they're comfortable with their places of power and money. Why would they want to change. I'm going to skip these. So I'll prove that well you know us to some monopoly upon structural racism and colonialism. And so the challenge that power is the issue is control over resources, like money is control over the historical narrative control over the framing of health and equity. And that's one of the reasons I believe that like, this is Dean Madeira so late CEO Madeira of AMA, and the job editor made the, and at least the Maybank made the post about being harmful, because it distracts from the historical narrative and the frame of health equity away from some of these true root drivers. Okay, I am going to skip ahead to skip a little bit solutions and you remember I shared that. And the point Monica's point about starting with stories not data. So Mark mentioned over the past four years I've started getting into improv and stand up comedy. And so, in improv, the most famous principles yes and agree with your team partners and build upon what they have said and give it to you. Listen, build positively up what your partner I said that eventually the scene end up in a good place. And Monica's terrific recent analyst article about counseling about code vaccinations. It really employs this yes and principle or the principles of motivation interviewing. And I think it's Mitch cast this point that he said that you know, is very hard to basically tell someone their racist and think that that's going to be solution. So I bet for example if we talked to Mitch longer, he would agree with this that it's important to have these conversations can avoid them. But the way we do it has to be more sophisticated than, you know, simple. Here's the facts man type of approach that we got to start with where that that person is and then try to move them in terms of understanding these issues of inequities and racism. So stand up is a different, it's a different, different beast in some ways that like this very different culture improv and stand up. This picture has my stand a mentor and Mona at Burma shine. After I done my longest set was the 15 minutes set at this time able tonight. And Mona has taught me this concept of the power stand up passive saying no to the absurdity and social injustice of biases stereotyping racism. And basically, like, in jokes that basically show how stupid and absurd stereotypes are. It's a way to basically teach in a hopefully approachable way. And so often in my sets, I talk a lot about identity and my Asian American background. One of the things we're taught stand ups is to try to make it our own in terms of like drying up on our own personal stories and what can you say that no other stand up to say, maybe a couple weeks ago, formed during this event. And so we did our sets 10 minutes sets each. And then we actually did a calm down version of what train we've done with the medical students. And that's where we asked the alderman and involvement here to basically describe how people perceive them when they meet them for the first time. What are the outside will get right wrong about these perceptions. So we actually, you know, actually got the alderman and another community leader, Timothy may involve in a really cool discussion about essentially structural racism and implicit biases, which I thought was a fruitful conversation for all. I was invited to write this sort of review for the general clinical, general clinical and chronology metabolism. And the revision is under review, but the way I end the paper is I do not have an easy solution for how to bridge the person divide and world views and cultures. However, I believe that the public must perceive that policies and interventions are fear and benefit them. The initial initial step is effective communication that encompasses intense listening active engagement. Yes, and ways of acknowledging the patient's starting point on the way to an aspirational goal, true respect and curiosity to understand the lived experience. And I believe that the vast majority of people are inherently good that we must appeal to people's inner moral sense in yearning for justice and human rights. So I will end there and Monica, why don't you take it away in terms of q amp a. Excellent. Thank you so much Marshall for a fascinating and power packed lecture you had a lot a lot in there. I'll, I'll take the the prerogative by starting a question. You talked a lot about structural racism and interpersonal racism. The need for us thinking about both of those for us thinking about the business case, as well as the sort of interpersonal and moral case and moving things forward. How do you suggest that we try to intertwine these simultaneously as we move forward. Great question. So you remember that that slide that conceptual framework slide I flashed a couple of times, you know so they have that that bar. It's sort of an artificial division between the cultural equity, and then I would refer to as like some of these technical steps are great things like payment or how we will redesign the cure system. The main thing you need to go hand in hand that that one without the other isn't going to work. And the reality is they all take time and so that I think one of my slides to be flexible slide mentioned that this is not a linear process it's not like well you know we do this and then this and then this and then this reality is that it's going to be bouncing around a bit, some but it's like where there is the opportunity word of resistance efforts where there's someone that wants to be a champion to do that. But what we've learned like the past year from some of our Robert Johnson workers that we try to short circuit the process of for example if we don't spend so much time coaching teams well the cultural equity part in those hard conversations, or vice versa Let's talk about cultural equity. I'm going to talk about like the practical ways that you incorporate in daily job and they're going to work. So a couple examples. We're thinking about the future of our Robert Johnson Venetian program now, and we are explicitly going to beef up the part about how can we do better in terms of having the conversations about anti racism and culture of equity. That's a great experience. I would say, in the beginning it was more the cultural equity piece, and the feedback we got at year four was that many of the frontline, that was great in terms of being more aware, but they didn't know how to apply the lessons in like their daily job in it or analytics or, you know, the front office staff and all. So they have to be combined. Great. What advice would you give, given the sort of socio political climate that we're in right now to the physicians, the researchers, all of us that are listening in the room you led with the comments. The tweets, the podcast, this environment that we're in where many of us are working towards social justice. And we're in the middle of a sea change and racial reckoning and trying to sort of push this work forward. At the same time, the very institutions that we're working in that we're publishing in. You know, are also not insensitive to these very issues of structural racism. And how would you suggest trying to move forward. There's a little bit of internet glitch and so that the part about structural racism at the end and the role of providers I didn't quite hear what the question was. Well, just just what are your suggestions as people are as clinicians and researchers and interventionists and policy makers are trying to make the world a more racially just place in space. And for our patients, yet the institutions in which we work, the places where we're trying to publish all of the places where we're trying to affect change, all of them are coming under scrutiny right now for structural issues and injustice of race. And so do you what advice do you have for those of us on the front lines in many different arenas, because you led your talk with the specific example of JAMA. And many of us are trying to publish in JAMA. And so what advice would you give. Is it improv to the standard principle of like, never sort of punched down, you can punch up, you can't punch down. And that's what I would say here that in our individual interaction with individual people so like with our patients with our colleagues with other staff at the mental center for example. I like to try to have that yes and type of way of approaching things, you know what you are going to be described in your way of counseling for example patients that are hesitant to take the vaccine, or maybe skeptical and all. And so that is not, you know, accusing someone of being racist and all is trying to start where they are, understand a perspective, and then essentially using these motivational and view techniques to try to change behavior over time. I mean, you're talking about power structures and one of the slides I went over because we didn't have time was this issue like when I don't tend to the grab the bullhorn and march the streets type of person I tend to be working the system type of person. But you know I recognize there are times it's important to have that bullhorn. And what conditions are when you know there's a gross inequity. There are differential between the oppressor and the oppressed and this little incentive by the powerful to change the system. So I would argue then that some of what you're talking about later in terms of like some of the structures and systems and policies. These are generally powerful organizations, powerful systems run by powerful people with wealth that have little center to change the system, you know the national example gave in country music. So there I think is a really important role for for those brave leaders such as yourself and like leaders to say it like it is. I mean you saw that a tone for example of Dr. Leitha made banks tweets, you know, that's, that's, you know, it's vital have leaders like that that do that. And I know that it's easier for someone like you or someone like Dr. Maybank as opposed to someone that's a fellow or like an assistant professor starting out to challenge the drama or challenge the But also to we can work with the organizations and this power and organizations. So even like if you're like, you know, someone junior as part of an organization, you know, this cloud. So, you know, as, as they say, and as you say, you know, Monica, you know, speaking truth to power. There clearly is a role for that and an important role, because, you know, that point about the drama podcast was that the sad reality is that there are there are still are our folks that that that need to continue to learn like the rest of us that you know we all have our biases and all that structure issues do influence outcomes and equities for a lot of folks. There's just a quick follow up from Dr. Vela, our colleague and friend who asked is there truly any credible excuse of educated academic physicians to deny the existence or magnitude of structural racism. You know, I don't think so. I mean, in terms of like, you know, it exists, and then we need to sort of call it out. I think the point that Mitch cast was raising is like, one of the most effective ways to do that. There are some audiences like, like in this case, like, for example, JAMA, AMA, you know, organizational change and some of the more conservative states or organizations. I don't like it is probably it's not going to be as effective as some of the techniques that use, you know, yes and some motivation into doing staying to the goal, you know, not sort of whitewashing a reality. But there are probably ways the message needs to be tailored to communication needs to occur. If our goal is to be effective as opposed to just making the statement for a given organization. There's always actually not seem to a question that we have from one of our medical students, Natalia Kossela. She says I spend a lot of time thinking about this tension between protecting the majority's comfort, so that we at least get some momentum going among them versus just being honest. So, for example, the deep, deep, deep. I'm talking and shipping our word, I'm deep politicizing of the term social justice to instead quality improvement in medicine is common. When I have brought this up with faculty and administration, I understand that attention they struggle that they're struggling with is saying less controversial words to make the concept more palatable to older and more traditional people in charge. And this is also weakening our work and betraying its real purpose. How do we handle this balance. It's a great question. And I shot to Natalia that she and I are working on creating a sketch comedy class that it could be different students or we may end up doing it with the medical center staff and faculty, where we were trying to basically train folks and being right and then perform sketches and then lead a dialogue with the audience regarding these issues. You know, let me first say I don't have all the answers in that like in some ways, I'm tapping into like a wider question with the basis of society regarding the alternative realities, the person ship. And so some ways the issues we're talking about are repeated in every field and across our wider society. And I think it's an open question, you know what are going to be the best ways to communicate. My own personal belief is a variant on the answer I gave to Dr. Bella's question on his question that we have to maintain the two North stars we can't whitewash. We need to tailor to the given audience and again it's about punching up is okay when a punch down. And then again if our goal is to change minds. We have to think about you know what is a way to essentially motivation to you and yes and in a way that doesn't sell out, in terms of not being truthful yet also can get through to the given person. And that's attention. And I don't help me like make different things like the arts things we're doing with box bomb and marks, we did with the ethics fellows we're doing to students. And I don't know who's hosted maybe sessions he's doing with Shirley will be with medicine. We're hoping that in some ways, when it becomes personal, you know you have these discussions that are with live experience, especially with people you know and all. And that becomes a more accessible experience as opposed to, I think for example we should talk to a model of institution you're talking to like the model of the drama model of the AMA. You know, you're not offending a person you're you know you're speaking out against the institution, which is different than like the smaller the group or organization then it gets more personal so it gets trickier. And Mark, do you have any questions or comments or Brian, do you want to ask for Dr chin. Yeah, one question I have and maybe this is splitting hairs but maybe there's actually sort of a practical reason for in terms of how one responds is that I in one of the earlier slides you had mentioned, you know some of these organizations that are sort of taking on that the model of racism, and some of them use the term systemic, and some of them use the term structural is, is there a difference in between those and in terms of how, how we may approach them or are they pretty much synonymous. Well that's a great question. You know, I, my guess is that people would interpret them. And one last last two I made this point about like, one of the challenges in this overall work is that when an organization starts having discussions, they got to start at ground zero terms like well, what do we mean by equity, what I mean by disparity, what I mean by racism, let alone things like structural and systemic. And actually I don't have a great answer for you, Brian is probably, you know, lazy thinking on my part in terms of like, not being precise for dirty, you know, is there a difference between systemic and structural. You broke up a little bit at the end there. Oh, the same like, you know, part of this lazy thinking on my part that I haven't been precise about to find a difference between systemic and structural and, but clearly both are different than the answer like well, those are distinct from interpersonal biases implicit biases. Let me throw it back to you and Monica, you know, how would you answer that question. I mean I was trying to sort of think about it through through the course of your talk and wondering if, if systemic is something that actually sort of incorporates the sort of cultural aspect like sort of creating a culture, where is where structural is where you can really look at at sort of the power structures and hierarchies. Maybe I don't know that's why I asked the question because I was I often sort of use them interchangeably but but there may be some real differences and how to think about it so I don't know Monica as well as has something to offer. The way that I think about it is that structural racism is more about the policies procedures the rules, the laws, the things that codify inequities versus like Marshall saying interpersonal racism or internalized racism. I think about the word systemic to me that implies that it's everywhere. And that it may be just a reflection that it's like the analogy that come our Jones uses like carbon monoxide poison, or radiation poison, you know, it's, it's slowly killing us all, particularly black and brown people, but that it's everywhere. And all forms of it are everywhere. But I think that all forms of racism are everywhere it's, you know racism is systemic, but there are different kinds of racism, and that structural racism is, you know, more about the policies and procedures. I think I had another nuance, your answers maybe think of something else to that I didn't cover in the prepare talk. You're increasing seeing like the statements that it's not just what it's not just like the end result but sort of how we got there or it's not just like what we're doing but the process of what we're doing. So let me give a shout out to, they're coming my colleagues of Scott cook and yelling a totic. They're two of the folks that have been heavily involved in the University of Chicago's equity initiative. And so they taught me about critical theory. And so it's idea like how basically that there are various systems where system and their systems of oppression. There are sort of obvious and less obvious ways that structures are built that can basically marginalized different populations and discriminate and lead to inequities. And so one of the examples is that like, who is at the table. How are people's input brought in. What is that that dialogue and so a concrete example is that, you know, like from the quality improvement field and toy quality management. Whole idea about like, sort of trying to level out vertical structures and horizontalize them so that the frontline car worker felt comfortable stopping the assembly line and bringing the supervisor telling the CEO that well, you know doesn't make sense to do it this way. There's no way to do it based on my knowledge from the frontline. And so, you know, it gets this issue like well how do we involve patients and communities in the solutions, you know, is it by doing a focus with them. Is it to have in part of the formal teamwork in the problem, give them an equal vote, having a community advisory board. I mean, each of these processes is different. You know, and I think if you think about it. The ones which are more likely to really address the root cause and start prioritizing patient outcomes and inequities, more so than others are ones where the patients communities have a strong receipt of the table. You know, this is the way organizations work and not unique to your Chicago but it's just the way organizations work. I mean, I'm thinking you're John Rawls here. So, I'd add that to, you know, so, so, and that's just the question about why we can't just do the technical part we have to do the cultural equity part and thinking about how do we do the cultural equity part. So really is sort of all intertwined. It truly is a priority of an institution. It's only so much that will be done. Marshall, could I ask a question that you spoke a little bit about but I'd love to hear a bit more about it. And that is how this new project of yours that that you've been thinking about and writing about and practicing. That is the improv and stand up comedy as part of the interactions between clinicians and patients. How that contributes, how that contributes to reducing disparities and overcoming a degree of racism. Yeah, you know, I'm glad you asked that mark. I actually think about this morning and you know remind me I needed to shout out to you in the McLean Center, and that you know, if you think about all that I've talked about today. And as Monica said, this is a pretty ambitious talk covering a lot of different things. I thought about this morning I said, you know, this really is the marching order of the McLean Center, and that the, the, maybe the key innovation you made mark was that you were able to take sort of abstract ethics of philosophical thought, and made it relevant to the frontline. And you know that frontline clinician patient relationship discussion shared decision making, so you're integrating abstract principles with practical reality. And so the answer your question but like you know where does something like the arts and improv stand up come in. And I'm hoping this is a way to cut through, you know, all the abstraction, all of the system structural talk, all the talk about rules, regulations, the policies to how do you reach individuals, because we know that in terms of all this to change the curve for the policies to change for resistance to change or the electric patient care to change. People have to buy into it and care about it. And so we're improv and stand up fits in. And again sort of harkening back to you, my improv partners and like a moment of stand up and all. The heart of I think those forms as well as arts in general is they drop on the human experience, you know, and I think like what we're trying to do with these exercises. Is what I think a good artist does of trying to draw from their own personal life experience. I mean that's why you know like you know a more seasoned clinician, you know, usually over time to get better right. And part of it is because we have more life experience. Similarly, it's interesting like when I look at improv additional folks who do improv. Sometimes the older folks. They can drive upon more life experiences. And so this is richness to that. And so I think what we're hoping to do with like the artists that we're trying to expose people to a broader set of lived experiences. And so as the power like when we did with the medical students, they would hear through the exercises, the lived experience of their classmates. So it's not an abstraction talking about racism or an abstraction talking about structural equity. They hear the concrete stories of their classmates, and how these inequities have affected real people in their real classmates. So if what we haven't talked about establishing a safe space and so Monica Vela particulars taught me like, you know, the importance of establishing a safe space. If you can do that. And you can make it personal. We can get go pretty far. So that's what I'm hoping that the arts can do. And which I think you think about like the McLean Center. I think that is one of your major contributions were. Thank you. Thank you so much. I'll just note that we have a comment from Connie or work who just wants us to remember that we have nurses that are key part of the healthcare profession. They're at the bedside, particularly seeing our COVID-19 patients, and that they're also facing their own inequities in healthcare organizations and how they're perceived and treated and just to make sure that we're conscious of that. Thank you for those comments Connie. I've tried to gear my talk to be basically, you know, word it in a way that applies to any type of clinician and non clinician involvement in this particular sphere. Mark mentioned, I've been really fortunate to be on this national MS and future nursing committee and met some tremendous folks and nursing nursing is incredible has incredible power potential power to advance health equity and in fact the name report is going to focus on nursing's role for addressing social terms of health and advanced health equity, and we're hoping that that this will help nursing be that we are for example like I'm advocating for it in the national community medicine report. Great. Thank you all so much for joining us. Thank you Marshall for a very insightful and thought provoking lecture. And we look forward to next week's talk. And thank you all again for enjoying joining us for today. Mark, do you have any last last comments. Only to thank you Monica for your lovely supervision, the program and the questions. And of course, to give my deepest thanks to Marshall for an extraordinary talk. And to mention extraordinary career achievements. But thanks very much Mark and I think people something to look forward to that like Mark is really a gamer. And so like when the revival theater opens up our troop that we have like a monthly show, which involves highlighting a university faculty member. So, whenever it's the first July that opens up where we have a new fellas coming in, guess who the faculty guess will be at this improv show. Dr. Seagler. Thank you. All right, have a wonderful Wednesday afternoon everybody next week. Doug White from Pittsburgh will be joining us. Excellent. Thanks. Thanks so much Monica Marshall. Thank you. Thank you. Bye.