Addressing Mistreatment in Medical Training: Creating Safer Learning Environments

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello, welcome to today's episode of MedEd Thread, an education podcast exploring mistreatment of medical students in academic medicine. I'm your host, Dr. Tony Tizzano, director of Student Learner Health here at Cleveland Clinic in Cleveland, Ohio. Today I'm very pleased to have Dr. Stacey Algren, associate Dean of Student Learning Environment at the University of Missouri, Kansas City School of Medicine, and Associate Program Director of its OB/GYN Residency Program. Also, joining us is Dr. Tim Lacy, director of Student Learning Environment at the University of Illinois College of Medicine.

Stacey and Tim, welcome to the podcast. To get us started, if each of you could tell us a little bit about yourselves, your educational background, your roles at your respective institutions, and how you became connected with Cleveland Clinic's, MedEd Thread. Stacy, we can start with you.

Dr. Stacey Algren:

Yeah, hi. So I am an OB/GYN who has worked with our residency program for many, many years, and I was offered the opportunity with the School of Medicine to take over the associate dean of the learning environment, which handles all the mistreatment reports for the school of medicine. And so in this opportunity, I have gotten to do a lot of work in this field as along with Tim, and we presented in April at the 'double AMC' (AAMC) meeting on mistreatment orientation for faculty, and we were approached by someone from Cleveland Clinic who thought this would make a great podcast to discuss. And so here we are today.

Dr. Tony Tizzano:

Yeah, I think that was Laura Greenwald. I think she was very impressed with your, with your presentation. And Tim?

Dr. Tim Lacy:

Boy, where do you start? Right. I've been at University of Illinois College of Medicine since September of 2018, so I just passed my seven year mark and the entire time here I have been in the Student Learning Environment Office. Sadly, it's a one person office. I'm the director and manager of one person and myself here. And my job in the College of Medicine is to think about incident reports and cases that may evolve from them, but also to sort of, I'm gonna use this term loosely, rove, be a presence in several different kinds of committees to sort of represent the interest of mistreatment in different areas.

So for instance, I came this morning from a clerkship director meeting and I was talking about being a pre grievance consultant for students. They come to me if they're thinking about an academic grievance, and those sometimes involve mistreatment and sometimes they don't. But I was the designated learning environment person to handle that.

But yeah, otherwise, I'm not a medical professional. I have a PhD and a master's in history. And the thing that helped me get involved in the Student Affairs and learning environment work is while I was doing my PhD work, I simultaneously had a graduate assistantship in a student affairs office at Loyola Chicago. So I've been sort of doing student affairs kind of work for the last 20 plus years.

Dr. Tony Tizzano:

It's great to have all perspectives. And I think that honestly the, the more diverse, the better. And wherever you have hierarchy, whether it be in medical education or within a university setting, I think there's opportunity for issues such as we're going to discuss. And perhaps for our listeners, many don't think about medical student mistreatment, but this is a, particularly, in my opinion, vulnerable group because they're just entering the clinical space. They're very keen on impressing and doing the right thing at the right time. They realize that all eyes are on them, they're going to be evaluated, they're looking for that all important letter of recommendation. And so to bring something forward is not easy. And I think at the end of the day, there's a disturbing number of students who report being mistreated at some point during their medical school, including public humiliation, perhaps some sexist comments from faculty as well as patients.

So in today's segment, we're going to explore how academic medicine centers are working to address these untoward and unacceptable behaviors to foster a more positive and, and perhaps psychologically safe environment. So with that, Tim, if you could kind of frame this topic for us and provide our listeners with some context around the prevalence of training mistreatment and its impact on students and their institutions.

Dr. Tim Lacy:

Yeah, thank you. The nationally available double AMC graduate questionnaire numbers are as good a place to start as any on this topic. And we have consistently seen in the time that I've been doing this work, so that this is just a seven year timeframe, but I know it goes much further than that, back. Over this timeframe, we've been seeing numbers that range in the high thirties to 40% nationally for schools' students, they're departing fourth year students headed into residencies, most likely. They are reporting negative behaviors encountered and experienced at about a 40% clip. And that includes the range of things that you mentioned before. And in addition, you could talk about requests for personal services, you could roll in there sexual misconduct, which then that obligates many of us to be mandated reporters in our Title IX offices, discrimination based on gender, sexuality, or ethnicity.

And then there are questions that have been recently added, for which I'm really grateful, about disability and negative behaviors encountered with regard to disability. And then the final category, the catchall question is about religion and other factors that may have impacted their experiences across the four years. So I think that's the larger context that all of us who deal with learning environment issues are trying to grapple with. Then there's a multiplier there of complexity in relation to your institution and your particular affiliates and the history of your institution with regard to its own numbers, right. Which may be higher, may be lower. So those are some of the variables that we're dealing with in the profession.

Dr. Tony Tizzano:

And so you mentioned the double A MC, so this is the Association of American Medical Colleges. [Correct.] So they're kind of a body that looks over all of this sort of, uh, information. You know, when you look at the impact on the student, you know, what do you see this manifest as?

Dr. Stacey Algren:

So over the history of medicine, I think in the past we kind of just thought it was a rite of passage. And looking back, I think a lot of us who've gone through medical training have had experiences where in retrospect you're like, that wasn't okay, but we accepted it. Or comments that were made to us. And I personally kind of just took it with a grain of salt, like, oh, that's how it is. It's the old school way, you know, you gotta suck it up. And thankfully we've come to a place to acknowledge when people are not being treated well, that it's not okay. And we have a lot of data to support that people that are mistreated, either students, residents, whomever don't perform as well, they don't reach their full potential. They don't learn if the, if the learning environment is not psychologically safe, people do not perform. And this leads to things like burnout, changing specialties, anxiety, depression, or leaving the profession altogether.

Dr. Tim Lacy:

And, and then let's add on another one, I'll, I'll just interject this here, of those who are mistreated, becoming mistreaters later. So they stick around and then they feel like, well, I went through this. I deserve to have the opportunity to haze others.

Dr. Tony Tizzano:

That well-understood cycle of abuse and that we somehow as humans managed to carry over. Thank you. I think that really helps us understand that this is not only important for the student, but it actually is impacting patient care. If we're talking about anxiety, depression, burnout, those things at the end of the day aren't just problematic for that individual, but they're also problematic for the population that they're treating.

So Stacy, what sparked and drives your interest around trainee mistreatment?

Dr. Stacey Algren:

Well, I think it's an area that we don't quite understand very well. And I think an area that we can actually improve and make changes. But it's been hard to steer the ship, like Tim was saying, we have had kind of across the board nationally, kind of a very steady rate of mistreatment despite a lot of different interventions or preventions. And so one of the things of my interest is how can we change this? How can we change the culture? How can we right the ship, how can we get that number lower? What are the things that other places are doing? How can we mimic it and how can we provide a better environment for students to learn where they don't have to refer back to the old school way of being beaten down to go forward?

Dr. Tony Tizzano:

So it's an area where perhaps sharing our best practices around combating this are important.

Dr. Stacey Algren:

But I don't think anybody's an expert in it.

Dr. Tony Tizzano:

No, that is for certain.

Dr. Stacey Algren:

Which is sad. And if they are, then they're not maybe sharing everything with everyone else.

Dr. Tony Tizzano:

Yeah, I can see that from both sides. It's a difficult area to become good at, you know, even in seeing patients going into these areas where someone may have had a history of abuse and how do you bring that forward is not always an easy thing. We're not really trained around some of these softer skills, you know, they, they come over time with wisdom.

So Tim, why would faculty who are hired to train future physicians, why would they mistreat those whom they are supposed to support?

Dr. Tim Lacy:

In my opinion, based on my observations in time of this office, the mistreatment is normally unintentional. Normally there's something has gone wrong in communications, maybe a joke has gone wrong, maybe there's a misperception on the end of the student. There might also be a lack of awareness of just the impact of certain kinds of statements or observations that physicians make in passing. There is specialty culture, which creates certain allowances and communication that new students don't always understand, right? Some dark humor or gallows humor that might occur in a certain area that students don't get.

Then there is what we touched on before, the sad cycle of abuse that occurs. If you were mistreated, you're very likely to be a mistreater later. And so how do we intervene in that complex set of circumstances? But yeah, generally I don't find faculty to be malevolent or intentional mistreaters. I want to give the benefit of the doubt for the most part. There are occasionally some who are just not nice people fundamentally and just do not have an understanding of med students and the circle of humanity. They're, they're sort of othered the annoyances that are tack ons to their primary jobs of research and treating patients.

Dr. Tony Tizzano:

Yeah, it speaks to the idea that what the world needs is more kindness and sometimes people are simply unkind.

Dr. Stacey Algren:

I think also just to add to this is that residents and and faculty physicians have stressful jobs. And I think some people handle it better than others. And I think unhappy people and stressed people sometimes lash out to those who may be around them and who tends to be around them is residents and students. And so I think it's a whole, the whole culture issue.

Dr. Tim Lacy:

A hundred percent. I could add on one more thing, and I think it's the business structure of the profession demands a certain kind of efficiency that is not humanly achievable at all points. And that's a source of that anxiety. I'm a systems guy, I like to think about systemic issues. And I do think that the business structure, even in academic medicine is intense.

Dr. Tony Tizzano:

Yeah. That is for certain. And you know, there is certainly also on top of all that hierarchy, and if anything I have learned over the years, uh, that has added if there's any amount of wisdom I've gained is if we can flatten hierarchy, we can do much better. You know, it could be throwing an instrument, any of these things that sets a stage for uh oh. Someone is, is angry and you're not going to bring something up because of that. And that can also ultimately impact patient care as well. And I remember having been a first generation medical student and college student, I really had no idea what I was getting into. And the first physician I got to meet in medical school, just shadowing in the very first week, came into the office, mispronounced my name, and then said, so Tizzano, first year and dumb as hell.

Well, I was five years older than the average medical student. I thought he was joking with me and I said, oh doctor, they may have let them in medical school back in your day that way they don't do that anymore. And I could have fried an egg on that man's head. And for the remainder of that series of exposures I had with him, I was always getting needled in questions. And was it to make me stronger? Was it to make you tougher? If we flip then from looking at the professor, the attending physician, and we look at the patient, what is to be done when the offender is a patient? And I've always heard the example, you know, during rounds, a resident and the attending students ask the patient, oh Mr. Smith, is it all right, if I examine you. And he replies, I would just love to be examined by a delightful young woman like you. What do you do with that?

Dr. Stacey Algren:

I think if a case like that, the attending has to step up and kick the students out or kick the residents out and just handle it. And we've had cases where in our clinic students have been kissed and, and other inappropriate actions. And it has gone as far as the, some patients have been dismissed from the hospital system, depending on the situation, they can go anywhere from, you can't do that in discussion, or to dismissal.

Dr. Tony Tizzano:

Yeah. And there are so many layers to approaching that and doing so appropriately because you know, the patient is, we work for them, they don't work for us and we need to satisfy their needs At the same time, they can be nervous, they can, they we can, trying to diffuse the situation. There's a lot of context, but I think that, you know, for the attending physician to step forward and say something in the moment with the students there is important for the patient and for the students to see. Because if it's swept under, like you have to exit stage left and I'm gonna take care of this, that right away says to them, oh, this is something that we can't be above board. So I think it's a cultural shift that is difficult, but I think it's important for us to try to move in that direction when we can. And we've all heard stories like this, what does the desired state look like and, and how do we optimize this within a student's educational experience?

Dr. Tim Lacy:

I'm not a practicing physician, so please take all of this with a grain of salt. I see sort of two angles on the patient issue. One is I try to make sure that I and the clerkship directors are informing students of how to report patient misbehavior in their particular clinical site. Who do they need to go to? Is it just the team attending and the residents, or is there a system that they need to report misbehavior to?

On the other hand, I have seen some mistreatment cases that have crossed my desk that have involved patients. And one of them was very close to what Stacy was talking about. There was a patient who was making comments about a young female medical student. It was a surgical consult and the patient was making suggestive comments about coming and sitting on their lap or something. And the thing that bothered the med student the most was that the attending didn't speak up for her, did not intervene on her behalf. And that could go a number of ways.

And I can actually understand a little paralysis, like if you're shocked by a comment, but then you have to recover and then you might make a comment to the med student later. You might even just say, I'm sorry about that. I should have, you know, spoken up on your behalf. But in this case, nothing ever happened. Right. So the student was at my doorstep with a mistreatment report because of that.

Dr. Tony Tizzano:

Yes, absolutely. That all important debriefing when something like this occurs in the appropriate setting. But I'm glad I, I have to give the student a lot of credit for coming to you and, and bringing it to someone's attention.

Dr. Stacey Algren:

Was gonna say also unfortunately, some of the situations with patients are not as simple. Not that these are as simple, but violence is a new threat also. And sense of harm or threats of harm. We see it a lot with patients with mental illness and it's hard to figure out where the line is crossed in having psychological safety also in a patient room when someone's threatening if you don't do something that they're going to kill you or things like that.

Dr. Tony Tizzano:

Yeah. Boy, that's a whole nother level. I, I must say as a former medical director, there were a number of instances where we literally had to bring to the police because of threatening behavior and someone going toe to toe or a spouse, partner, going toe to toe with a physician over some reason. These are things that I think every industry grapples with, but in medicine it's, it's really made more difficult because of that patient caregiver relationship.

So it's clear that more conversations occurring around the topic of mistreatment and perhaps for institution like yours and ours, it's top of mind or at least front of mind. What are the necessary steps to further our goals to counter these behaviors?

Dr. Stacey Algren:

One of the first things that we can do is education; that it's not okay. And then one of the things that we really try to promote is to report things because if we don't know they happen, we can't act upon them and then it gets normalized. And so speaking up when something happens and allowing others to look into it in management, I think helps the overall environment. And then it also hopefully intervenes into maybe some of the bad actors who are doing things that they think are normal, which are not, you know, there's a lot of talk about prevention and how do you go about doing, and that's a whole other topic because obviously the things that we have done has not necessarily moved the bar. But I think in getting people to talk about it, recognize it, and being not fearful to come up upfront and say something has happened to them and ensuring students, residents that there's no retaliation. I think that's where the bucket should be focused.

Dr. Tony Tizzano:

Yeah, we say it, do they believe it? And I, I wonder, you know, there's a tendency even in orientation, if we were to bring up to the entering class that this is the expectation, but the piece that's missing is the attending physicians aren't there. If this was a, a talk that was given to everyone collectively, they all got the information at the same time, the student would say, ah, my attending physician is hearing this and the attending physician is saying the student is hearing this at the same time. I wonder if that might impact things differently. Thoughts?

Dr. Tim Lacy:

Yeah, it should. This is still a trainee/trainer culture and exemplars and mentors and their examples matter a great deal in fighting a problem or instituting a new initiative. Like you have to have the mentor attending buy-in and then it has to come also from your deans, your leadership, your clerkship directors. This mistreatment cannot be tackled by one office at an institution. It has to be a total institutional effort. At best you can have someone who is like an orchestra director, but otherwise you need total buy-in.

Training of incoming faculty I think is extremely important and not always thoroughly accomplished by any institution. And then trainings, there are whole issues that attendings have with, you know, yet another module that I have to do about, you know, fill in the blank topic and the time consumption and energy consumption associated with that. So there's kind of a producer consumer end of this, encouraging our students to be allies and to stand up for each other teaching how to intervene or to deal with a problem in the moment before it gets bigger.

That's hard. It's hard to do. It requires bravery and students are career focused, as you said in the beginning. They are hyper aware of how negativity impacts perceptions of them even when they're not at fault. Just having any kind of negative aura around them to cause some kind of misperception about them. This requires a a total institutional and professional effort to mitigate mistreatment

Dr. Tony Tizzano:

And it's gonna occur over time. And I have the luxury of of participating in an art and practice of medicine course, which is a lot of soft skills. And we talk about microaggressions, mistreatment, and, and we break out into smaller groups of only eight and, and it's under the cone of silence to where whatever they say in that room goes no further, which is takes time. And you have to share, you have to share vulnerability with them so they understand that yes, they can talk about these things and over and over they will say, look, I'm not gonna speak up. I have to tolerate this for two, three, maybe four weeks during a clerkship. I can tolerate anything. What I need is a good letter and I'm not going to take the chance of tarnishing that because this period of time in medical school is a stepping stone to getting a residency and getting a license to where I can actually work. It is a tough call for them.

Stacy, you mentioned earlier in a conversation we had getting prepared for this that you have a committee i, I believe it was an expect Respect committee. Tell us about that, what you've put together.

Dr. Stacey Algren:

So our Expect Respect committee meets once a month and it's made up of major stakeholders within the school of medicine. So we have representative from curriculum, we have representatives from student affairs, inclusive excellence, quality improvement, we have HR, we have a whole list of people including our learning environment, who come together to review all of our mistreatment reports for the school of medicine. 

They're presented in a de-identified way to protect both the reporter and the reportee. And we also are, equity and Title IX is present also at these meetings. And so we review each of these cases, go through it and the actions that are happening behind all the cases. And then we kind of follow the trends and we have had to institute changes and or programming around some themes that we have seen regarding mistreatment that has occurred. Or maybe not mistreatment, but perceptions of, let me, and I can give you an example.

So recently we have had a lot of mistreatment reports filed, uh, from students saying that they're being mistreated because they're being interrupted on presentations, are not allowed to give their full presentation or not feeling like they have had equal time as other students have had in that realm. And we feel this is probably coming out of a sense of stress with a step one going pass fail and everybody wants these letters and wants to shine on the rotations. And while none of these have been felt to be mistreatment in the sense they're obviously making students anxious and not feel well. And so we have had taken this back to curriculum and we're trying to communicate with the departments that are seeing this. And as a clinician I can see exactly how this happens. Like you're doing three hour rounds and this student has the patient that's in a last hour and you still have a lot of patients to get through.

The attending may shorten their presentation or look to the resident or shorten their amount of time face to face with an attending. Or in clinic if you're backed up, they may not want to hear every single detail of a history that the student so delicately took and stuff. And so we've had to relay these back to this, this is what we're being told, you know, perhaps the attending can say, okay, you have this amount of time to present and if we get to this time in the day, I may cut people short. It is not against you, it's just a time factor or laying some kind of groundwork. And we've had several of these and, and I was like, this is not mistreatment, but how do we combat this because this is what they're feeling.

Dr. Tony Tizzano:

It's all important communication and feedback and how to accept it and how to give it. So yes, you were about to say something Tim?

Dr. Tim Lacy:

Just to affirm what Dr. Algren was saying, uh, just this morning and this very same clerkship directors meeting I was talking about and that prevented me from getting here earlier. We were talking about mid clerkship feedback and the pressure now that clerkship directors and maybe site directors are feeling to make sure to set proper expectations around mid clerkship feedback, right. By saying that, you know, this is not meant to indicate right now at this point with very little data that you are at an honors status right in your clerkship. So trying to manage expectations around that related very much to the anxiety that Stacy was mentioning about students being hyper-focused on clerkship performance as an indicator of their strength of residency application and hoping for those letters and the honors out of that.

So yeah, that results in reports of mistreatment to me because students are coming later and saying, well, they said I was doing fine at mid clerkship and then at the end I get this detailed feedback about how I'm like, I'm just sufficient. Right? [Right.] I'm just proficient. Right? And so what happened, right? How did I go from being fine and good to just being proficient? And they read the mid clerkship feedback as I'm doing really well, right? When really they were just sort of following the double AMC standard of like, you need to know if you're failing. Right. [Right.] Or not failing at that. So that creates opportunities for messaging and misperceptions and feeling like you were maybe mistreated in the evaluation process.

Dr. Tony Tizzano:

Yeah, and I think that just because we've trained in medicine and it's intense, it doesn't necessarily always give us great communication skills because we have this hierarchy piece of it. So there's a lot to bring together. I'm really impressed with some of the things you had. And you mentioned something called badge buddies as well. What's that about? And have you seen these efforts move things a little bit?

Dr. Stacey Algren:

Yeah, so we were trying to find, you know, communication with students is always interesting and what they want and what we like is not the same emails they don't read. They need something quicker and faster. And so we created these little badge buddies that go right on your ID and on it we used a QR code that goes to a link tree that has all the mistreatment stuff right at their hand. Because what we've found is that students are saying like, I don't know, how do we prevent it? I don't know this, I don't know what you're doing on your double AMC questionnaire. Because unless they have needed the information, most students don't utilize it, they don't need it, which is great.

Dr. Tony Tizzano:

Yeah.

Dr. Stacey Algren:

But this is right at their hands.

Dr. Tim Lacy:

We just created one this summer at our college. We did not have one. And I engaged in a research project to figure out like all the different varieties of badge buddies and we also created one and it's to help with those perceptions about prevention.

Dr. Tony Tizzano:

So this badge buddy has a QR code that you can go to to see this information. That is an absolutely outstanding idea because so often we don't know what the resources are. I work remotely. I'm not always at the Main Campus. There are so many resources, I have no idea. I don't even know how to find them. But this is the place. I think that isn't just superb idea.

Dr. Stacey Algren:

We do also have posters all around our school of medicine that also have the same information. It just seems that like they just don't see it anymore. We're trying to have multiple touchpoints and not only can they go here and find a how to submit a mistreatment report, they can find information on what's considered mistreatment and what's not. They can find support, they can find how we evaluate reports so they know exactly if they submit a report, how it's managed. So we try to make a a simple one step. And this actually came out of working with students. I think that's the thing, like we have, I have a core group of students that I work with on mistreatment who are passionate about it also, and they are helping us bridge the gap in communication and things regarding it. Because what I think will work and what my colleagues may think works and what we've done in the past obviously hasn't worked. And so we have to figure out the difference between the students and us and how to fill in that void of communication,

Dr. Tony Tizzano:

That all important gap. So for both of you, what do you see on the horizon? What are the next steps? If you had a magic wand and could make this or that happen, what would that look like?

Dr. Tim Lacy:

I think some of our faculty needs some intense professional development about two things. One of them is LGBTQ issues, language culture connection, right? Connecting to those student populations. And then also more education about students with disabilities and how to work with them well, not just in a barely minimal technical way, but how to help them flourish. Both of those populations in medical school, I think those are two things that are happening now and that some of our senior experienced faculty members are still troubled by the need for change that is there.

Dr. Tony Tizzano:

Yep. That is such an important thing. Stacy, thoughts from your perspective?

Dr. Stacey Algren:

I think that I, I like what Tim was saying, like faculty engagement and faculty understanding about the impact it has on students and how it affects their performance. I still think that encouraging reporting is one of the key things because if what we don't know, we don't know, and if we can get people to speak up, then we can address issues and engage departments. And I think that is where the change is gonna come in the culture.

You know, there's always gonna be a bad apple here and there. I don't think we're gonna a hundred percent eliminate people from saying things that are not appropriate. I think that's human nature and I think that you would see that across the board even outside of medicine. But I think bringing an awareness to it is appropriate. I also think that there is a little bit of frank mistreatment and then there's that stuff that's a lot in the gray zone that we get.

Dr. Tony Tizzano:

Yeah.

Dr. Stacey Algren:

And I think that there can be conversations around that because the things I was talking about earlier with students, it's all about perception and they feel like they're being publicly embarrassed by having their presentation cut off early. And for some of us from a different generation, we're like, that's not public embarrassment. Let me tell you what public embarrassment... [Yes, yes.] you know, so there's a perception also of, of things. And I think that that may also be fueling some of the numbers that we see. And not to say that's right or wrong, but that gray area has to be probably attacked also.

Dr. Tony Tizzano:

Yeah, absolutely. Creating awareness on both sides always becomes the key. It's not easily achieved. And even for the instructor, some would say, I feel like I'm walking on eggshells. I have to be careful what I say. It is a matter of education time. I, I'm so impressed with the work you're doing. Are there any thoughts or questions that I didn't pursue that you feel are important for our listeners to know?

Dr. Tim Lacy:

There is resistance still among some of our administrators and some of our people in the profession about promoting reporting. Right? Like that you are creating a bias about problems existing that don't exist. And I just don't agree with that. And I hear it from other learning environment professionals that that perception is still out there. So yeah, under reporting is something that needs to be solved.

Dr. Tony Tizzano:

Well, thank you both so much, Stacy and Tim. This has been a fascinating and wonderfully insightful podcast To our listeners, if you would like to suggest a medical education topic to us or comment on an episode, please email us at education@ccf.org. Thank you very much for joining us. We look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.