Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Braden O'Neill, family physician at North York General Hospital, assistant professor and new investigator at the Department of Family Community Medicine at the University of Toronto. Today's episode focuses on the importance of time as a commodity in family medicine. I hope you enjoy the show. Tell me a time that you had to make a change. You know, I want to hear about the story, the impetus- you know, speaking about stories and speaking about engagement, sometimes we don't do a good enough job of engaging our patient. Tell me a time where a patient engaged you maybe to make a change.
Dr. O'Neill:I've now been in practice for two and a half years. So, uh, you know, it's been a real whirlwind of kind of learning all the things that you have to learn once you finish residency and you start to figure out that, uh, being a family doctor and especially doing comprehensive family medicine is, uh, you know, it's, it's a very complex, nuanced, uh, thing. It's very intellectually challenging and there's a lot of kind of advocacy and system navigation that goes on. And, uh, over the past couple of years I've, I've taken on about 750 new patients. I'll take a few more on, but that, you know, sort of is basically building up an entire practice from scratch. And, um, so when you asked me, was there a time where, uh, you know, a patient encouraged me to look at something or think differently, it's hard to know where to begin. I, I, I can think of, um, I can think of a couple situations. One in particular where we all have these patients and we're, we're, we're doing our absolute best to take care of them within the confines of the resources that are available. And frequently those are a combination of the resources that the healthcare and social care system has, but also the resources that patients have. And, you know, I remember a, a situation where I, I felt really challenged. I felt really sort of exasperated by someone who I felt wasn't listening to my advice and, and uh, um, I just couldn't figure out why they didn't seem like they understood that I was trying to help them. I couldn't wrap my brain around it. And then they started telling me about their life. They started telling me about some of these things under the surface. Um, some of these things that, uh, you know, I completely understand why they don't wear on, on their t-shirt walking down the street. And, uh, it really, really made me realize that, you know, we have these conversations in clinic, but they frequently only go so far and to really be able to take care of people, we need to find some opportunity to get to know them a little better.
Dr. Rezmovitz:So can you give me an example of, of something that you did or you've done to get to know them better?
Dr. O'Neill:One of the things that, uh, I try to do when I meet a new patient is not talk. I'd let them basically run out the clock. They come in, we go through some logistics and then I just say, well, tell me about yourself. And I initially remember feeling that, you know, this is a very inefficient way of, of, of talking with people. I'm not getting the right information, but it's amazing how people get there. And to my knowledge, there is no study comparing consultation length between clinicians who just kind of let people say their piece and only interrupt when you know, the patient is, is, is done versus interrupting right away. But I sort of suspect that, uh, you'd find all sorts of interesting things if you just force people to deliberately sit there on their hands and, you know, wait for people to tell their story in their own words.
Dr. Rezmovitz:So you touched on how you let the patient, you know, run the conversation, if you will. And I think too long, um, we've forgotten as family physicians how important that relationship is between the doctor and the patient, between the patient and the doctor, between the family and the doctor- we're family doctors, right? And so knowing what people value, which is what you're allowing them to do, right? You've given them the most important commodity in 2019, which I think is time- time to speak. And then through that opportunity, we can figure out where to support our patients. And by doing that, we'll, we'll identify what their values are and then we'll find the alignment in caring for these people. Does that make sense to you?
Dr. O'Neill:You know, um, uh, I, I think of Ian McWhinney, um, who was, uh, one of the founders of, uh, of family medicine as we know it today. And, and especially academic family medicine and, uh, uh, he described that family medicine is a relationship based discipline. It's the only discipline in medicine that defines itself by relationship. Every other discipline- and I know some people are gonna listen to this and they'll argue,"Oh no, we do that in psychiatry,""oh no, we do that in internal medicine." You know, that's true to some extent, but what brings together the family doctor and the patient and the family doctor and the family is an ongoing relationship. And that relationship occurs through acute issues. It occurs through birth in many cases all the way to death. It occurs in chronic issues. We deal with physical health and mental health and, um, you know, there aren't many opportunities that we have in society. We're, we're so privileged to have this in Canada where we have free, at the point of care, primary care, not everyone has access to it. And that's a really, really important thing. But for those who do, you can just call up your family doctor and you can bring them any problem. They might not be able to solve it exactly, but they'll try to solve it. And isn't that an amazing thing? Isn't that an amazing privilege?
Dr. Rezmovitz:It is amazing actually. We, um, not a lot of people have what we have to be so connected with, with people, um, to the point where, uh, you go to the hockey game and, uh, your patients, uh, see you and go,"Hey!" You know, and, and they're so enlightened. Like their face just lights up, you know, and then they're like,"you're my doctor." Right? That connection. You know, I don't have that with my, uh, car dealer. I don't have that with many other people. But, uh, you know, I have it with my doctor cause there's, it's such an intimate relationship that we have with them. So we are, we're truly blessed as, as family doctors to have the privilege to take part of patient's lives and, and, and that intimate knowledge that we have about people and that, um, and the confidentiality that we have to maintain, right? Cause I never say hi to my patients unless they, they say hi to me first. I never want to put them at a point where they would have to explain who, who I was in their life, right? But I want to get back to, to the things that you did, especially in Oxford. Um, and you mentioned how you realize that, uh, you know, family medicine- are there many family medicine Rhodes Scholars?
Dr. O'Neill:There are actually, uh, there are actually quite a few. In fact, in this department, we, uh, uh, we have two of us, myself and Nav Persaud. Um, you know, the criteria for winning a Rhodes Scholarship are basically around demonstrating that you care about other people in some way. The Rhodes Trust, of course, makes it, you know, much more eloquent than that on the application form, but, um, at its heart, it's basically looking for people who see and demonstrate that they see in some way, um, that everyone's life is worth something. Um, so it doesn't surprise me that there are lots of family doctors, at least among the, uh, uh, people who are in medicine who, who end up doing Rhodes Scholarships. Cause that's kind of the, the, the group of people in the orientation that, uh, candidates for the scholarship house.
Dr. Rezmovitz:And so what did you focus on in your scholarship?
Dr. O'Neill:I did a PhD, uh, which in Oxford is called the DPhil. Um, one of the things about Oxford is that they have a different word for everything, even where it's not necessary to, they just come up with a different word. Um, and um, so I did it actually looking at how people's health literacy level-which is your ability to read and understand health information and use it to make decisions- how that affects their use of the internet for health information.
Dr. Rezmovitz:Did you ever look at medical students' health literacy regarding Harrison's principles of internal medicine? Cause I have to tell ya, I don't know if many of them know about the book, but because everything's on the internet right now. So I'm just curious if people are actually, you know, uh- which focus to did you look at?
Dr. O'Neill:Well it's, it's really interesting. I think things have changed a lot in um, the last eight years. I started my PhD and I finished it five years ago when I started. We would sit in meetings and say, you know,"Oh well they looked it up on the internet." But of course, no one says that anymore. That's obvious. You looked it up, you looked it up on the internet. Where else did you look it up?
Dr. Rezmovitz:Yeah they Bing'd it. Or Google. Or[ inaudible].
Dr. O'Neill:We have to be agnostic about those things. Do you have any other search engines that you used? Platform agnostic. So your PhD is on semantics, uh, and on the language itself or is it on the health literacy? It was on how people's health literacy level affects their use of different types of resources. So I looked at that in several ways. It all sort of culminated in a small randomized controlled trial where people were randomized to one of two kinds of websites. One had patient stories, pictures, a narrative based information about a condition. The other had more standard facts and figures type information. And we measured people's health literacy level, uh, at baseline. And um, there was this belief in the literature and, and, and I think to some extent in kind of popular culture that, you know, there are people who get it and people who don't, and patients who understand things and patients who don't understand things. And this study, not conclusively, but to some extent demonstrated that actually there is no difference between how people with different health literacy levels use resources on the internet. And I think that's, that's really important because when we're thinking about making things for people, you know, it's, it's, it's not enough to say- Oh, there's going to be this group of people and, and they're not going to get it. You know, they have low literacy or low health literacy and those people used facts and figures, information. They used patient stories just in the same way.
Dr. Rezmovitz:Did you make a recommendation out of your, your PhD about which way we should be going, um, going forward to help our patients? Is there, cause what I'm understanding is there's, there's no difference from you for about how we set up our websites. People will figure it out just the same. Is that- am I understanding that correctly? Yeah.
Dr. O'Neill:I think there are two things. One is that today everyone uses the internet or almost everyone uses the internet. Uh, there are certainly, you know, some people for various reasons still don't have access. But that's a very small and increasingly smaller amount of people. Um, so the first thing is people are going to look up things, and if we don't talk about it in consultations, we're missing out on an enormous amount of the thinking that people have done about their health issues before they even get there in the first place. You know, we think, Oh we 15 minutes with people, or maybe 12 minutes or maybe 17 minutes. But actually by the time people come, especially for new issues or chronic issues that they've had for a long time, they may have spent hours researching it.
Dr. Rezmovitz:So someone recently gave me a mug and they thought it was the funniest mug, and I bet you about 10 years ago, I would've thought it was a funny mug too. And the mug said, don't confuse your Google search with my medical degree. And so 10 years ago I probably would have laughed at that. And today I say, so someone gave it to me and I said, you know what? It's not funny. And I'll tell you why it's not funny. I said because it's dismissing the patient's role in partnering to figure out what's going on. Google has everything. I mean, well search engines- I want to be platform agnostic here- but you know, we find everything on the internet. Um, I will use an antiquated term, like you said, I will look it up on the internet. Um, but it's there. And so why would I dismiss all the work that they've done? In fact, most of the visits going to be in reassuring people or help like acting as an interface to the information that they found to help them figure out what the next steps are. Because they've done a lot of the work. You actually don't have to explain most of the stuff. They understand what's going on, but it's interfacing with the information that they have and, and, and taking it to the next step and it's part of the management plan. And so I didn't actually like the mug. Have you seen that mug yet?
Dr. O'Neill:Yeah, I have. It's funny, even before you started telling the story, I, I thought that's where it was going. Um, people post this a lot on the internet. Uh, people put it on Twitter. Uh, you know, it's, uh, it's offensive.
Dr. Rezmovitz:It is! How are you supposed to partner with a patient if you're dismissing them already and saying, you know, this paternalistic approach to medicine, which is my medical degree. It's assuming that you know, everything. How is that possible? In fact, the patient probably knows more about themselves than you do. And so engaging them and connecting with them as a, as a partner in their health, to ask them what they've actually looked up already is probably an excellent question.
Dr. O'Neill:I think we're at this really interesting time in, in, um, in healthcare and in medical education where the democratization of access to information has meant that there's very little that physicians have access to that anyone else doesn't have access to. Now, there are lots of problems with what information is promoted and I think regardless of what search engine we talk about, there are issues around, you know, what ends up on the first page of Google may not be the best thing for that person at that time because there are other interests at play. You know, Google is trying to make money and they do really, really good at it. We are trying to be in the business and healthcare supporting people and supporting patients and families, but people can have access to almost whatever they want from any kind of resource. We don't own that in our libraries anymore. And I'm not sure that we've quite caught up in medical education with how to understand how to deal with that and how to sit with people in a room that 30 years ago, they really needed you to be able to bring that knowledge from the ivory tower or bring that knowledge from the library. Well, they had that knowledge three days ago when they called to book the appointment and, um, they want to discuss it with you and they want to say, well, I found this. What do you think about that? Having said that, every time I have a consultation like that, I, I've never felt that my knowledge or my approach, the things I've learned weren't useful. A lot of the times we do have special skills in healthcare, uh, to be able to synthesize information, uh, to be able to prioritize information. You know, how many times has a patient brought in a, a lab value for example, and say,"Oh, I'm worried it came up in red." And you said, well, actually you don't have to worry about that."Well, why not? It says it's wrong." Well, actually I'm able to explain that. I know why not. Um, and uh, so that's a really, really important part of what we do. But it's different than the way it probably looked 30 years ago.
Dr. Rezmovitz:Yeah. So have you ever had an experience with a patient or a learner where they've challenged you on something or where you had to make a change and you realize, wait a minute, maybe they're right. Maybe I need to, to change the way I'm doing things now. Cause this probably wasn't the way that you always were. I mean you, you probably were trained in the, in the older way. So I'm just trying to get a sense of when- like how this happened for you, where, where this realization came from. I like it by the way.
Dr. O'Neill:I think one of the really important times that this comes up is in, uh, uh, lifestyle type issues. And the thing that comes immediately to mind is smoking cessation. So, um, I was taught, you know, at every visit with a patient who is a smoker, you must offer smoking cessation. And there are lots of effective interventions for smoking cessation. We know that. And I've had patients for whom I've offered that every single visit. You know, time and time again. No, no, no, no. And what I realized with some people- this is not with everybody- in a way- we, we talked a bit about the importance of knowing people is that, you know, people will get there when they're ready and your job isn't to pressure them into something or to pester them at every visit. It's to make it clear that the consultation with you is a safe space to bring up anything that there is no judgment, that you will support someone regardless and that often that means that, you know, people aren't going to say today,"Oh I have to make this change." But if you create that safe space and you say, okay, that's fine. If you ever want to talk about that, when you want to talk about that, come and see me and we'll talk about it. And I can think with a couple of patients where, you know,- I, I'm, I want to emphasize, I'm not advocating for not offering smoking cessations quite the opposite- but what I'm advocating for is that the, you know, the core of those conversations, it happens over time. It might happen in the 12th consultation, but you get there eventually.
Dr. Rezmovitz:It sounds like what you're advocating for is meeting people where they're at," and helping them follow you because you took the time to meet them where they're, when they're ready. Instead of going out in front and saying, I don't smoke. You shouldn't smoke. You should come meet me where I am." It's, it's taking a step back and saying, wait a minute here, let's, let's go through the stages of change. You, you're in that pre contemplation stage. I need to think about how we're going to get you to that contemplative stage. Well, the only way I can do that is support you and make the recommendation. I had a patient very similarly who was a lifelong smoker and he was 94 years old. I thought, why would I even suggest smoking cessation? So we got to the point where we would laugh about it and I said,"John, have you thought about stopping smoking?" He's like"only long enough to light another cigarette," and it became our thing. I remember there were a couple of visits where I didn't even ask him about smoking cessation and he said to me, uh,"you're not going to ask me today?" I said, about what?"About stopping smoking? It wouldn't be the same without seeing you." And I said,"okay, have you thought about stopping smoking today?" He's like,"Nope." And it was our thing. But you know, it was in his best interest considering, you know, the COPD that he had, but it became our thing. And that was where the, the relationship sparked from, right? That joy of me showing that I cared about him and him showing that he did not care for my thoughts. It was nice. It was a, it was a, it was a nice moment that we shared all the time, but meeting people where they're at, obviously he's not going to change. He's 94 years old. He said to me,"I love smoking. Why would, why would I stop? I'm 94 years old. I've beaten the odds." Yeah, you did. I said,"I might join you for a cigarette one of these days." So I totally get where you're coming from. You know, if we could really support our patients, um, and demonstrate that we're there for them instead of shooting on them. We had this with another, um, guest on the show about talking about safe spaces and what, what constitutes a safe space. And we discussed the concept of a brave space actually. And um, allowing people to take risks because they feel supported is way better than telling people"this is a safe space" because you can't tell people. You have to- I think you have to show them, not just tell them. And so it takes a long time. And that's where the continuity of family medicine really plays a huge role in what we do and to support our patients.
Dr. O'Neill:A lot of the people we care for, for a variety of reasons don't have a lot of people in their lives who they can turn to unconditionally. I, uh, can't quote numbers on that, but, uh, you know, if you want to come and spend a day with me in clinic, I bet we'll see quite a few people who, um, who for various reasons would meet that and the magic of what we do, I think in large part is being able to be that kind of person in someone's life. You know, we- I've been taking on new patients, uh, for, for two and a half years and I had a husband and wife recently and they said, well, we're looking for new family doctor. Okay. Did you have one before? Yeah. Yeah, but he just retired. He was my family doctor for 50 years. It's your family doctor for 50 years. How many people in your life do you have a relationship with period for 50 years? And how many people do you go to when there are good things happening and bad things happening and you're not sure if something is nothing or if you're going to die? It's a very, very special space that, uh, that, that we occupy. And there are lots of factors that I see as someone who, you know, fairly recently finished residency or are sometimes you feel like they're colluding to, to, to uh, hurt what it is that-the, the very essence of what we get to do. I mean, there's only so much time and uh, as as appointments get shorter and shorter and, um, there's more and more paperwork, you know, things are lost. Inevitably things are lost in that. And the, the, one of the biggest challenges that I see for us in comprehensive family medicine is really about, you know, how do we keep that space open? How do we push back against some of these forces in services?
Dr. Rezmovitz:It's really, a really difficult time. Over the last few years, I've been looking at CanMEDS roles and, and looking at the role of, um, improvisational theater with, uh, CanMEDS role. So I got to understand the CanMEDS roles, all seven of them. And I realized we're missing one. We definitely are missing one. We're missing the physician as magician. And you say the magician? Yeah, the magic. So you, you touched on the magic that we offer patients. And that magic is making time for people, right? And if you can really find a way to make time for people, you'll develop that relationship, that trust that people need so they can come to you unconditionally and ask for your help. And that's when you're really going to see the benefits of that continuity that we have in family medicine. I really wish we could find a way to offer 30 minute appointments to every single person under the stars. I think it would go a long way to developing these relationships, but pressures, you know, of, of taking on patients and, and, and supporting our whole practice makes that very difficult. So it really, you know, in the spirit of November, I just heard this last week, do you know about November? It's where you learn how to say no to things, but I really think learning how to say no and pushing back and really giving patients what they need, which is time and space so that they can talk uninterrupted will actually get us further than, than making sure that our mandate is, is kept.
Dr. O'Neill:One of the amazing things about family medicine is just how much we do, right? I, uh, of course I'm going to say this because I'm a family doctor and this is a family medicine podcast and, but, but I really, really believe this, that if you look at what we do in a consultation in 12 minutes or 17 minutes or 30 minutes, if we're really lucky, it's unbelievable. It is actually unbelievable the amount that we do and we do it safely and we do it sensitively and we give people the opportunity to talk. I think sometimes we, we, we beat ourselves up a lot, you know?"Oh, we weren't able to do that. We weren't able to do that. That person's mad at us." You know, that person's called to complain, but we don't sort of reflect on, I really like how you said that the magic that we do- it is a bit of a magic trick. And there's some times in clinic when you're really on and you know, maybe you're only running 12 minutes late and, uh, Oh, I've, I've, I've dealt with six issues with this person and eight issues with that person and Oh, it's not so bad. This person has diabetes and depression. That's only two or three issues. I can handle that no problem. And you make it all work and you think, wow, this is incredible. How did I do all this? Of course it doesn't take much to tip it over the balance and then you're 45 minutes late and you know, we don't run late because we're sitting on the beach or, uh, playing computer games.
Dr. Rezmovitz:I figured out why we run late. Actually, I've, I've, I've noticed, um, and I was working in a clinic once and um, I made a comment to a patient. I walked in, I said, listen, I apologize for the delay today. Um, but we, we have a party in the back. And so, uh, that's, that's what the delay is. It turns out I invite one person at a time to the party and then I just go, you know, I just keep having a party with one person and then the next person and then the next person. And that's what it is. We just keep partying with these patients one at a time. Uh, if we could find a way to party everyone together without, you know, revealing confidential information, then I think it would be a lot faster from an efficiency standpoint. But we're not in the, in the game for efficiency. We're in the game for care. And so they laughed obviously at that. And then we had a little connection cause she's like,"well, I guess it's my time to party." I said,"that's right. It's our time to party. Let's go." And you go and you have your, you know, eight minutes with a patient. But it was, it was something, right. And it's all about that, that spin. It's how the perspective that you, you take on your relationship with your patients. And so I'm going to challenge you with a concept that, um, I've been working on, and I probably should, I should probably write this up in a commentary or something like that, but you know, you mentioned that you have six, you know, you just dealt with six issues with a patient or eight issues with a patient. You feel really good about what's going on. What if, you know, what do you think about this? What if we as physicians are really practicing a moving meditation? What if when things are going really well, what you're really doing is, is meditating- you're finding that flow that's working really well. And have you ever had your meditation interrupted? Well, that happens to us all the time. And in order to get back into the meditation, we need to find a way to get that flow working again so that we can continue seeing patients. Because there are times when you're just seeing patient after patient, but it's flowing and there's no issues whatsoever. But it just takes that one thing and learning how to deal with that distraction that we have in medicine to get us back into flow is really what we need to be focusing on so we can, we can be there for our patients. What do you think of that?
Dr. O'Neill:I have a friend who's a, an emerge doc and he told me recently that uh, at some point in the middle of a shift, four hours went by and he did everything he had to, there was some complex issues. There were some simple issues, there were some procedures and uh, all of a sudden he looked at his phone and he realized that four hours had gone by and uh, it's exactly the word he used flow. He said"it was amazing. It just flowed." The big challenge is how to number one, change the structure of what we do and how we see patients to accommodate that. The second is, what are the skills necessary to be able to do that? I don't think we necessarily learn the skills that are necessary to be able to do that. To my knowledge, there is no meditation course in the undergraduate medical education- I could be wrong. It's now, you know, 10 years since I started, medical school and as a, I think someone said 10 years out from medical school, 50% of what you learned will be wrong. The problem is you don't know what 50%. There may be lots of really interesting initiatives, um, that, that, that I don't know about but, but some of what you're getting at is maybe there is an element of, you know, what we do that is exactly the same way of doing something that we've done for a very long time, which is one room, one patient, open the door, close the door. Next room, next patient, open the door, close the door. Maybe that needs to change somehow. Maybe what we say in the room needs to change. Uh, I think, uh, what we say to start consultations is probably exactly what people 50 years ago said, which is what can I help you with today? I say that 30 times a day. And, uh, uh, is that the right question? It may be, it may not be. We've, we've talked a little bit, uh, about the internet and the fact that people are using the internet and going online and looking up their symptoms and looking at possible causes of things and you know, could patients do more of the work of the consultation outside the consultation, reflecting on some of what they've done so that when you come in you already have a kind of schema for the conversation. Maybe that allows you to dive deeper into something. I don't really know the answer to this, but I think what we do is actually going to start to look very different and it should because I think there are probably ways that we can do it better. Well, I think one thing is to encourage people to come with questions, materials, thoughts. Right now, uh, a lot of the time people will sort of test out the waters, you know? Does it seem like I can be honest about the fact that I looked this up and I'm worried about that. Does it seem like I can be honest about the fact that actually the only reason that I'm worried about this is because my friend had X and died suddenly. You know, that gets teased out slowly and carefully, but I think is often quite explicit in the patient's mind. It's just that it's not explicit in our mind and so it takes some time to come together with those things. Everyone sort of talks about groaning when people bring in long lists of issues. But you know, I can't think of a time when a list of issues has ever actually been that challenging. What enables you to do is say, okay, you have, I, I remember I once had a patient and they had 18 issues. They had a list and it had 18 issues on it. And I looked at it and I thought, how is this possible? What are we going to do? And then I said, okay, um, well, what's the most important? This one. What's the second most important? This one. What's the third most important? I looked and I looked at the time, I said, we can't deal with anything else today but we can deal with those three."Okay, that's fine. You know what the others I'm actually not worried about I, I just, I just wrote it all down and that worked." How many times have you written something- written an email for example, but not sent the email? You just write it to get your thoughts on paper. You feel better for doing it. You close the email, you'd go away. Why would we expect that people's health would be any different? You want to write things out, you want to make things explicit, you want to share them with someone, but that doesn't necessarily mean that every consultation has to be 45 minutes, but I think it means that we need to bring the information into the consultation of it differently.
Dr. Rezmovitz:I love listening to new ideas and your perspective on healthcare. I wish we had the time to explore it further today, but like you just said, we got it all on paper or you know, a voice if you will. And then we'll have you back for part two. I can't wait. Are there any parting thoughts that you'd like to, uh, to give to any of our listeners or, you know, if only they knew?
Dr. O'Neill:Well, I think, uh, you know, first of all, thanks. Uh, thanks for the conversation. It's, it's been really fun and da, uh, pretty wide ranging. Uh, you know, we've talked about, uh, uh, the technology in healthcare and, um, people looking up stuff on the internet and, um, uh, harm reduction. Um, and just reflecting back on it, um, you know, uh, this is what happens when two family doctors talk, uh, because you can't separate the social from the psychological, from the biological. Um, that's just not what we do and it's not what we do because it's not how people live. And, uh, so I think it's pretty interesting that that's kind of how things have gone and how we've covered things. But you know, for people listening- who are listening who might be patients, I think our conversation is an accurate reflection of the kinds of ways that family doctors think about problems, and I think that's pretty cool and I'm actually pretty proud of that.
Dr. Rezmovitz:That's awesome. Me too. I really want to thank you for coming in today and I can't wait to get you in the studio again so we can do part two at some point in the future. Thanks, Braden for coming in.
Dr. O'Neill:You're welcome.
Dr. Rezmovitz:This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullin, Brian Da Silva, and the whole podcast committee. Thanks for tuning in. See you next time.