 So now I would like to invite our panelists up We have a very distinguished panel and we're gonna have conversations not only with us, but with you about how do we move? Transparency and learning forward in the environment. We're dealing with today. So Panelists, please join me. I would sit look All good. So I you know, you can see the names of the panelists on here They are all international experts in this area and as we go through I'll just highlight them as I call them Out and you know, Alan, I want to start with you. You've had an illustrious career Alan spent many years up in the Boston area and Research and publications and really understanding the dynamics involved here We're excited he's recently come to Maryland at Hopkins and will give us a chance to work closer together and overseeing the Armstrong Institute and quality and safety for Hopkins, but Share with us what you've learned through your 15 18 years of trying to figure this Legal scenario out sure Well as you pointed out I think what we've all really come to learn is that it really is an ethical and a professional imperative That when things go wrong we let people know what happened We let the patients know what happened and of course apologize and then take steps to make it better So it doesn't happen to the next patient You know what I've seen over the last 20 years is a remarkable shift when you talk to clinicians or people involved in health care When I used to ask them is disclosing the right thing to do they used to be debate about 20 years ago now today When you put that question in front of everybody everybody says absolutely it ought to be done Of course the challenge lies in what you were talking about which is if you ask them then Well does everybody disclose and of course everybody says well my hospital does but others don't that's always the challenge that you hear I think what we've seen over the last In more recent times is we're seeing a bigger push around transparency just as we've seen in society in general I think people are getting behind the concept more because they've also realized that if we don't know what's broken We can't make it any better people have really locked into that concept as well And we're starting to see now as people keep complaining about the liability issues We're starting to see more and more data come out to show that even if liabilities are concerned it shouldn't be We've now seen at least four or five systems publish their data on what happens to claims and expenses after they start these types of programs Candor type programs or that what was done at the University of Michigan and what we've seen is your liability doesn't get worse In fact in many cases the claims go down the amount you pay to your lawyers goes down And it turns out patients tend to be very happy with these programs for obvious reasons So we're starting to see more and more Growth in these types of programs in this concept, and I think that's where we're going. I'm hopeful. We'll get better at this with time Great. Thanks Jonathan, I'm gonna turn to you Known you for a number of years Jonathan has been a national Reputation in plaintiff's attorney severe You know what a patients and families tell you when they walk through the door And what do you hear on a constant basis that you could share with everyone? First of all, I think I need to be on the other side of the table as the only plaintiff's lawyer in the room It's a little itchy over here I've been at medical negligence for 44 years as a trial lawyer. Most of us are dead it's rather stressful and The question comes up is why do people come to us other than the medical mistake? Because the medical mistakes. I know we're driving to zero. I'm all in I'm with med star. I'm doing my best to help But why did they come? Well, here's why they come because the predominant climate in the United States today is hostile It's adversarial It's destructive It's horrible for the injured patient and family. Why? Because typically what happens is when a medical mistake occurs No one does come to the patient or the family if appropriate and no one tells them what happened truthfully I'm gonna be honest with you people. They're lied to There's a lot of lying going on out there in 44 years I've seen literally Thousands of instances so what happens a medical mistake occurs the hospital goes into lockdown the records are sent to risk management What's that mean? The patient can't get them succeeding health care providers have trouble getting them Sometimes they're redacted a little patient bumping sometimes. They're altered secretly It happens The patient's not told anything The patient becomes disillusioned Angry Betrayed by their own system. Don't forget. I'm old We had Marcus Welby Everybody remember Marcus Welby? He was on a pedestal Everybody loved their caregiver. Why? truthful responsive Telephone calls were not ignored Rude-ness didn't occur My favorite rude story in 44 years We had a gentleman who's the victim of medical malpractice Goes up to his doctor because the doctor didn't tell him he was the victim of medical malpractice. It says doctor. What happened? And the doctor says I'm busy. You've got 15 seconds. Ask me what you want well It's a true story. How does that play? With the patient so the patient starts out as your ally The patient is deeply respectful of everybody The patient is depending upon you to heal them an Unfoured event. I'm gonna use some of the language. I've heard occurs synonymous with medical malpractice or medical negligence and Your system shuts down When the patient needs the help most which is after This event The patient may need a hospital bed. The patient may need rehab. The patient may need custodial help The patient may need occupational services. The patient may need a host of help then and What happens the system turns against them and turns them into the enemy and Then when the insurance interests get become involved. I got plenty of stories Their mantra is just say no we can beat these people down. Maybe they'll die and When some of the insurance not at all and certainly not MedStar But when some of the insurance interests win a catastrophic case, they know they should lose. What do they do? They celebrate Believe me. I know they go out and Celebrate that that brain damage baby that everyone knows they're responsible for will not be compensated So I look at this system after I'm 72 years old shouldn't have told you that We need to do something we need to do something and Then I learned about candor and I'm taking up too much time because lawyers do You did promise me some of your time. I did but I'm taking it back. There is a billable hour situation coming on here Okay, what do we do this candor program that I was introduced to through of course David and Larry Smith It's the exact opposite The patients told the truth What a refreshing notion for me. I Don't have to fight through two five or seven years of lies To finally get to the truth the patients told the truth and then the patients cared for The patient remains an ally of yours. The patient has a better outcome And you save money and your hair health caregivers Are not as depressed Because they're helping I Took too much time. Oh, thanks, but I flew 3,000 miles to tell you that Peter I'll have any time left. Yeah, you don't need any time. Yeah, I said it all Peter I'll turn to you next and you could see Peter is at a long career in safety and quality But now is the current CEO for the International Society for quality and health care iskwas. It's known Peter I it is about really designing and systems and processes and how can we do that? What are ways we could accomplish that? Yeah, well if you listen to most of the talks today, it's about system design Unfortunately, we have a system that is working for health care of a hundred years ago Used to go to your doctor and then to your priest and that was it And you didn't survive Now we've had a lot of success in people surviving again older yet the whole model of health care stayed the same We divide people up. We don't we look at different parts of the body We don't look at people as a whole we don't integrate care and when things go wrong Everyone runs for the hills. Just as you say it's not my part of the problem Particularly nowadays with chronic disease. So the design of our old system of delivering care is Based on a model that doesn't fit what we require now and with that is how we deal with things that go wrong is that Doctors have this idea that we are always right in the old way and that we do not like failure and It's very rare that in medical school. You talk to deal with failure. You're supposed to succeed Not dealing with harm. You're supposed to always deal with success and yet when that happens You don't know how to do it So the system of delivering care needs to be redesigned for the current need of integrated chronic care And you heard earlier from Peter from a boss care should not be in the hospital But should be outside the hospital however, the system here as in the United Kingdom United Kingdom may need for Political reasons and here for financial reasons Hospitals are very unlikely to give up their expensive buildings and expensive departments and integrate care to provide it in the community It's either politically or financially just not possible Unless there is a will and finally the business model is totally wrong. I don't believe we are in healthcare. I Don't think healthcare is my business is the pediatrician I believe safety is my business However, if I speak to doctors and nurses and say what do you do? They do not say I'm there to keep my patients safe They'll say I'm there to heal them. I'm here to cure them. We're ready. We should be saying This the healthcare this we actually our business is safety We happen to care for patients as well But we can't do it unless we do it safely and that's what the airlines do if you go into an airline They say our business is safety. We happen to fly the plane as well and Until safety becomes what we do Then all we're doing is the band-aid onto the problem Great things and Mike you see Mike Durkin is from the UK is a senior advisor has been in healthcare safety policy legislation clinical Mike and onto what Peter talked about around the systems and processes specifically Legislation and maybe education also. I know it's very passionate for you. Yeah, thanks, Dave So I'd like to go back just a few years to our story in the UK to try and combat the growing harm that was In place because we weren't paying attention to reducing the chances of people getting a VTE or a pulmonary embolus and We'd known like many countries across the world. We'd known what to do As clinical professionals, but we were just too lazy to put them into practice And it took in the UK a partnership between patients the public and Our parliamentarians the politicians to really drive that change to first of all start to be transparent in the data that was available and it was only when we started to public report data on risk assessment processes across the country that Hospitals and individuals particularly doctors started to pay attention that they should be doing appropriate risk assessments And then appropriate prophylaxis to reduce VTEs and and consequent pulmonary embolus The really interesting thing for me, and I used to say it was a sad thing, but it's an interesting thing I think now was that When we knew what to do and we had the tools in place across our universal health coverage system We're still only getting returns from about 40% of patients across the system that were gaining and getting a Assessment about their risk We introduced a financial penalty financial incentive To align that incentivization process and a bit like we heard earlier today within six months We went from 40% risk assessments to 95% risk assessments And so for me that demonstrated that there was an opportunity for The medical profession to recognize that they were only one part of the journey in terms of improving health care and health care improvement is a partnership between all players in this and Most notably and we have to say this the patient and their family and we talked about it before Are the best experts of their own care and they're the best experts of their experience of care? We're not we come in and play our own part and I think we have to keep that central tenet Every time we talk about trying to improve and develop policy around this area of transparency So we have a particular journey and we did well. I think I came into the post of enabling VTE Improvement and then the National Patient Safety Improvement at the same time that Jeremy Hunt came in as the Secretary of State and I'd like to also reflect therefore that No matter who is in the room unless we have the representatives of the people in the room At whatever level that is that's a local level not regional or national and in this country would be state level Then we lose the opportunity to make great changes Because it is with that partnership that we can actually introduce huge change and sustainable change Although you might look at the UK at the moment in terms of its inability to come into a decision about whether We want to be in or out of Europe We still have a process of listening to the citizens of our people of our population Much more so than actually we do as doctors and as healthcare workers, you know We so so the other element for me in terms of policy development We have to really understand that whole process of communication and listening So I just want to drift down into the answer your question if I may about the the importance of policy development and The importance of listening to what is really Vital for change we tried to start building our whole processes of being a transparent system By looking at what data was a required and we found that actually we didn't collect the data Peter's point We didn't collect the most appropriate data So we've now to introduce the system of cell of quality data is at a Down to a ward level which everybody can can have access to but that still wasn't enough Because we also believed that we needed a duty of candor That wasn't just a professional individual duty, but was one for organizations To build and we introduced this this duty of candor an organizational level and Sean will attest to this About five years ago, but it's only in the last two two years or so that organizations have been tested To demonstrate that they are sharing the data with their organizations because often when a mistake is made It's exactly the same point that Jonathan made in our country when a mistake is made in a hospital The first drawbridge that goes up is usually the hospital side Trying to prevent exchange of information We heard early from Jamie Preventing exchange of information is at the core stone of most of the times where relationships break down and when relationships break down I have to say sorry Jonathan the legal profession have a feeding frenzy They're able to come in because we haven't got our act together in the first place So we've introduced this organizational duty of candor we felt that was built on the fact that as professionals In healthcare workers, but whoever our whatever our tribe was we were held by this approach That we would actually also share when things went wrong But we know we don't because we're human beings and and our our esteem and our ego take over So we we are often fail our patients by not sharing that information So we've actually now started to introduce that approach that actually the most important thing going back to Peter Porno first point is is it's not necessarily your professional identity that drives you and drives your change It's your ethical identity and the ethical identity and the elements to which we can actually bring our own ethics to Bear are those that not just look at the value and the drop-in waste But actually the values of those who are working together in a team so for me the whole our whole answer to policy development is Reestablish our ethical identity as a set of professionals working with our patients and our politicians and you'll hear later I think from Steve in terms of the curriculum development how important those challenges to our students are In developing their further for the careers, but I'll come in later on other points. That's great. Thanks Jack turn to my hero last here, but probably most importantly you and Teresa Despite the difficulties travel across the country Talking about this approach Share why you do it and why this has become your mission I want to first say that I'm after watching the video. I'm not a fan of high definition I I'm not a doctor. I'm not a lawyer I'm not a CEO. I'm not a I used to be CEO of my house, but my wife told me that There's no longer You know my my purpose is if I can Tell my story what happened and the way MedStar dealt with my medical error And if I can reach one person And make a difference and one administrator one doctor one nurse about the importance of patient safety You know, I went into surgery With the idea of a little bit of pain in my right arm and Well in reality, I don't have the pain in the right arm anymore But I don't have anything in my right arm anymore MedStar Transparency Made such a big difference in my life and that Even from the operating room The surgeon called my wife. It was in the waiting room operation was Scheduled for an hour and a half two hours at the most and it ran about five hours and my stay was to be overnight and I Got out about five months later Well, it was the fact that the surgeon came out and sat down with myself my wife my siblings My children and explained to us exactly what happened and that it happened in his OR and he was responsible And the president of the hospital came in and explained and the hospital Risk manager came in and said anything you need anything you just asked for and it's taken care of and I Had the idea that I was told that acute physical and Therapy was what I needed and I wanted to get that and they provided it and it It was first couple months were critical and I want to give it a hundred percent So now I Such a believer in the the transparent approach to Medicine because it's through that transparency that The hospitals and the doctors learn because if everybody closes down we go into the Delayed and I defend process who learns from that the doctors don't talk amongst themselves administrators don't everything becomes a clamshell and By being open and transparent not only with the patient and the family, but amongst themselves You know the care for the caregiver such a big part of this they have people that they can go to and You know they go into the profession to help not the harm and something has happened and You know or mentioned earlier about the 400 physician suicides a year Some of that is a result of not being able to live with what they did in Patient harm And the last thing I just want to add Dave is we were talking this morning about zero and We were asking for a future Whether we should shoot the goal for 2025 or 2030 I'm telling you now 2020 Should be doable These are the movers in the shakers I'm so honored to be here in front of this type of national and international crowd of That can make things happen and I'm begging you please for the sake of all patients in the future take the message home and Open honest transparency Let's achieve zero Medical error deaths in by 2020 Let's go to some of the questions there's some good ones here I wanted to share and Alan I'm going to go to you for the first one here What happens when in cases or events that we don't know yet whether the care was Substandard yet something went in a direction We hadn't anticipated. How do you define that gray zone? Yeah, that's a great question And I think this is what causes a lot of consternation when people try to Say that they're going to be transparent with their patients or set up systems like this And through I've been lucky to be involved in a couple organizations that have built these programs And I think what we've learned is it's actually still pretty straightforward as to what you have to do in terms of the best practice When something's wrong you go to the family and you say look we're sorry that you got harmed We think something might be wrong here. We're not sure yet We're going to investigate and the key word here is quickly and get right back to you I think a lot of people think that these conversations with families are a one-time thing They're not they need to be ongoing conversations But the key is to start them early and let them let patients and families know what you know and don't know because they're actually quite Understanding of it. You don't want to wait till you do your complete investigation Because sometimes that could be six months later and you rise you made a mistake showing up six months later after no word Can be a little awkward, right? So that's why we advise people just sit down with the family Let them know you're gonna look into it and you'll get right back to them Yes, can I just come in so so we're good friends, okay? but one of the one of the Aspects that we find in the UK after spending the last three years four years now trying to develop a an independent Safety investigation system. We've called it healthcare safety investigation Branch it will be body soon and and and Scott helped with his experience as one of the experts Witnesses for that developing program We found that and subsequently since it's been started over the last 12 months that a one of the key aspects of safety Investigations in hospitals is the variability of model that is taken up the Inexpert approach to root cause analysis and the inexpert approach to Communicating an ongoing liaison with families and the patients So we've we're starting to develop an exemplar model because we we think if we leave it to the 500 or so hospitals that operate fairly independently across the UK will end up with 500 different models Because that's what we have now. So so I think there is a there is a real challenge across the world actually To to look at some of the other high-risk industries that we've got and see where they've taken us And they have gone to usually one model and and an adherence to that model Wherever you are and I think that's that that's the area for me because I think otherwise We're doing our patients on our deserve it and our staff a Disturbus by not having a professionalized approach to safety investigations in health care Yeah, I support that the the need to have Clinical stop trained first to acknowledge something went wrong. I think that's that insane It's the acknowledgement that something happened not the explanation of what happened because often what happens is they theorize This could have happened this could have happened and it's totally wrong because they haven't done the investigation And that's the kind of approach doctors get into is Given the answer before they know the answer of what could have happened and the different Differentials that they're taught to do to find out when they diagnosed they're going to diagnostic mode And then I told you shut up because they they're making the wrong diagnoses So they're the way to go forward is firstly to acknowledge and then to give the path that's going forward and The model that we were using a Great Ormond Street was from Australia the assist model of really acknowledging Asked in the patients to tell them the story. What do you think happened? What do you think should happen? This is what we will do and This is the timeline and how often we'll come back and it's very much like the candle system But the idea is that you to do that You have to have trained people within the hospital who are know how to do that and then just as Jack said the the actual clinical team that has been involved is traumatized as well and they're the second victim and that kind of approach now needs to Has to be addressed because if you don't care for the second victim Then you'll never get to the open a disclosure that you want them to give because they're so traumatized at the same time Well, and so the importance is to look at the trauma on both sides and often often This is difficult for the the victims and the families to understand to accept that we also have to care for the Victims on the other side who are part of this because two two people two groups are involved So the surgeon who causes the error or does the error is been due to liberally necessarily But it's traumatized by the same problem So it's a different kind of trauma, but if we really want to get this Synergy together between the patients and their families and the openness that we require We need to go from both places both sides But you have to have in every hospital the culture of openness and transparency that this is the way we do it We are acknowledge that something's gone wrong and we're going to find the cause and we have a system to do that That's reliable and is timely. Yeah, that is very important. It's time It doesn't take ages to actually look at it But in the airline industry if something goes wrong the pilots make a report when they land They don't go on holiday. They don't go away. They don't go playing golf They don't go go in out of the hospital out of the system They write their report because the root cause starts immediately in health care We chasing after health care providers to provide the evidence I know that Jonathan comes in here but we often want to talk about the the causation being related to under resourced Staffing teams, but also the the resourcing that goes behind the investigation of such instance is also hugely under resourced And as Jonathan mentioned, it's usually in someone designated in a risk management role Who's then becomes the investigator holding it usually at the end of one lock long dark corridor where most? Clinicians and nurses don't want to go down But that's an under resourced element of the system as well So if we're going to be looking at a whole system approach, it's not just resourcing on the wards It's resourcing in looking into what has happened. Well here in this country that the problem one of you might call it a problem We don't have a transportation safety board for hospitals. Yeah, so we don't have any independent evaluators and So in my experience, it's very dependent the entire process of the investigation is very dependent on who's doing it So there are certain insurance carriers with whom I'm intimately familiar Who can defend anything? After all a colleague can find a colleague short of cutting off the wrong leg and I got some people may argue that to defend it So with this transparency and this honesty and this team to come in and do an investigation part of the program has to be an honest investigation with board certified hopefully specialists who are not friends or relatives of the Potential defendant and who are known to be able to Dispassionately look at the facts and give an opinion. Otherwise, this system will not work Well in reference to that though Dave MedStar has Created a go team. So when there is a a serious harm is committed They have a go team made up of from the hospital different disciplines who go and do an immediate evaluation and Whether it's a medical error or not they begin the process of covering medical expenses You know, I owe so much to Larry Smith Who is the you'll hear from tomorrow who's the VP of risk management and Dave Forgetting me where I am today But the go team idea is Experts respond to the scene of the incident make an incident evaluation right there within the first hour and And Then down the road they may do a six-month evaluation and they may come back and say well, it really wasn't a medical error We're not gonna ask the patient for to pay back The things that we waved or the items we may given but from this moment forward It's we were operating within our proper guidelines and we'll move on from there And I I just think that's a fair way to do it Let me just add a little bit more to that Jack and thanks because it really and for those interested in this candor Toolkit that was developed by AHRQ you could find it on the AHRQ site And it's it's composed of five different components and through the MedStar Institute of Quality and Safety Marty Hatley's here to McDonald others We're working with over 300 hospitals in the United States now Who are different points of trying to implement all five components? Jack talks about the first team one of the key components is training your organization around the term serious unanticipated outcome Because if we wait sometimes it could take us a week a month to figure out Whether our care was substandard it could take labs outside console, but we activate Once we get the serious unanticipated outcome care went in a direction. We hadn't anticipated The phone call or the hotline is triggered and three go teams are activated The first go team is that team that says okay We got to pull together a team and this the event review go team is part of the candor Toolkit the event review I think is one of the best event reviews ever developed It is it was developed by human factors experts patient safety experts and the National Transportation Safety Bureau Who came together spent four months looked at best practices and it's designed to start the process And as Jack says there are safety and human factors people who do we've eliminated the term investigation Because investigation sounds like I'm coming in to find who's at fault It's an event review and we want to understand and learn So that team goes in and they have nothing to do from a hierarchical or organization standpoint with That department you can't have the chair of the department doing the event review And this is a team that learns how to ask the five You know w's knows how to say we're here to learn from safety a second Go team is activated for care for the caregiver Separate set of people who engage with the care team and then the third refers to what you're talking about There are trained teams that we train up at hospitals that are your better communicators We know in our hospitals there are people who we call our special communicators They are not the type of people you want in these and it's just in time Training for people who've been involved in a serious unanticipated outcome because they want to hear from their doctor From the nurse whoever is the primary care what just happened and we train them the first thing We don't know what happened But we make a commitment to them that we will find out and as we learn we will share and if you've got questions Please share them with us and we do that until we finally we do know and it's a combination of first empathy and Then if care was some standard empathy with apology But it does involve like Jack said bringing family members in Larry Smith will share tomorrow Because they thought dad would be home and now dad is going to be in the hospital next week Who's going to pay for lost wages in those situations if we wait for seven eight nine months out to start working settlements? Jack would tell you do you have to remortgage his house just to pay for rehab and stuff So there's a whole comprehensive approach to this that I think is good I want to get to you know one particular question Jonathan one for you if we had If health care hospitals or systems were willing to pay for care Regardless of how long it was needed afterwards Should those be carved out of any other settlement where everybody's splitting the pie Let me see if I understand this question if if a patient is given care After the event yeah, they agree that they're gonna do the if it takes five years or how longer they Pay that here's the issue that and maybe someday but today no and the reason is Boy, do we have disparate opinions on what level of care a patient should get after being malpracticed upon as some people would say It's colloquialism. I don't say that but there's a big difference of opinion As to what this brain damage baby needs over the course of his or her life I have never gone into litigation in 44 years when we've agreed with the defense as to what this costs For example, the defense thinks that the mother and father wrote a work for free for the rest of their lives given care to the child Well, of course, what's the divorce rate? It's impossible. They need help We believe that's child is gonna need surgery They always say no this child is not gonna need surgery. In fact, they come back and say child go and die anyway We have all kinds of lifespan issues So no It won't work until people Can honestly work together and come up with a plan that makes some sense We I consult with 500 board certified specialists and subspecialists in medicine and surgery in the United States We try and use objective people And we put use exports to put these plans together to give optimum care to the baby not The lowest level of care or unacceptable care and we've had a fundamental disagreement about that for 44 years So no Okay, so it's I have to declare a bit of an interest conflict of interest here I sit on a board which which we in England it used to be called the NHS litigation authorities now called NHS resolution One of the key elements for our that drives our litigation processes and our costs in the UK is our neonatal injuries related to this scenario and In looking at the data that we've found and we've we have Billions tied up tens and tens of billions tied up in in future costs for for looking after children Who suffered from a neonatal injury the biggest driver of cost has been the time? taken to Resolve the issue between the legal parties and the amount of money that actually gets then ends up going to the Individual is is hit hard by those legal costs So our big driver, and I'll share it with you Jonathan about how we can do this Our big driver is to reduce those legal costs so that more is taken up and available for the families Because we do know that these children are living longer living relatively healthy lives Because we're able to construct whole systems approaches around them and that requires more funding and they need the funding rather than the legal profession So I'll just figure as a pediatrician who is a neurodevelopmentalist and these are the kind of children and I used to look after But I recommend you both look at the Japan Japanese system in which there's Compensation agreed straight away and in a no blame kind of situation that we're going to pay up We're going to work out what it costs for the life of the child and we're going to do this in a way that doesn't They don't go into legal fees would go into parent time because actually it's not the legal fees It's the time for the parents. So as you say The divorce rate is very high The families break up the effects on the siblings is great and none of that is taking to account in the courtroom What happens is that you've got to pay for the whole family's Rehabilitation because their whole family is disabled not only that the baby is disabled so it changes their whole life and And so there are two ways of doing this particularly in this kind of one where you where our care has got much better So the babies are becoming children and they become an adult and you've got to look at a long-term plan Over many many years and one no one can predict exactly how long that's going to be of course So so I agree with both of you, but I said there's another system if you look at Japanese very political Yeah, and I I know we're at a time, but no I want to save the last comment for you As the patient as we always do. Okay. Thank you They answer the question that John was answering If I understood it correctly When I left The operating room from that moment forward MedStar for the next two and a half years Covered all my expenses. I didn't you know Not a penny out of my pocket They bought me a new car they bought me the wheelchair they provided all my Therapy at home they provided a a nurse to come and stay with me and To help with my wife Eventually went to outpatient therapy they covered all that so for two and a half years They provided me with everything that I needed And was very grateful for two and a half years into it We decided my attorneys and my brother happened to be a malpractice attorney and having to work for a Reputable When you agree John a reputable law firm another one other than mine Step below yours, but I'll go with that. All right, not not publicly. This is private. Yeah, so When we went to settlement we had a monetary figure that we were looking at MedStar had a monetary figure they were looking at and we sat down with the mediator and over the course of six or seven hours We came to what? We agreed my attorneys and I was a fair settlement and would cover us for the rest of our lives and MedStar and the manufacturer of the device that malfunction Agreed that they could live with so and they did carve out the piece that for the two and a half years that I was covered so You know, I think it's fair to say yes, you can carve out that and maybe not in all cases But in my case, yes, I think it was fair to carve out that section that they had provided me Well, great, please join me in thanking this wonderful panel and a lot more work in this area Thank you