My 3rd Capital TransPride, Washington, DC USA

Capital TransPride 2015 55384The transgender pride flag is a symbol of transgender pride and diversity, and transgender rights (View this photo on

As the subject line says. And as we predicted, the venues for Washington, DC’s Capital TransPride would get bigger and the rooms would get more full. We didn’t predict how big, though – 500% increase from last year.

The World: Learning to Love Better

New data from the Human Rights Campaign (@HRC) shows that of 2016 likely voters, 22 % of people know someone who is transgender, up from 17 % one year ago. This parallels the trajectory of acceptance of lesbian, gay, and bisexual individuals, with a higher slope on the curve.

U.S. Medicare has reversed its coverage stance (see: Just Read: Medicare bids farewell to the 20th Century in covering transgender person care, and maybe pokes fun at itself, too… | Ted Eytan, MD), as has the Federal Employee Health Benefits Program, to name just a few.

I connected with more people who are receiving health care and I could see the difference immediately. This cohort will be this year’s ambassadors of total health, which will create another – trajectories …

…at a faster pace

In the last year, some of my establishment medical colleagues have mentioned that they feel things are changing too fast. When it comes to achieving life goals through optimal health, change can never really happen fast enough.

Why be a doctor if you aren’t going to help people achieve their life goals? Fortunately, I am one, I am going to, and all of my colleagues will learn to as well 🙂 – many of them already are, and in my eyes, they are the best doctors in the world.

Kaiser Permanente Platinum Sponsor Capital TransPride CTP15 Washington DC USA 55222

Kaiser Permanente Platinum Sponsor Capital TransPride CTP15 Washington DC USA 55222 (View on

With more allies

In the meantime, proud once again to be part of the medical profession, the health care system here in support (Kaiser Permanente Mid-Atlantic States @KPMidAtlantic is a platinum sponsor of Capital TransPride).

Capital TransPride also hosted the first ever workshop on how to be a successful ally – another packed room, with people from multiple states (!) present.

I was also joined by a talented photographer with a really good camera this year, because diversity looks beautiful. Enjoy their photos as well.

While making history

DC People and Places 54033

Reeves Municipal Center in 2015 Washington, DC, now safe and comfortable host to the future (View on

The Reeves Municipal Center was built in 1986 by Washington, DC Mayor Marion Barry: “…. meant to bring government services closer to a struggling neighborhood and to revitalize a corner still recovering from the 1968 race riots. (Washington Post)”. There’s a sort of photographic homage to 1986’s Washington, DC contained within (you can see the photo here).

1986’s or even 1995’s Washington, DC was not friendly to people who are transgender, until 20 years ago this year. Then the City violated its own human rights act in allowing a transgender woman, Tyra Hunter, to die, with negligence and malpractice, after a car accident.

Now, 20 years after that, the City is the most protective of transgender (and all of LGBTQ) people in the United States, and its municipal buildings are hosting their celebration, sponsored by municipal entities (The DC Library, first year @DCPL) complete with gender neutral bathrooms.

Who knew if Marion Barry would have predicted this outcome, it happened nonetheless. Trajectories …

My photos are below. Enjoy, questions and comments welcome as usual.

Just Read: Medicare bids farewell to the 20th Century in covering transgender person care, and maybe pokes fun at itself, too…

even assuming the NCD’s exclusion of coverage at the time the NCD was adopted was reasonable, that coverage exclusion is no longer reasonable.

In english, this means that Medicare’s former determination in 1981, 33 years ago, that gender confirmation surgery should not be covered, is now history. Medicare entered the 21st century only 14 years too late. With glass-half-full, that’s 3 years faster than the length of time it takes for science to make it into practice 🙂

Definitively stated: Gender confirmation surgery is safe, effective, backed by science

There is an excellent review of the literature within which puts to rest any notion that gender confirmation surgery is experimental (it isn’t), that there isn’t evidence to support its use (there is, plenty), that it isn’t safe (it is).

The experts cited note that the surgical procedures used in gender confirmation have been validated (and are covered) in other medical conditions, such as Mayer-Rokitansky-Kuster-Hauser syndrome, or MRKH, in which women are born with a complete or partial absence of a vagina, cervix and uterus.

With regard to safety, 1985 appears to be the turning point year, where surgical technique improved to the point that compliation rates and hostpital stay requirements went down significantly.

The decision also points out something that wasn’t called out in 1981, which is the lack of safety in a situation where treatment is not offered:

…(Gender Dysphoria) ..if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death”

By the way, all of these symptoms of no treatment, leading up to and including death, are covered in health insurance plans even if the medically necessary care is not. In other words, as stated by the American Medical Association, coverage for this care is probably preventive.

Laughter is good medicine – do I detect a little humor in here?

I assume there are many ways to wipe away a 33 year legacy. You can do it with solemnity but you don’t want to appear too solemn because then the legacy won’t be sufficiently wiped. I suppose you can inject some humor into it as well, and that’s what I spy in this paragraph on page 18:

the 1981 report (and the NCD) cited an alleged “lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism” as a ground for finding the procedures “experimental.”

…and then goes on to say that the same report cited studies that ran in length from 3 months to 13 years and

If these studies do not qualify as acceptable long-term studies, the basis for such a conclusion is not adequately explained in the NCD record.

This is unmistakeable medical speak for “you have got to be kidding.”

What else can I say except, I enjoyed it :). In reality though, a subtle poke at the past helps a new generation of medical professionals tease apart data and bias, which are clearly and transparently wrapped up together in the previous coverage decision. Which is now vaporized.

Health plans are changing their coverage decisions in response

A careful review performed by my digital librarian (Google) shows the impact. Check out the difference in this coverage decision from a large commercial health plan in California, from 2012 to 2014. You can see the edits that move this medically necessary care into the same domain as all other medically necessary care. Check it out.

“Use this page to view details for national coverage determination (ncd) for transsexual surgery (140.3)” – this is the “heritage” coverage determination, which was invalidated on May 25, 2014. (see original)

Fit for the museums of the future…

In addition to saving the coverage decisions above, I’ve also clipped the 1981 National Coverage Decision for posterity. One day it will hang on a museum wall (Perhaps this one? @LGBTMuseum ) where people will stare at it in disbelief.

This saga reminds me of a quote I will never forget by one of my medical school professors, Andrew Weil, MD (yes, that Andrew Weil), who once said, “We’ll look back at what we did to people with cancer in 20 years and be aghast.” Maybe that’s the quote that will be printed on the wall above these heritage pieces as well, and I am so happy to be in medicine on the other side of those 20 years. I only wish we didn’t have to wait so long.

seattle gay marriage 5

Congrats, sorry it took so long

Welcome to the present, Medicare, we’re glad to have you!

Photo Friday: The right answer is to involve patients in every decision

Ted (me), Mark Scrimshire ( @ekivemark ), Kait Roe ( @kaitbr ), at the Kaiser Permanente Center for Total Health ( @kptotalhealth ), for the Care Innovations Pre-summit. Photograph taken by Jason Bhan, MD ( @gomedivo ), jackets by Regina Holliday ( @ReginaHolliday ).

DC Care Innovations Summit Viewing Party at KP Center for Total Health

Care Innovations Summit Viewing Party at KP Center for Total… – Eventbrite. Washington, DC is at it again!

I’ve been spending this week gearing up for the Care Innovations Summit in Washington, DC, which will be on January 26, 2012, as well as a pre-event happening the day before. From what I have seen so far, I can say that passion for innovation will be filling the DC sky this week.

As luck/serendipity would have it, the actual summit is “checked in full,” however, Kaiser Permanente is hosting a viewing party with live link to the Summit at the Center for Total Health. That’s where I’ll be.

Hashtag is #cisummit , feel free to register at the link above before it fills and we’ll see you there.

Are you integrating Intensive Behavioral Therapy for Obesity into your medical practice?

I recently posted about the “CMS Proposed Decision Memo for Intensive Behavioral Therapy for Obesity (coverage by Medicare)” and received this query. I don’t know the answer, so I’m posting it here to see about the wisdom/experience of the crowd. Please add what you know/what you’re doing in the comments!

(we are) trying to learn more about this is being done in the real world, post ACA.  We’re just trying to learn the nuts and bolts to help providers get reimbursed for this service so that they will be encouraged to actually provide this counseling.

Incidentally, the final CMS Decision Memo for Intensive Behavioral Therapy for Obesity (CAG-00423N) – is now posted, feel free to look to it for reference, it discusses guidelines for coverage, along with the science behind the effectiveness for Intensive Behavioral Therapy for obesity (and there is documented effectiveness).

Medicare To Cover Obesity Counseling Without Cost Sharing

Medicare To Cover Obesity Counseling Without Cost Sharing – Kaiser Health News.

Since I’ve mentioned this to more than a few people recently, I’m writing a post about it.

This is significant for two reasons:

  1. For changing the way health care is paid for, from procedures to counseling, which talking AND listening.
  2. For changing the way we think about obesity treatment, from thinking about it as untreatable (which is a myth), to thinking about it as treatable (which the science supports)
#1 has potential implications above for other things in health care that have been underemphasized (by they way they are reimbursed) such as advanced care planning (think “Engage with Grace“). It’s worth checking out to see what the parallels are.

Presentation: The Kaiser Permanente Innovation Journey – DC Health Innovation Summit

This is the presentation that Marilyn Chow, Marilyn Chow, DNSc, RN, fAAN, Vice President of Patient Care Services, and I gave at the DC Health Innovation Summit, part of 2011’s DC Health Innovation Week.

I am not the hugest fan of Slideshare’s formatting, so I’m including as a series of images below, as well as with a transcript on the bottom. Enjoy, feel free to embed.

Marilyn: Hi, I’m Marilyn, Vice President, Patient Care Services, for Kaiser Permanente
Ted: Hi, I’m Ted, a Director in The Permanente Federation of KP Medical Groups

M: Welcome to the Kaiser Permanente Center for Total Health. Many of you wondered if you would get time to experience the Center during your time today.

T: With that in mind, we would like to spend the next 30 minutes introducing you to five innovations that are portrayed on the Center’s digital walls, and to people here from Kaiser Permanente who you’ll want to meet and learn more from.

M: The Kaiser Permanente Innovation System is people, spaces, tools, networks, methodologies that an organization has in place to support continuous innovation. It’s in our DNA, which means that any problem we encounter, whether identified by our senior leaders or our frontline staff, is seen as an opportunity to make patient care better, more affordable, more accessible.

With that in mind, let’s start the list.

The first innovation is Complete Care. Complete Care includes Proactive Care, which touches the patient, before, during, after, and in between visits.
Kristen Andrews is here, from Southern California Permanente Medical Group where she is the Regional Proactive Care Group Lead.

Includes: Proactive Panel Management, Proactive Office Encounter (Outpatient visits), Proactive Inpatient Encounter (Inpatient visits), Proactive Office Support, as well as condition management leads for Diabetes, Asthma, Hypertension, HIV, and chronic kidney disease.

You shouldn’t have to have luck in order to have your life saved in our health care system. 2/3 of the time a patient presents with a gap in care, it’s to specialty.

Michael Kanter, MD told me that when he brought up the idea of specialists doing primary care, they looked at him like he was from Mars.

In 2008, Kaiser Permanente Southern California was #1 in the United States in breast cancer screening % for women. In 2009, they were surpassed by….Kaiser Permanente Hawaii. In 2010, KP Hawaii was surpassed by…Kaiser Permanente Georgia, all well above the 90th percentile of health plans, with KP Georgia being #1 in the United States.

On the left is a photograph of Elsa Torres, a medical assistant at Barranca Medical Center, Irvine California, when I asked her what this means, she said “Some people work to cure people, we work to keep them from getting sick”.

On the right is a photograph of Kristen’s badge, the same pin I am wearing on my jacket. It says “POE, Saving Lives, One at a Time.” I first visited KP Southern California to learn about Complete Care a year ago in San Diego at Rancho Bernardo, and I kept hearing people say “this is about saving lives.” The same was the case on a visit to Orange County this year.

Even the language they use is truly patient centric – they speak about prevention, teams, and tools in ways that humans can understand.

The Second Innovation is….Equity Dot

Raymond J. Baxter, PhD, is Kaiser Permanente’s senior vice president for Community Benefit, Research and Health Policy. . Dr. Baxter leads the organization’s activities to fulfill its social mission, including care and coverage for low income people, community health initiatives, environmental stewardship and support for community-based organizations, as well as research and the Kaiser Permanente Institute for Health Policy.

The equity dot is literally a “dot” on the Kaiser Permanente Quality dashboard, called “The Big Q.” The equity “dot” adds the measurement of disparities to the measurement of performance, across 16 HEDIS measures.

Ray Baxter has led KP’s work on health equity and elimination of health disparities. It’s because of him that our key quality measures can be broken out by race, ethnicity, gender, compared to benchmarks, and trended over time. This fits into the six aims of Quality in the Big Q: safe, effective, efficient, timely, patient-centered, AND equitable care. Continuing on the theme of breast cancer screening, we have documented that ALL racial/ethnic groups are above the 90th percentile of health plan members in receiving recommended mammography, and a gap between white women and African American women no longer exists.

From this measurement work, innovations towards identifying practices and tools to address health care disparities have coalesced through the ECHO work (Equitable Care Health Outcomes), that Ray can tell you about.
What do you do when you have a commitment to Total Community Health and you’re confronted with the shocking statistics around racial and ethnic disparities in health care?

On the left is a call to action from Kaiser Permanente about the overdue attention to disparities in health care. On the right is a map generated by Kaiser Permanente Care Data Analysis showing the link, among KP members between place, poverty, and obesity in the East Bay.

We know that Total Health requires equity and social and economic well-being, which includes the care we provide, as well as supporting the environment beyond the the doctor’s office.

Scott Young, MD, is the Associate executive director, Clinical Care and Innovation, The Permanente Federation, LLC

This is an example of the patient centered transitions bundle. Dan Hyunh, MD, leads a follow-up call program staffed by MD’s, nurses, and pharmacists, making sure that medications are understood, appointments are made, and if needed, changing and documenting in the electronic health record bridge between hospital and next encounter. Dan told us that his team will provide feedback to hospital teams and they will change their process as a result. For example, looking at the IV antibiotics example, were sharps disposal containers provided with discharge? This was something we learned when care teams saw the impact from the patient perspective.

We started this dialogue talking about people, spaces, tools, networks, methodologies.

Now I would like to tell you about some of our people and our processes.

Starting in 2003, we worked with IDEO and developed Innovation Consultancy to bring human centered design in house. Human centered design is when you tackle problems by first observing the needs of your users.

I would like to mention two specific processes developed through the Innovation Consultancy work.

The first is KP Medrite. Imagine that you have installed a state of the art electronic health record with barcode medication administration, as many hospitals are today. Are the problems with medication administration in the hospital solved?

We learned from our research that 17% of a nurse’s time is spent doing medication administration, and it was unclear, chaotic and full of interrupts. Through observation, prototyping, and co-design with our nurses, we developed a simple, elegant, and safe solution, which we call KP MedRite.

In the photograph above, you can see one of our nurses with “no interruption wear” on her body. It is a signal that the nurse is engaged in administering medications, she or he is not to be interrupted.

The sash is the sexy part of KP MedRite; there are three other components that Chris or Christi can tell you about.

The second Innovation from the Consultancy I would like to tell you about is Nurse Knowledge Exchange Plus.

Using the same techniques used to develop KP Medrite, we worked to solve the problem of not enough time at the bedside for nurses. We brought nurses out of the conference room and to the bedside in 2004 with Nurse Knowledge Exchange. The “plus” came in 2009 when the Consultancy worked with nurses and the entire unit to protect and optimize patient-nurse interaction during shift change.

The results are a 20 % increase of nurse time spent in patient rooms, 19 % decrease of nurse time spent at the nurses’ station. Patients and families feel involved in their care, and nurses are able to focus on the priority of getting a good safe report and being with patients.

Both of these projects have placed freely downloadable, comprehensive change packages on our external web site.

M: Ted, there’s one more innovation
T: Yes, Marilyn. That’s the original innovation that created Kaiser Permanente – Prepaid, integrated, comprehensive health care. You can learn about it in the orientation center.

This is Sidney Garfield, MD, around 1938, and a little part of his story:

“Unable to make ends meet on the usual fee for service, I finally tried prepayment and thus happened on our basic concepts of health care. The people, with the barrier of cost removed, were coming to us earlier. We were able to treat them earlier, prevent them from getting complications and keep them from dying.” (1945)

On The right is a prototype of a new type of medical office – this prototype was built inside the Garfield Center for Health Care Innovation. 11 of them are now operating in Georgia.

On the lower right is a sign showing how our heritage is reflected in everything we do. At the State of the art Kaiser Permanente Irvine Medical Center, the roads are named “Prevention Way,” and “Wellness Way.” These are actually labeled as such on Mapquest. I took a photograph of this because I remembered that at another hospital I once visited, the side road was called “Top Doctors Way”.

DC Health Innovation Summit recap, next time in Cleveland?

There was a bit of a twitter flurry started by this tweet over the weekend.

It came about through a mashup of my experiences during DC Health Innovation Week – and I was only one of two people (the other is Ravi Poorsina – @ravipoorsina) who attended every single event. But before we get there, let me recap DC Health Innovation Summit. As the press release says:

WASHINGTON, D.C. — One of the government’s newest catalysts for innovation is co-host of an event bringing together health innovators for collaboration that aims to transform health care through knowledge sharing. The event will be held at a one-of-a-kind space devoted to discussions about health.

Leaders from the new Centers for Medicare & Medicaid Services Innovation Center, along with the U.S. Department of Health and Human Services, the Office of the National Coordinator for Health Information Technology, Kaiser Permanente, Vangent, Inc. and 100 other national leaders in innovation will gather at the Kaiser Permanente Center for Total Health on June 10 for the Health Care Innovation Summit.

Here are the photographs from the event, click to enlarge:

As you can see from the pictures, the event format was very open and I think well received by attendees. To this day I have not found a group of people, any group, that can’t operate this way…the thirst for engagement crosses ages and titles (see: If you’re worried that unconferences don’t work for all audiences, look at these photos )

There’s what was discussed, and then there’s who discussed them. I definitely felt and feel that there is an emerging community of people who are devoted, with real commitment of time and resource, to figure out ways to deliver health care more effectively, more affordably, and more in a tangible way patients and families can perceive – more time with the doctor, more information to make good decisions, more involvement in preventing illness and preventing errors. When you have the head of the CMS Innovation Center ( @CMSInnovates ) and the CEO/Co-Founder of MassiveHealth (@MassiveHealth) Sutha Kamal (@suthakamal) in the same room , you can go from medicare reimbursement to app platforms in 3 seconds flat. Add a little Chris McCarthy (@McCarthyChris) and Christi Zuber ( @czuber ), the thought leaders of the Innovation Learning Network (@healthcareILN), including but not limited to Lyle (“Dr. Lyle”) Berkowitz (@drlyle1), the ePatientDave (@epatientdave) and the icing just gets thicker and thicker.

I helped staff the event yet on reflection was able to be in several great breakouts, thanks to the law of two feet (love that law!). A funny moment, when Christine Kraft (@ChristineKraft) and Geeta Nayaar, MD (@gnayaar) were seeking each other out to discuss “Why doesn’t love have a billing code?” each thinking no one else wanted to discuss….and yet everyone wanted to discuss. The first step is legitimizing the question.

The Cleveland Connection

As I said above, because I was in every event last week, I was able to make connections between the content that impressed even me.

When I saw Jen Dyer, MD (@endogoddess) for the second time last week, it was after the summit and during the code-a-thon. In fact, here’s the photograph of the conversation.

2011 Health2Dev Code-a-Thon 2670

Jen lives in Columbus, Ohio. She’s a pediatric endocrinologist, innovating using communication technology (SMS, twitter) to support kids with diabetes. As I referred to in my post about the ‘a-thon, I tend to pick up the passion that’s around me, and Jen is working on apps/technologies to better connect kids to their condition managements/care teams. So I asked her to frame a situation in her clinical care that would benefit from big innovation, and we began talking about new diagnosis of diabetes in children. For non-clinicians, you should know that being diagnosed with insulin-dependent diabetes as a child is a big deal. It requires admission to the hospital, mostly for the purpose of getting everyone on the same page, intensive patient and family education, and then intensive follow-up after. As Jen told me, the hospital setting isn’t required for this teaching, it’s just where it’s done today, at enormous cost to the health care system – 5,000? 10,000? dollars per day? What would it be like if a passionate doctor-expert could create a new model that delivered all of the same goals – engagement with care, true understanding of the treatment plan, connection to other families and the care team, without the hospital. What could that $10,000 per day do? We could find out by going to Cleveland (she told me Cleveland is perfectly acceptable in her Columbus-ness). So that is the synopsis of my conversation with Jennifer.

There’s more. Another attendee at the Summit mentioned the tremendous amount of innovation happening in Cleveland, by institutions like The Cleveland Clinic (@clevelandclinic).

There’s more. Gail Sands, who’s currently at the Cave Institute and has a strong record of innovation as a former leader at Kaiser Permanente Ohio, sent me this video:

There’s more. I love the spirit of Cleveland and the people in health care there. I last visited Kaiser Permanente Ohio in 2009. Not enough people know how much innovation is happening there every day.

There’s more, but this time I’ll ask readers to post in the comments. If I was so honored to share the KP Innovation Journey at this event (slides being posted soon), I wonder if Jennifer Dyer might do the same as part of the innovative medical community in Ohio. I’d come to watch her.

All of this said, this is not my meeting and I don’t get to decide where to have it. I did hear at the end of the day that there should be another one in 4 months. That’s October. Discuss in the comments below, all of it.

Thanks to everyone at Vangent (@vangent_inc), CMS Innovation Center (@cmsinnovates) and Kaiser Permanente (@kpnewscenter) for a great get together for all.

Now Reading: Putting (as high) a priority on patient experience as clinical experience (Data embedded)

The (Data embedded) part of this post is a new option (at least to me), care of the Community Health Data Initiative, which I wrote about previously.

The statement in this article:

Yet efforts to measure quality have focused predominantly on the clinical aspects of care, rather than on systematically meas- uring and improving patients’ experiences with care. This lapse seems indicative of a broader failure to recognize that these experiential attri- butes can translate directly into improved clini- cal outcomes for patients, often at a lower cost.

Caught my eye because of a wierd fracturing of the data I noticed when I was running it for @ReginaHolliday .

Take a look for yourself (again, thanks to CDHI and

Here are national averages for clinical processes of care in hospitals:

Process of Care Measures – National Averages only

Here are national averages for patient experience with care in hospitals:

Survey of Patients’ Experiences – National – Top Box Scores only

Only top-box matters

Note, I only included the scores that are “top-box”, either 9 or 10 out of a 10 point scale or the answer “ALWAYS” to the experience question. Some people might say that this excludes the “sometimes” or “almost” answers, and I think the answer to this question is definitively answered by the Disney Corporations of the world (and read: If Disney Ran Your Hospital if you want the detail), who only look at the top-box score to judge their success. They think of % customers who rate them a 5 out of 5, and look for 90 % there, because that equals loyalty. Anything less is failure.

Clinical processes of care – 80’s to 90’s

Taking out the scores for fibrinolytic (which is complicated by factors like time/space/clinical condition) – these clinical things, which are “things you do to people” look like they are done most of the time. If these were scores on a medical school exam, they’d be A-, B+ not bad. Our hospitals deliver the medications that treat illness and prevent worsening of it. Note that there’s one patient experience-y measure in here – Home management plan of care for children with asthma – this isn’t a medicine you give to people, it’s a discussion that you have with people. The score there is 54 % on average. Let’s look at paitent experience now.

Patient experience of care 50’s – 70’s

So these are not “things you do to people,” these are things you do to empower people do something they mostly do on their own – heal. The highest score here is 80 % for “doctor always communicated well”. Look at the rest – pain control 68 %, would definitely recommend the hospital 68 %, always quiet at night 56 %. Let’s see,  getting scores like that on a medical school exam might rate in the C – F range.

How do we feel about the difference?

I’ll leave that as an open question for people to answer in the comments. And I’ll also say that I didn’t really connect these dots for myself until I read Christine Bechtel and Debra Ness’ (of The National Partnership for Women and Families) excellent paper (based on information from this campaign: @better_care )AND I saw the numerical data (combined with a strangely photographic memory, I’ll admit). So I’m connecting them for you here.

From my own experience i’ve observed a lot more of “let’s make sure the beta blocker is on board” in hospitals than I have “let’s make sure we always communicate well to our patients and their families.” In terms of igniting innovation, this is good, no, great news, because it means that there are a lot of good ideas that haven’t been tried yet. An no matter what anyone says, not everything has been tried before.

The even better news is that innovating here will do things for American health care beyond anything we’ve dreamed of clinically – it’s a big statement, and I believe it – here’s my presentation on this subject.