Perspectives in IR: getting to know the SIR Foundation GEMS

Episode Transcript

Recorded live from the Cook Booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics. This is the Cook@ SIR podcast series.

Hello everyone. My name is Vishal Kumar, your local friendly interventional radiologist out of University of California San Francisco, and I’ll be one of your hosts for today’s podcast. We are thrilled to welcome you all to SIR 2024 and for today’s conversation about the SIR GEMS program. For those of you who don’t know, the SIR GEMS program, which stands for the Grants for Educating Medical Students, was created and launched through a generous endowment from Dr. Alan Matsumoto and his family. This program provides a unique opportunity for medical students interested in interventional radiology who come from diverse backgrounds, opportunities to network and scholarship for participating in away rotations. We are joined by living legends within the field of IR for today’s conversation about the GEMS program. I’m honored and humbled to welcome doctors Janice Newsome, Hirschel McGinnis, and Alan Matsumoto to the panel. Before we begin, we would like to express our gratitude to Cook Medical for providing us with the time and space to discuss the SIR GEMS program. I would also like to express my personal gratitude to Dr. Alan Matsumoto in entrusting me and our team members with his vision for what the SIR GEMS program is meant to be. So really to get to the meat of the conversation, Dr. Matsumoto, what would you like the audience to know about the SIR GEMS program?

Vishal thank you for your nice words and the welcoming introduction. The GEMS program was conceived in 2019 and announced at the 2019 SIR annual meeting and the intent of the program was to develop a program that would grow the diversity of the pipeline of interventional radiologists to better serve and represent the growing diversity and needs of our patients, hopefully to increase the cultural competency of interventional radiologists and the specialty of interventional radiology. The hope of the GEMS scholars program was to allow these GEMS scholars to gain a broad exposure to the specialty of IR, and also to allow them to network with other GEMS scholars and thought leaders in the space of interventional radiology to form relationships that would likely go on to enrich their future professional lives and networks. We want them to develop relationships to feel comfortable with and to become part of the larger IR community. We are very fortunate from the start to gain the support of Cook Medical, Boston Scientific, Siemens Healthineers, W.L. Gore, and Penumbra to help fund the program. And it’s been very exciting and we were hoping that the program would grow, but I think under your leadership, Vishal, and with the contributions of folks like Dr. McGinnis and Dr. Newsome, it’s frankly exceeded all expectations. It’s been really pretty wonderful to watch evolve.

Well, thank you Dr. Matsumoto, for that reflection and insight. As you said, the GEMS program has changed over time. Initially, as you mentioned, the goal was to recruit those students who have been under-recognized and historically marginalized throughout medicine into the space of interventional radiology. Could you comment about some of the eligibility criteria that you’re looking for, specifically first-generation physicians within IR?

Well, the intent was really to grow the socioeconomic and cultural competency of the specialty of IR and those that practice IR, and my family and I had a strong feeling that regardless of your ethnicity, color, religious beliefs, first-generation physicians tend to bring a little extra special passion towards the fact that they often are leading their family and their parents are very proud and they want to make a difference. So that was actually important to us. When I applied to medical school, Asians at that time were considered underrepresented minorities, and I realized that, gee whiz, you can have two Asian parents and you can have an Asian child, they’re not necessarily disadvantaged compared to maybe a Caucasian family with a single parent. And so it was really that first-generation physician that I thought was the key component to bring into the GEMS program. I think that hunger to make a difference and to be part of something bigger themselves, and actually to feel part of a community that maybe some of us never felt like we had the option to be part of that community was important. So I think that was important part of this program and to increase the cross-cultural awareness that makes healthcare providers hopefully to be more open to unfamiliar attitudes, practices, and behaviors.

Thank you, Dr. Matsumoto. Dr. Newsome, you have served incredibly as a faculty and a mentor out of Emory University. You have been a role model to scores, hundreds, if not thousands, of students and physicians. I consider you a personal friend and a role model as well as a mentor, and you’ve been with the GEMS program since its inception, helping evaluate students, helping provide, as we said, sponsorship, mentorship. What would you like our listeners to know about the GEMS program?

Thank you, Dr. Vishal, and I am incredibly honored to be included in this conversation that I think is so very important. So GEMS is such a special program, and I’m so glad that it’s also called GEMS because that is, to me, I don’t know if you know, I love jewelry of sorts. And so every time I get to talk at GEMS, I try to bring some gem of sorts. And when I think about gem, the actual natural process of making a gem, I look at what it takes for that to happen. And sometimes you don’t get the best of the gems unless it’s under pressure or deprived of light. And I think about that often when I think about the GEMS program. And people are always talking about “What do we need to do to increase the number of marginalized doctors in our blank specialty?” And then there is GEMS, a program that actually does something about it.

So when I think about GEMS, I think about the program itself, something whose time has actually come to fruition right now, and that the vision of Dr. Alan Matsumoto and his family to actually do something about something that we have been talking about for years. I am always ecstatic when it’s time to meet the students. I get a crazy fool when I see a former GEMS scholar at any meeting whatsoever. So to answer your question, what does GEMS mean to me? What do I want people to know about this? I want people to hear that this is a program that is answering a question, an issue, something that we have been talking about and trying to solve for a long time, and that yes, it may not solve all the problems, but this program is doing something about it.

Thank you, Dr. Newsome. Always appreciate your perspective, and I couldn’t agree more that some of the best gems are formed in the crucible of heat and pressure that require resilience, which we see amongst so many of our scholars. Dr. McGinnis, welcome to the conversation. You have helped serve the GEMS committee in so many different ways. You have delivered, over the last few years, some of the most impactful presentations on microaggressions, overcoming imposter syndrome. What would you like our audience and listeners to know about the GEMS program?

Dr. Kumar, I want to thank you, the panelists, and Cook for providing this opportunity. So I remember the exact moment when I found out the GEMS program was going to be launched, the exact moment, and I thought “Finally, finally, I’m going to get an opportunity to do something that, to me, feels like I was born to do in IR.” My focus in mitigating healthcare disparities is really to focus on the workforce component of disparities. A lot of times we’re looking at the patient healthcare disparities. I believe that we’re not going to be able to solve those patient outcome disparities unless we also fix the workforce disparities that exist. And I’ve been working on this matter since I was a first year, when I was an intern just out of medical school. I’ve always been interested about how do people decide to go into a career in medicine?

And then from there, how do people decide to go into a career in radiology and interventional radiology? What are the things that attract them? What are the barriers? What are all the different things that have to fall just right to get someone into a niche, but powerfully impactful, specialty like ours? And I’m still learning. Every year I’m learning more and more about the complexity and fragility of this process. I think GEMS is uniquely situated, and I think Dr. Matsumoto was really long sighted when he included in his group of people that he wanted to bring into GEMS was first-generation physicians. I don’t think we really always consider how hard it is to get someone to navigate that pathway through the career in medicine when no one in their family has ever done it before, especially in families where no one’s even been beyond high school.

There are financial barriers, there are cultural barriers. I think what GEMS does is bring all these people together. It gives them a family. It gives them a source of interpersonal support that’s really important because the training pathway is extremely long. It’s rigorous. There are pressures and demands. They’re going to be victories, and they’re going to be setbacks. Having these personal connections is invaluable, and I think GEMS is uniquely situated to take this nascent talent and cultivate it and develop it and bring it into the fully formed medical workforce. It takes a long time, but it can happen.

Dr. Matsumoto, Dr. Newsome, did you have any further comment?

Part of what I’ve also seen is folks like Hirschel and Janice have always been magnets to bring about change in a positive manner for increasing inclusivity. But what I’ve been amazed by is the variety of other people this program’s touched and institutions that have become engaged with the GEMS program. I’m so thankful for and inspired by the fact that all the GEMS scholars have matched at IR programs. And many of the institutions that match GEMS scholars feel so privileged: “Hey, I got a GEMS scholar in our program!” And so that has really been pretty cool to see. Some places that you just would never have thought that would embrace this program have latched onto it. And it seemed natural and unforced, and that’s what I’ve appreciated the most, just seeing it evolve.

You can’t see me at all, but I just want you to know that I am cheering, doing all kinds of movements with my hands, just to put an emphasis on that. So I’m at Emory University in Atlanta and Vishal and everyone else that is listening, yes, we do have the most GEMS in our program, and we’re so proud of it and so happy for it. So if you’re jealous, you’re right to be jealous. We did have many of the former GEMS graduates as a part of our training program, and I can say that they’re shining bright.

They’ve taught me so much about what we need to do to help them. I went to public schools throughout elementary school, junior high, and high school. I went to a public university, and then I went to a private medical school, tertiary center, IR program. I found out about IR, they mentored me. They got me through the process, and I wound up at an excellent residency and fellowship. It all just kind of happened for me. The GEMS scholars have taught me, other people have had very different pathways to IR. I wasn’t aware until recently how many medical schools in the US don’t have an affiliated university hospital. A lot of these students are coming to us about having affiliated residency programs in IR. This is a challenge. We have to find ways to get into these programs to promulgate the message of IR. When we find students who are interested, we have to have ways to expose them to IR procedures, have them have IR mentors, maybe a system with IR clerkships, and guiding them through the process of what it takes to get into a program. And they’ve taught me so much about what the needs are of the students that are there, and that’s been very enlightening over the last year.

I also want to say that when we originally conceived this, we thought about scholarships where the GEMS scholars would go to an individual institution, they’d have their individual experience, and then when COVID came around and you took the bull by the horns and said, “What are we going to do with the GEMS program?” And you created this interactive educational experience over six to eight weeks and brought in so many different speakers that expanded the network that served as a significant multiplier for these GEMS scholars to develop a network. And what was very impressive to see is GEMS scholars bonded with each other, and they truly did have a community amongst themselves. So that at last year’s SIR, they were all hugging each other, high fiving each other, obviously hugging Janice, who they all love. And so it was what you actually did taking a difficult situation and turning it into a positive experience.

I want to really talk about the credit you deserve and give you a shout out because that changed actually fundamentally the concept of what we originally conceived of for GEMS and turned it into something so much better. So I think that to build on what Hirschel McGinnis was saying, this sense of, I’m not alone climbing up this mountain or pushing this rock up a hill, but it’s really, I’m with other people and these other people support me, and now I feel much more comfortable now that I’m not alone. I think that was actually a phenomenal transition, Vishal.

So maybe ask—

Well, thank you for the acknowledgement.

—this question, Vishal, because I want to know from you, what do you want? What does Vishal, the leader, the legendary leader of GEMS who has taken the vision and ran with it further and faster than I think anyone would’ve thought, what do you want people to know about GEMS from your heart?

Oh, well, thank you everybody for your acknowledgement and appreciation. I have so many notes that I’m taking here about the conversation, but I think what I want people to embrace, my vision is that SIR GEMS becomes too big to fail that, as you said, it is the most intentional direct pipeline pathway that has been created within our specialty to be the change that we seek within the workplace. If you look at the metrics, for those who don’t know, there are about 160 spots roughly every year within the integrated position. GEMS has now evolved due to the generosity of not only Dr. Matsumoto’ family, the endowment, but corporate sponsorship to allow up to 15 scholars per year. And in our fifth class total, we have now graduated over 50 GEMS scholars. And as you mentioned, if they apply into IR and DR, we are seeing success rates over 95%.

Not all of the students have yet gone through the application process. So we’re very, I think, proud to see the first step in changing the faces of IR as we go forward. But this is a generational career-long endeavor and aspiration that we may not see the change we are hoping to see until my career is over. This is something that takes 10 to 20 years, decades of change. But I think because we have so few IR specialists nationwide, it will not take a huge number to actually start making changes the way we see. And Dr. McGinnis, you mentioned this statement that the students have taught us so much, I could not agree with more. Because when I came to you with the vision of a virtual curriculum where we could just bring people together, I wanted to create an IR elective, plain and simple, we’ll tell you about UFE, we’ll tell you about prostate, that’s it.

But I didn’t realize that in a time of tragic, catastrophic loss in the COVID pandemic that the silver lining out of this virtual learning environment that now people had become more accustomed to being a part of, created a space of, as you said, community, family, and networking. And we realized that they don’t really need to hear seven lectures about portal hypertension. It may be worthwhile talking about imposter syndrome and wellness and what it means to actually suffer from burnout and to share conversations of true transparency and honesty that you wouldn’t get in a classroom. And some of the feedback from the students is heartbreaking and encouraging at the same time where they say, “This was the best experience of my entire medical career,” which makes me very sad for the institutions that they’re a part of sometimes, but also very proud of what we were able to create with GEMS. And I think this is only the beginning, right?

We need to see these students and scholars through to the finish line. We need to make sure they become IRs down the line, that they become thriving faculty and academics and private practice, and that one day they are the chair or the committee members of the next-generation GEMS program. And I think Dr. McGinnis, I wanted to turn to you. I know you recently published alongside Dr. Dan Sze, a retrospective review of AAMC, NRMP, and ACGME data regarding gender, race, and sexual orientation in terms of IR workforce representation over the last 10 years after we’ve received medical specialty status. And you talk about this concept of being a welcoming community, a welcoming culture. You also highlighted the increasing numbers of sexual and gender minority providers that are graduating into medicine and considering IR as a specialty. From your perspective, what do we need to do to ensure that our culture, our community, continues to be welcoming for the current GEMS graduates and the future GEMS scholars?

Thanks for that question. I think the answer is a little complex just to kind of set the table here nationally in the US, about 7% of the population identifies as LGBTQIA, but there are steep generational differences. Generation Z identifies at rates of 20%. Now the AAMC inquires in an annual anonymous survey of graduating medical students about sexual orientation and gender identity, and there have been some significant changes. In 2016, about 5.5% of graduating students identified as LGBTQ, but this number more than doubled to 12.6% by 2023. During that same time span, there’s been a fourfold increase in the number of medical students identifying as transgender, beginning at 0.3% in 2015 and 1.3% in 2023. These percentages sound small, but the numbers are significant. In the US, about 21,000 people each year graduate with a medical degree. This suggests that the next 10 years, 30,000 sexual and gender minority physicians are going to join the medical workforce. 30,000.

The percentages can be small; the numbers are significant. Those numbers to me are very interesting. And the question I have is, what is the leadership of medicine doing to make sure that they are prepared for a workforce that is this diverse? One of the things I learned from one of our GEMS scholars was that— they’re gender nonbinary, and when they went on their IR clerkship, they didn’t have the same housing as everyone else. They weren’t allowed to go into the same place. It was a rental property. They had to, at the last minute, be diverted to another location and had to spend a month on an air mattress. It was dehumanizing. It was depressing, but it’s what the scholar had to do to get through that important clerkship. What I realized is you can be at the greatest institution with the greatest professors, the best equipment, everything, but culture is going to trump everything. We’re going to have to cultivate cultures that are simply more aware and more accepting of the diversity that is coming out of medical schools, and be aware that excellence presents itself in a myriad of forms, and we have to become a little more perceptive about what excellence looks like, what leadership looks like outside of the typical forms of which we’ve seen it year after year. Did that capture what you’re looking for?

I think so. I agree. It’s a very complex issue. And Dr. Newsome made a joke about having the most GEMS scholars, but I think one sentiment, one response we’ve received consistently is how powerful it is for the GEMS scholars to see IR faculty and physicians that look like themselves. And I think it is an unfair task that we ask all residency training programs to have diverse faculty. We know how nearly impossible that can be, but I am elated. I am happy to recognize that we have, if you will, GEMS centers of Excellence, institutions that embrace the GEMS program, the vision, that hope to carry this through and can show students that, “Hey, in these institutions, you know you’ll be embraced. You’ll be allowed to thrive. You are allowed to be your full identity, your full self without question.” And while the IR community as a whole may not be at that perfect place just yet, I think we have to make the incremental changes at the institutional level for the scholars to know that there is a place for me within IR. Dr. Newsome, Dr. Matsumoto?

I was just going to mock Hirschel a little bit by saying “Did that sound okay? Did that capture what I’m trying to say?” Because it is a very, very Dr. McGinnis end of statement, and I love it, and now I’ve adopted it. So Vishal, we have to start doing that after every thought. Was that okay? Did that sound all right?

Well actually do it. I do that to check in with my patients and my learners. Now, Dr. McGinnis is a consummate teacher. So many wise pieces of information. Dr. Newsome, I wanted to ask you, you have been such an instrumental member of the Road2IR as program director for the Global Health Outreach program, setting up a residency in Muhimbili. Have there been parallels to challenges that you see within the GEMS program as well as Road2IR?

Wow, that is an amazing, amazing question. So one of the best things, Dr. Matsumoto, that has happened with GEMS is during the time that we couldn’t travel because of the COVID global pandemic. Dr. Kumar here, Vishal, had the wherewithal to have our Road2IR scholars join some of the educational offerings for GEMS. And it was mind blowing. And now the students that have now become attendings still remember that and have been integral in GEMS. So many of our GEMS scholars want to know about global outreach, and them being able to join in and meet some of these other students in the US that they actually align a lot with, they have the same angst about “How do I know that this is what I want to do?” or “How do I navigate this?” And many times, I don’t even have to say a word because someone else that is on the call answers the question for the other person and the other person.

So it’s a reminder, Dr. Vishal, that we live in one big world, and the needs that our students want and feel at Emory are the same at UVA. And it’s the same in Chicago, and it’s the same in California. It turns out it’s the same in Tanzania and Rwanda and Uganda. And besides the basic things about the curriculum of maybe they’re not going to learn about what is the histrionic ultrasound ablation, but I find that there’s some fundamental things that people need in order to thrive, and they need to feel that they belong. They need to feel that they’re a part of the community and that they’re recognizing they’re not invisible. They need to feel that there are people that really care about them as humans and that people care about their success professionally. And that to me is the biggest similarity between the GEMS program and the Road2IR program. Yes, we believe that interventional radiology is an amazing, amazing specialty.

And people have heard me say this all the time, and I believe it to my core that, if you believe something, for sure, if you believe that what we do really improves health and it really saves anybody’s life, then you wouldn’t want to just do it at UVA and you wouldn’t want to just do it at Duke or at VCU. You would want to make sure that everywhere, everyone has this opportunity. And that is what drives me in my work in the global space. And it actually fulfills me so much and drives me being a part of the GEMS program.

And I know that one day when we’re long gone, this legacy will live on, and that as we kind of bring the IR community from all around the world, that they too will start being able to pass it on and say “Yes, I remember when I logged onto that Zoom and it was about women’s imaging, and yes, we talked about UFE and postpartum hemorrhage, but we also talked about what that looks like in Uganda.” And all of a sudden people’s eyes were opened and we talked about not just the disparities that exist in that space, but then we gave an opportunity for somebody to say, “You know what? My mother almost died having me.” Those are the powerful things that it’s so hard to put in words, but I’d say that if you get a chance to be a part of this community in any way, either by coming to one of our sessions, or if you’re listening from one of our corporate device specialties to sponsor someone, if you’re just an SIR member and you’re like, “I believe in this, how can I get involved? How can I sponsor and mentor someone?” not just with your finances, but with your time. If you can open your heart a little bit, oh man, you’re going to be receiving a lot more than you give. Oh, by the way, did that sound okay?

Oh, I think you were muted the whole time. If you could repeat that, that would be appreciated.

Ha ha ha ha, so funny.

But honestly, I think it is such an inspiration to hear you talk about IR. Global health was a blind spot of mine when we started the curriculum. And I remember the feedback was, “Can we hear about what IR is doing outside of the United States?” And over the years, with your constant presence, we had Nima, we had Fabian, talk about Road2IR. I was lucky enough to be a part of it this past November. And what you said is so on point that when you see the magic and power of IR in communities that need it in a sustained way, you are literally creating IR providers in Africa. This is not a come for two weeks and leave Road2IR is incredible. I hope Cook offers you the same space and time in this podcast series to really highlight the impact of Road2IR. But your conversation, your piece about being a part of a community, I mean, I will never forget that. So thank you for letting me be a part of that. I think it’s a really nice segue back to Dr. Matsumoto. A lot of the listeners may be thinking, “Hey, this is, I’d love to be a part of this.” What would you like to tell them? How can they be part of GEMS? How can they be part of this family, this community, and this legacy of getting IR to where we want it to be?

Vishal, thanks. I heard Janice say one particular word and that was “aligned.” I think all of us are fundamentally aligned in our spirit and morality of what we want to do in healthcare, and that is make a difference in a patient’s life. But we all come from different cultural backgrounds. We all have our unique characteristics and perspectives and life experiences that define us as individuals. But some of those unique characteristics, if we focus on how we are aligned, can bring us together. And really, the hope was in creating a GEMS program to create a sense of inclusiveness regardless of our unique characteristics, and really focus on how we are aligned spiritually and morally about our mission. And the hope is that by bringing people with these different backgrounds together, that we create an environment where all individuals, regardless of their uniqueness and backgrounds, can contribute fully and are given the opportunity to contribute fully, to feel valued and feel engaged, and to be supported to achieve their full potential. And that’s what the hope is. I mean, the Road2IR, GEMS, all this is really leveraging the differences that we have that actually make us similar so we can increase our inclusive community and recognize that those differences should not be separating us, but in many ways should bring us together in that alignment of our efforts around really making a difference for patients’ lives. I think that’s what we want to go with this.

Well, I appreciate the feedback. If you want to get involved, feel free to email myself, Vishal.Kumar@ucsf.edu. Feel free to let any of the members know if you see us at the meeting or you in the future. We are looking to build the biggest family, tribe, community that we can, and feel free to stop by the Cook booth during the conversation or during the meeting to keep these conversations going. I know people have a lot to do both in Salt Lake City and in their normal lives. I feel like I could talk to you all for hours, and I really do from the bottom of my heart, appreciate sharing this space and time with you. Okay. Well, as we wrap up today’s conversation, I’d love to go around and just hear each of your closing thoughts on the GEMS program. Maybe we can start with Dr. McGinnis.

Thanks again for this opportunity. You know most of us are just born proceduralists. We love doing procedures and living in the procedure room, but this is different. This is part of what I call the great work. The great work is to ensure that high-quality, value-focused, minimally invasive therapies are going to flourish across the world and be a mainstay of contemporary care. And for that reality, we had to have a keen interest in the IR training experience and the composition of the nascent workforce. Diversity, equity, inclusion are important because equity and fairness matter, quality matters. And the current, well-documented patient healthcare disparities are simply unacceptable. Improving diversity in the radiology workforce is a search for and a commitment to cultivating excellence. And we’re not going to be able to mitigate healthcare disparities and patient outcomes unless we also contend with the disparities in the medical workforce. Both are the residue of the same dynamics of interpersonal, cultural, and internal bias. I want to thank Dr. Matsumoto for launching GEMS into existence. It’s going to make all the difference. I think it’s nothing less than indispensable. Was that okay to say?

That was amazing. And maybe I’ll just follow up on that. What are my last words? I’d say that there’s so many things that you don’t get to choose in life. I saw this the other day; I wrote it down. I added a few things as well. “You don’t get to choose your birthplace. You don’t get to choose your skin color. You don’t get to choose your birth parents. You don’t get to choose your birth language. You don’t even choose your birth name, your born abilities. You don’t get to choose your ethnicity. But there are always things that you can still choose. And you get to choose to be kind. You get to choose to be generous and grateful and respectful. You get to choose to be humble and self-aware. You choose to be happy and you choose to be grateful.” And I’m so glad that I’ve had this opportunity to serve with some of the most amazing people in IR and to do this work that Dr. Matsumoto has put out as a vision and a call to action from many of our industry sponsors who also believe in this work. And my last statement is that because of GEMS, a better world is coming.

I think for medicine as a whole, for interventional radiology as a specialty, and frankly for the world in general, diversity is a given that we should embrace. I think inclusion is a choice we should make, and that equity is a goal that we should all strive for, not only for our patients, but also for our providers to allow the patients to have the best life they can live, and for our providers to reach their full potential in an environment that supports their full potential. And I think that is a hope for all of us just in life in general. If GEMS can contribute to that hope in any way, I think that would be a success.

That was amazing. And I just want to ask our moderator and host tonight, Dr. Vishal, Dr. Kumar, VK, what are your last thoughts as we wrap up this podcast? I know that you wanted to give Dr. Matsumoto the last word, but I feel that maybe the last word should come from you. Thanks again for all you have done for making GEMS a gem.

Well, thank you everybody. As you said, Janice, I want to choose to be grateful. I want to first and foremost thank the GEMS scholars, the past, the current, and the future scholars for letting me, for letting us be a part of their journey. We do not take this privilege lightly, and if we can do things better, you let us know how, please. But thank you for letting us be a part of it. I want to thank you all. You don’t know how much you all mean to me, how much you have shaped who I’ve become, how I perform as a physician, as a human. So thank you all. I also want to take a moment to express my gratitude to Emily, Victoria, Jumana, and the SIR Foundation staff for helping make the GEMS program a success. I want to to thank Renee Black and Cook Medical for allowing us the space and time to have this conversation, hopefully a conversation that will continue at SIR 2024 and beyond. And I want to thank, if the listeners are still to this point, for putting up with us, for engaging in an inner conversation and dialogue, and hopefully embracing and sharing in the same vision that Dr. Matsumoto put forth back in 2019 when I think he set the world on fire with his Dotter lecture at Austin. But thank you all. Hope everybody has a wonderful time at SIR 2024, and we look forward to chatting again.