Dr. Kismet D. Rasmusson outlines the important role advanced practice providers play in treating and managing heart failure patients while sharing her personal experience with developing a team-based heart failure clinic.
Back to Symposium Page » Thanks raj and uh thanks Dr Mander, enjoyed the talk as always. Um it is my absolute pleasure to introduce Dr Kismet Rasmussen from Intermountain Health, Salt Lake City. Um and the way this came about as interesting I think christmas and I would you know, we were talking about doing something on a national forum um to uh sort of engaged advanced practice clinicians and talk about you know the integration and collaboration with health systems and um heart failure, cardiologists and the general um care of the heart failure patient. And then I was like you know this would be a great opportunity as well if you could take some time out of your schedule and join us. So thank you for making time this weekend to join us and speak to us on all the work you've been doing at Intermountain and um both at a personal level with clinical care and also in terms of the work you've done with heart failure, readmissions care process pathways. Um and we all look forward to um learning from you and please teach us how you've done things there. Thank you again. Dr Rasmussen. Well thank you so much. Doctor screw pasta for what a very kind invitation and introduction. Um I, you know, I've been so honored um really and so fortunate to have such a career in heart failure. I have really enjoyed this journey and I'm just really happy to be here today to talk about how we foster heart failure expertise and advanced practice providers. And the acronym for that is a PPS. Um I really have limited disclosures. I've done some limited work with these companies, either as an advisor or a speaker. Um I'd like to start with setting the stage by mentioning this important article that was published last year in the Journal of cardiac failure on building a heart failure clinic. It's really a practical guide from the heart failure society of America and it really goes through how to create and sustain a really well thought out heart failure program. It provides considerations for not only patient care but operational considerations and um and it recognizes variations in practice whether your academic center or private or hybrid. Um and it really again helps build on the importance of the heart failure clinic. So this is a really important read if you work in the space of heart failure. And from that article is this important quote that I like to spell out and that is the A. P. P. S. Or advanced practice providers including ps clinical nurse specialist and nurse practitioners are critical to the functioning of any heart failure clinic. Well that kind of goes without saying, I think these days there are a lot of a PPS out there in cardiology and heart failure. But the question and the point of the talk today is really to talk about how we take a novice a PP. To become an expert a. P. P. In the world of heart failure. And this can include a new graduate, a. Pp. Or somebody who's been in a P. P. In a different area. We've hired some who've been wound care experts, for example, or others who have been a lipid experts or preventive cardiology experts and brought them into the heart failure fold and have helped them become heart failure experts. So today I want to go through three main areas really the need for heart failure, A PP. Expertise, lessons from our center. And again, I just so appreciate this opportunity to talk about some of our experiences and then other ideas for honing expertise and heart failure. Well, we all know about the growth of heart failure. Um, we know that there's actually projected physician shortages and I'll talk more about that in a minute. Um, We also recognize over the years the complexity of heart failure care. Um, you know, when I started in heart failure, I was recruited from general cardiology practice where um, I was a nurse practitioner. And um as I was leaving the general cardiology practice, the cardiologist, one of the cardiologists I worked with said You're going to be so bored in taking care of heart failure patients and I have been nothing, haven't been, not bored one minute. In, in the 21 years, I've been taking care of heart failure patients because of the growing complexity. Um, I find it really fascinating and always challenging with that. We have challenges in health care delivery. We have silos of care. We have, um, uh, you know, evidence based care that needs to be implemented on consistent uh way we have metrics that we need to report on. We clearly know that there are significant challenges in health care delivery and further cardiologist. More and more have been integrated into health care systems. And with that they're not only our view and productivity requirements, but other requirements excuse me, that make it a very busy proposition for cardiologists. And then of course we all know in heart failure that we have been under utilizing guideline directed medical therapy or G. D. M. T. In heart failure. The champs just study that came out a few years ago. It was a shocking reminder at the gaps that we have in terms of optimizing medicines that are life saving for patients with heart failure. And so the need for team based care over time has grown. Um, you know, I could go on and on about the need for how do we engage patients and teach them and the cost of heart failure. But this really sets the stage for why we need a PPS and team based care. So I'd like to briefly touch on the projected physician shortage. We know that there are 6.2 million patients with heart failure in the United States. This is projected to grow uh by up to 46 by 2030, which is astounding. Um I like to take your eye to the left side of the screen. It's the A. B. I. Am american Board of Internal Medicine um that actually states the certified cart physicians in advanced heart failure in the top of the red box there, about less than 1200 across the United States and around 32,000 who are certified in cardio vascular disease and internal medicine. Um And so you can see the number of heart failure and transplant specialists are quite a small proportion. Um Yet there's likely very many patients uh cardiologist within the second category that are also taking care of a lot of heart failure. But then when we look on the right side of the screen, this is information that I've learned from a site called Med Axiom. And I learned about this site this week that actually is really rich with information about physician and A PP practice. So if you've not heard about them, I've included the website. So you can check it out. They've got blogs and articles, But they a few years ago published that the median age of general cardiologist, 34 of them are over the age of 60 and a quarter are over the age of 64, meaning really approaching retirement age. And then newer information from Med Axiom has shown. The estimated annual departures by cardiologist Is 2000 per year. With annual number of of those entering the workforce at 1453 per year. And so we have a net negative of cardiologist enter the workforce around over 500 per year. And then when we look from the advisory board information we can they have shown that the projected growth of the physician workforce is only 7% compared to 28% increase in the workforce of nurse practitioners and P. A. S. And what this shows then is that we have some solutions that are really important solutions to consider how we can take care of patients with heart failure and in general cardiology. So I have to show this um this little funny cartoon um this this isn't nearly as effective as I thought it would be. And this is somebody pulling a lawnmower that's the A. P. P. That's unplugged in. And a little little mouse says hey plug it in. Well I mean this is funny but you know, we all know that the reality is that it's just not that simple. And um and so let's review the requisite training for a PPS to set the stage. Uh Everybody has their their training, the program, their medical education with nurse practitioners. It's a combination of the medical and nursing model for physician assistance. It's uh kind of a mini medical model. Um And they go through clinical rotations. They have graduate degrees now and some have doctorate degrees. They are licensed professionals, They're board certified by national organizations and some have gone through residency and fellowship opportunities. Uh And what this has led to is a is a class of, of providers who have experience and then autonomy and taking care of patients. What I'd like to do next is also take you on a journey of the heart failure literature, um, and the progressive role of A PPS in not only heart failure but cardiovascular care. This is an article that was published in in 2000 and circulation. It's American Heart Association scientific statement on team based care with patients with heart failure. And this has really laid the groundwork for the roles of different types of clinicians, providing care to heart failure, as well as, um, how team based care works and how we take care of patients with heart failure. Next, moving fast forward to 2012 is this joint position statement that was published in the Journal of Heart and Lung from the Heart failure Society and the American Association of Heart failure nurses that was advocating for the full scope of nursing practice and leadership in heart failure and this was really a call to action. Um This is based on the increasing evidence over the years that has shown incredible value of nurses and the excellence of care that has been demonstrated in clinical trials um and and through quality improvement efforts that have been published. And it really advocates for the use of nurses that are functioning at the top of their training and in full partnership with physician. So really important article and I happened to be on the board of American Association of Heart failure. Nurse is at the time and was fortunate enough to participate in this position statement. Then we move forward to 2015 in this article from the A. C. C. Or American College of Cardiology put out a policy statement on cardiovascular team based care and the role of advanced practice providers. And this really builds on their experience in years of being progressively inclusive of A PPS. Within the A. C. C. They developed the cardiac care associate by 2010 they included A PPS to be able to have the fellow distinction in the american College of Cardiology or F. C. F. A. C. C. Designation. Um and then they really um in 2014 and preparation for publishing this article they created a think tank of leaders in cardiovascular care to really address the challenges that we experience in cardiovascular care and what team-based care offers and different models that were out there in terms of defining roles. And then they set forth with planning competencies to show how advanced practice providers could become competent in providing cardiovascular care. And this leads to this article that was published just last year again from the A. C. C. And the Journal of American College of Cardiology. The the final not the final but the clinical competencies. Uh foreigners practitioners and physician assistance in adult cardiovascular medicine. It's a really important article for a PPS. And it really builds on all of the knowledge that we've been gaining over the last 10-20 years. And it's really that specific document that has those clinical competencies. And it's really based off of what's called co cats or the core cardiovascular training for physicians. And and it recognizes the cardiovascular expertise is usually for us A PPS. It's on the job training. We don't have a specific cardiology track in our programs. And um and so what this document and these competency do is, excuse me is it provides education and knowledge across the span of cardiovascular care and its sub specialties in in all of these areas that are listed from acute coronary syndromes to critical care, cardiology, heart failure, vascular medicine and and so on. So this is a very important article and this also draws on um what the physicians use for their training in advanced heart failure and transplant. That includes both in an outpatient heart failure care assessment, thermodynamic shock, decompensating heart failure, pulmonary hypertension, mechanical circulatory support and heart transplant. This is an example of some of the lists of medical knowledge, system based care from this article that has fed into the competencies for A PPS. And ultimately, what we want to do for team based care is get away from the trickle down care team design where a physician uh downshifts task to an A. P. P. Who downshifts task to a nurse to an Emma into front desk staff. This kind of model has really been shown to lead to burnout and and really staff dissatisfaction and we really should focus on more of a holistic care team redesign that's shown on the right. That really allows for every team member to have their role, have an important role that's acknowledged within the team and use their expertise based on their training and work at the highest level that they can. And by that we are able to show value for all of the team members and really work together as a cohesive team. I love the the work that's put out by the advisory board such as this. Um And I really if you're not familiar with the advisory board, I really encourage you to to look around and become familiar with their tools. Very important. Again, back to that med Axiom site, you know, I've got no relationship to them but I found that they really are able to provide other guidance for us. Um In terms of of how we plan, think um and optimize the utilization of A PPS. We, in terms of planning for the A. P. P. Roll if you're not using them or you want to expand their role, it's really important to think about what that role looks like. Is the A. P. P. Going to work in the hospital in the outpatient setting or maybe both. Um And and how does that work within the model of your program? Are you uh that and transplant center? Are you just are you a bad center? Are you just doing heart failure? I'm not just but are you doing heart failure and then refer your advanced therapy patients? All of this is important so that you can really craft what the specifics of the A. P. P. Roll looks like. And then preparing patients and referring providers about that role that you will be using A PPS. Or even if you are using them to make sure that your patients know about their role. For example, I love it when physicians will say, hey I'm meeting you, you're welcome to our clinic. This is our plan and your next visit is going to be with one of our one of our practices, A PPS who's going to see you the next few visits. Um and then we'll come together as a group to report on your progress. So really it's so important to prepare patients and then have a PPS feel inclusive in the group. And also true for referring providers to know that you have a group practice that includes A PPS. But then so importantly, is really being able to onboard new A PPS with purpose, expectations and strategy. If you don't have those, um, you may get through an orientation and realize that you haven't really achieved specific milestones to really hone that expertise. Uh, and I think that this is really important for setting the stage for somebody new in your practice. Yeah. Um, sorry, I'm not sure what happened to my visuals on this side. Um, but how do you really develop heart failure? Excuse me, expertise. Going back to the green article that was published last year if you don't remember anything from this talk, I think this slide is important. Um, where developing heart failure expertise really takes a good mentor uh, that can be physicians or other A PPS, um, with the importance of shadowing attending heart failure specific courses to gain that medical knowledge. Um, and then to really have graduated clinical responsibility um, and independence and autonomy. And this is the way to develop that heart failure expertise. Mm We have had I think an amazing last four or five years in heart failure. This slide is busy. It shows to me four of some of the most important documents related to heart failure care in the upper left. In 2017 the A. C. C. Published the expert consensus decision pathway on the 10 pivotal issues of treating patients with reduced ejection fraction heart failure. Um This has been so important and updated just this year in 2021. Also published in Jack. On the right side of the screen is the 2019 a. c. c. expert decision pathway on the management of hospitalized patients with heart failure. And um in the bottom right is the newest article on the universal definition and classification of heart failure. Um That is so important for us to be able to use similar vernacular. Um and and the way we think about heart failure, not only for us for our patients, for other um others who aren't in the heart failure space. But these are are really how to guides. They are so important that every time I read them and I read them at different for different reasons and I gain new knowledge from every time I read different parts of these articles, these are so important for anybody that's working in heart failure. Um So I hope that you have done so or will plan to do so embedded within um the um 2017 guide are these 10 important principles for treating heart failure on the left and blue how to implement and titrate and switch G. D. M. T. R. Guideline directed medical therapy in the middle. The challenges that we face and taking care of heart failure patients and we all know these the referrals coordinating care, patient adherence specific cohorts like african americans and aging and frail the cost of care and then on the right how to manage the increasing complexity of heart failure, the comorbidities and then palliative care and hospice care. And then further in that article. I love this. It's like a high order algorithm that takes you from uh studies that it should initially be done when you're diagnosing heart failure down to serial evaluation and tight trading medications and then a path for if people aren't responding the I need help acronym where we refer for people who are not doing well versus others who are going to a maintenance mode. And then we have planned for monitoring their response and considering other therapies like um like CRT or defibrillators or whatnot. So again this is this is important knowledge that we can gain and then it's a matter of putting that knowledge into practice um as we become heart failure experts, I also love this image. This um sorry for that. I have a little error in the reference. This was published in 2021. Um But this is um an exciting time for treating hef ref heart failure with reduced ejection fraction ef that's less than 40%. This builds on our growing knowledge of knowing about rask inhibition, inhibition. We've added napper. Listen inhibition in recent years we know about inhibiting the sympathetic nervous system with beta blockers and the old Austrian system with cameras. And we importantly are learning about the role of SGL T two inhibitors, not only in treating half ref but also in preventing heart failure, but then it's also exciting to think about other uh treatments for reduced ejection fraction heart failure, like uh like the soluble guan uh going to late cycles, um uh stimulators, the various sig watt that was in the victorious study. We have the galactic HF study that looked at um a captive moukharbal And um other studies that have looked at um at treating anemia with iron. When you think about these recent studies, seven in particular, they studied um the benefits of these therapies and over 36,000 patients with reduced ejection fraction heart failure. And so we have new knowledge and we really need to be able to understand how to titrate guideline directed medical therapy and um use that expertise within the nuances that we all know exists within taking care of patients with heart failure at the end of the day, what we want to create our heart failure specialist, whether their physicians, whether they're a PPS nurses the whole team because we know of the complexity of heart failure and you know, I love this article. This is a manifesto of collaborative longitudinal cardiovascular care and heart failure. And and dr Srivastava is one of the co authors. I think that this is also a very important article because of what it speaks to is the need to work with this expanded ecosystem of other cardiovascular specialists and primary care to really optimize the care of our patients with heart failure. Um, you know, we talked to our patients about, hey, we may be the muscle people, but then we're going to send you to the Rhythm people, the electricians because of, you know, your heart rhythm disorders. And we're going to send you to the valve people for valve issues and or two surgeons for advanced therapies or revascularization. Um, it's really important for us to work well within this ecosystem and have our patients understand how that flow looks for them as well. So I'd like to move on to lessons from our center. Our team really started, I was recruited from General Cardiology to start a heart failure clinic for Intermountain Healthcare. Uh In the year 2000 we had two heart failure transplant cardiologist. We started with two A. PPS and quickly moved to three. We had to RNS. And you can see over the years from 2010 to now, 2021 we have five physicians. We have 11 A. PPS with some P. R. N. S. And I've moved into more of a non clinical role, but I still see patients in clinic. We have nine RNS and some who work in a PRN capacity. So we've really grown over time. The Foundation for our program has really been having a sound leadership structure with administrative support of our program. This is an image, you know, I don't need to go into the details of our leadership. It's certainly changed over time, but the point is having leadership and administrative support for A PPS. And your program is huge to the success of your program and ability to take good care of patients. This is an image of one of my first heart failure mentors and one of my first A P. P colleagues. Um and really what a successful team and a program takes is having a good vision having visionaries. What does this look like? Where are we going? What is our five year plan? Um I owe so much to dr dale Roland, who was my mentor in terms of what he's taught me about heart failure, how to approach heart failure, how to uh take care of people and how to talk to people. Um even in clinic yesterday, I was taking care of an L VAD patient who was struggling and and I used Dr Wendland's one of his quotes that he taught me and that was, there are no home runs in heart failure. Um You know, we have little pitch hits along the way, we may make it to first base, 2nd 3rd, maybe sometimes we'll make a run, but we need to pay attention to all these aspects of the complexity of heart failure, so we can really end up saying that we've left no stone unturned, and we're thinking about everything like depression, cardiac rehab, sleep apnea, and whatnot. Um but I think that that's always been a one liner that I've learned from him that I continue to take forward to this day. Um You might ask why I'm showing a Snickers bar and I just have to show this because for many years we would make bets on in patients who were sick with d compensated acute heart failure, about what they're right heart cath pressures were. And um so we would take care of them every day. We would diaries, then we would add G. D. M. T. Um and then we would send them to the Cath lab to get baseline human dynamics to see how we were doing. Or if they were in need of advanced therapies and whatnot. And we would bet with Snickers and you know, I love this. Um this this he really made heart failure fun and challenged me um and really made me put my knowledge and my assessment skills and my instinct to play. Um and and I was able to build confidence by by doing that in a fun way. So with that we were able to celebrate clinical challenges but then also capitalize on really important teachable moments in our early days of our program, we actually started with parallel programs with heart failure being um taken care of by some and then that and transplant being taken care of by some other A PPS. And with shared physicians. And we realized um very fairly quickly that that model was not an optimal model, that heart failure is a continuum and the spectrum. And we all needed to be experts on that continuum. And so we merged the heart failure in advanced therapies into the advanced transplant clinic. Advanced heart failure clinic. This is a picture of our team. It includes everybody. Emma's nurses, A PPS docks are admin. Um you know, pictures like this of course bittersweet will never forget what year pictures like this were taken of our team. But this is a so fortunate to have an amazing team like this to work with. So what about getting started? Well, it's so important to hire for a good team fit. And what do I mean by that? I think what we've learned over the years is that even somebody that is a new ground or with no heart failure experience, if they're a good fit for the team, you can teach them heart failure and they will become a great heart failure expertise. And we've been able to do that um with many different A PPS that have joined our team and a good fit means they're gonna, they're motivated, they're enthusiastic, they want to be their their hunger for, hungry for knowledge and hungry for expertise in patient care and work well with the team and all the different roles. It's important to then be able to on board with milestones and expectations and really set the stage with leadership with a meeting in that first week to review those expectations and then perform check ins at time intervals 30 60 90 days that not and will only include appraisals by mentors but also self appraisals of the mentees um and the new hire so that you can assess how they're doing and adjust the the onboarding course is needed. The there are tools from the advisory board that can actually help you do this if you're not familiar with with implementing that. Um What we've been able to do over the years and this is a direct result of the competency check list that has come from the A. C. C. Document as well as for the advanced heart failure and transplant training for physicians is we've put together our own competency checklist. We have included hyperlinks of the most important articles that people need to read in becoming familiar with heart failure. We have a bad competency checklist also hyperlinks and important articles from the work up of a bad patient to complications and hospitalist and treating high blood pressure, even dental prophylaxis. And then part three for us is the checklist for transplant patients. Again many hyperlinks of important articles um and so much of this can be done through self directed reading but also um timed reading where there's a plan with the mentor. In terms of you know today we're going to focus on or this week we're going to focus on heart failure. Next week we'll focus on other aspects of advanced therapies. So that's been quite successful for us. We also have a shared drive where we have folders full of these documents and add to it continually as the literature changes. And you can see there's a whole list of anything from amyloid to palliative care um and heart transplant and team based care. Um This is uh you know, huge repository for uh for the literature um that we encourage people to reference and go back to in a self paced manner. We also on a regular basis from our physician get documents like this that are the latest board review topics. This is an example on new onset heart failure. Um and so we include that in our on boarding and our reference library. Uh and this also includes important case based questions um that really are able to test your knowledge and provide answers with reasons why the correct answer is correct. Um So I think that this these this kind of learning is also really important in the trajectory of an orientation. And even for more experienced people to continually test your knowledge. We then have have gotten more organized over time with an impatient orientation. Um And that includes setting expectations for what the day will look like when you're on the in patient service. Getting report on patients, looking at patients or scrubbing the chart as we call it. Um Getting information about overnight events, rounding on the patients, developing a plan of care, placing orders, placing referrals, completing a note, follow up on tests, diary sis, labs whatnot. Um And then we always do afternoon rounds on in patients and then plan for night coverage. So um so this is you know a typical day in the life of the impatient world for for our service. But having that expectation and training people accordingly is important. We also really focus on the path of physiology and hemo dynamic expertise. For years one of the expert nurses and our thoracic I. C. U. Has mentored many nurses a PPS and even fellows in training about using a swan and how to troubleshoot swans. We have other expert interventional and non interventional cardiologist who do incredible right heart casts and we send our trainees to the Cath lab to learn from them. Um But you'll never forget um important formulas um that are the basis for what we do in heart failure like that Sharon's harmonic gradient tPG and the PVR pulmonary vascular resistance and what those um formulas mean how it can aid in the assessment of our patients and how it can help guide our therapy moving forward and understand um There there um hemo dynamic. So really important to develop that expertise in the outpatient orientation. We again um orient people to what to expect during the day. They need to be able to look at patients and understand how to navigate in our complicated electronic medical records. Look at events since last seen medication reconciliation and optimization. Uh and how to figure out how to engage patients in a meaningful way provide ivy diuretics and clinic, which we do, You know at least 3-5 times every week. We complete daily notes, use templates, follow up on test labs, wrap up at the end of the day, follow up on details and place referrals and then also integrate clinical research into our into our day. Um so what this shows is um is that planning um uh progressive way to gain independence and autonomy and a PPS as skills and knowledge evolve um allows you to take the training from following to a reduced workload to then a full workload. Um But this is you know obviously needs to be individualized for every person it takes into consideration their experience, their training, um their personality motivation and whatnot. Um It's important not only to have the right person but to use skilled mentors to foster presentations and curiosity and presentations. We need to be able to tell the story. Um We need to be able to understand what sick looks like and what that inaction is not an option if I don't if you're not a saturday night live uh follower. This is very funny from saturday night live in terms of um you know the only prescription for a fever is more cow bell and this is one of my attendings who says give me more G. D. M. T. Give me more cow bell so that we don't let inertia get in our way. Other tips, timely feedback sharing pearls and mistakes using checklists and protocols and having those available is so important. These are examples of some of our guides. We have a Utah cardiac transplant program, pocket guide and even on the right is is something that's one of my partners uses for the impatient world. Mhm. Ultimately it's creating a culture of respect and really being able to add value, mutual respect for all of the team members. We've been able to go from a group practice where we all take care of our patients to a PP. Panels that has immensely improved job satisfaction and patient satisfaction in our clinic. Um And it's been so important to be able to create a niche in heart failure across the spectrum. Um so that others can develop their own expertise, like pedes transplant transition. For example, we have a nurse practitioner who used to work in the pediatric transplant world and now helps these pediatric to adult transition to the adult center. So let me finish up with other ideas for honey expertise, lifeline learning and national organization participation. This on the left is an important article led by Clyde Yancy about lifelong learning um that we know is so important, their global challenges, global opportunities. We know that there are so many opportunities for continuing medical education and review courses to understand heart failure. Um and you know, novel ways of becoming involved in learning about heart failure through this leadership program that dr Shrivastava was was part and in developing I think is really innovative and it's kind of like speed mentoring and heart failure and other areas like um like clubhouse that offers audio um cardio text topics that you listen and learn about heart failure and other cardiology topics. And of course there are podcasts, there are cardio twitter. I can't say enough about following different experts on car and cardio twitter seeking certification. There are new certification opportunities through the heart failure society this year in heart failure cert and an optimal medical therapy. And what this does is validates professional expertise. I think volunteering, joining national organizations and being able to meet other heart failure experts certainly increases expertise. This is a group of my colleagues where we talked about 100 years plus of heart failure nursing expertise. We've written textbooks together um and I think being able to participate in research and manuscripts and collaborating is so important. This is an example of some of our early work and collaborating together as a PPS. Um and I've been very fortunate to have other external collaborators where where we've come together as different heart failure experts and published important articles, Even increasing community awareness about heart failure and and getting the word out about the community um is a way to hone expertise, creating clinical pearls, speaking in quality improvement, even doing something simple like taking an article and writing a clinical pearl adds to personal expertise and mentoring others we know is so important. Um We hope to create a cardiovascular A. Pp. Fellowship that will increase, increase A PPS. And we've been able to foster a PP leadership in the clinical area, operational and quality improvement area. So I'd like to just finish by some pearls from my my fellow cardio twitter goers. Um and these include that we need to foster the multidisciplinary and interdisciplinary collaboration with a shared mission. Uh We need to participate in grand rounds and panels. We need to get involved in societies, we need to participate in research and policy and quality improvement initiatives, use the patient centered approach, foster culture of professional growth, have a mentor friend who really cares and fosters your overall growth and development, internal rotating heart failure clinics or programs um and network um and follow amazing people like I've been able to do on twitter, so again, I'm so happy to have been here and and share my expertise um in heart failure and hope that this has been helpful to you. Um and I'm happy to take any questions. Thank you and that was absolutely spectacular. Um I just wish we could have done this in person this year, but uh hopefully next year and would love to have you uh come down to SAn Diego and uh teach us more. I suddenly learned a lot and I hope the audience uh found this. I mean it was extremely youthful and thank you again, thank you, appreciate the opportunity