Takeaways: From clinic-to-home innovations; higher bar for in-office visits; unbundling of careRead more...
American Psychiatry Association's head of Innovation Dr. Nina Vasan speaks with Bambi Roizen
Bambi Francisco Roizen, Vator Founder, and CEO, speaks with Nina Vasan, Chair of the Committee on Innovation at the American Psychiatric Association and Executive Director of Brainstorm: The Stanford Lab for Mental Health Innovation
BF: I'm Bambi Francisco Roizen, COVID-19 has upgraded our lives and we may possibly change our behaviors when we come out of this shelter in place and find ourselves in the new normal. No doubt as a society, our mental states have been tested. Joining me to talk about our mental health is Dr. Nina Vasan. She's an American psychiatrist and author of the Amazon number one best selling book “Do good well, your guide to leadership action in innovation”, she's also a clinical assistant professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. And she founded the American Psychiatric Association psychiatry Innovation Lab, which has incubated 60 plus mental health startups and if that weren't enough, she also is the founder of brainstorm labs at Stanford. Is that correct? Nina?
BF: Forgot to add that in. But I got it in there. But let's talk about the APA. Because that's how you and I met through the APA Innovation Lab competition. They have nearly 39,000 members, it's the largest psychiatry Association in the country. So you could speak on their behalf. In terms of the biggest concerns, you're hearing from the nearly 40,000 members and their patients. Can you give us a sense of what the discussions are within the APA in terms of the big stress points that are hitting the country?
NV: Yeah, absolutely. And so, as you said, you know, the APA, I think it's actually the largest psychiatric organization in the world, and also the oldest, the oldest Medical Association, the country, interestingly enough. And you know, I think that when I think about the biggest concerns that folks are talking about everything from, you know, the psychiatrists in small towns all the way through those who are in the middle of New York and everywhere in between. There are two big buckets of concerns that people have. First is around our actual I'll even rewind, I'm gonna say three big buckets. First is around our patients themselves and looking to see from the epidemiological perspective, what has happened and what is going to happen. So thinking through what we need to do as individuals as an association and as a society to prepare for what's ahead. And I'll say more about that in a little bit in a minute. The second is to be able to think through the changes that are going on in the healthcare system in response to COVID-19. And how we, how we really take care of that. And then the third is, I would say, probably the newest element that people are talking about that has not really been a part of discussion before, which is what we're taught hearing so much about what do we do as healthcare workers? And what are the issues and concerns for healthcare workers themselves, right? So there are these kinds of three buckets with our patients, US ourselves as clinicians and providers, and then broadly kind of like what that means for society.
I'll break it down a little bit to kind of talk through some of the specific concerns. So first, in the sense of, I think that there is an enormous amount of worry just recognizing that this is a mental health pandemic, and a mental health crisis that we are actually just starting right now. We've been focusing on the infectious disease pandemic side of it, and what we know as a result of both the infectious disease as well as the sheltering in place, that has been the kind of societal and environmental response that we're all finding ourselves in, as well as the incredibly devastating financial crisis that has started to happen and will continue to happen with you know, these huge increase unemployment and everything, that what that means and the mental health sequela of all of these is really, you know, beyond anything we've ever experienced before. What we know in terms of looking at past data, everything from data from China and Italy over just the past few months, as well as when we look historically at things like 2008 financial crisis, Great Depression, 911 these kind of big disasters or or collective traumas that we faced as a society as a country or even in small groups that we are expecting, we already have seen and only continue to expect a few really big things to happen pathologically. One is an increase in depression and suicidality.
Two is an increase in trauma. And that means when we think about trauma, there's really a whole spectrum where the severe part of that is post traumatic stress disorder. And then there are a lot of folks who might not be in that quote, so area, but we'll still have a lot of trauma symptoms that need to get treated. And then finally, a really big increase in substance use, you know, everything from marijuana, alcohol, opiates, kind of the whole gamut. And then we actually have this fourth area of recognizing that there's this big social context in terms of decreasing decreased access to care, and recognizing that when all these three things are going on, we need to be able to increase access to care, increase, ease, increase, you know, the way that people are talking and thinking about medication and treatment. And so what happens when we're all ready, you know, at a time and place where we're at home, not able to live our regular lives, how do we help people get the care and treatment they need? So So I mentioned the I you know, I was talking about these different statistics around what we expect to see we expect to see all these issues, suicide, depression, substance, trauma really, really go up. And I think what's important to recognize is it's not
Not just going to go up, it's already gone up right in the last month or two. And it's not even just that it's going to go up in the next couple of months, when we look historically, like, for example, at the Great Depression, after the Great Depression, the peak of suicide was actually two to three years after all those kind of events happened, you know it Black Friday, Black Tuesday, flex look like Friday. You know, like, after all that happened, it was actually a little bit later than what you might expect. And so what that means for us as psychiatrists is that we really have a big challenge ahead of us that's going to last now for a few years. And so we need to be able to respond proactively knowing that these things are very likely to happen. One, what can we do to prevent them from happening or getting worse, but then knowing that we can really expect this stuff? How can we put everything in place from policies to federal policies to funding to education, stigma, and create an environment that allows people to get the treatment that they need?
BF: That's quite a bit and we can go all different directions therefrom Why does this happen? Why is there a lag? But one of the things you mentioned was prevention. We are in the 21st century. We are anticipating this, we have zoom, we have telehealth. We have a very connected, albeit a socially distant society, but we are connected, and we can even monitor people. So how are we doing to be able to prevent, say 23 seeing a peak in suicide rates, we have the tools so how are we doing things differently to add more prevention?
NV: Yeah. Well, I think first what I like to talk about is that the changes that have happened now in the last couple of months that I think are setting us up for success in this way. One is exactly as you said, there's been a huge shift now to tell us health and, you know, certainly, a lot of that is because we were forced into it right because of shelter in place now really is the only way to deliver care. And I think what's interesting actually is that, you know, in mental health, there's this whole spectrum from inpatient care and even inpatient locked units, through partial hospitalization programs, outpatient programs, rehab programs. And then on the other end of the spectrum, outpatient, and even you know, online groups aa meetings like that, and everyone in that entire spectrum over the last two months now has been pushed to go into the, you know, use zoom and use all these video teleconferencing types of platforms to be able to deliver care. And I said, like I said, No, for example, I do outpatient care at Stanford, and I have a private practice. I'm doing it in the private practice, but even on the inpatient units, they're using video to do things like group exercises and art therapy and things like that because they want to minimize risk of transmission on those inpatient units. So the
The video side of things, I think, is it. What's good is that it's been around for a while. And I think there's certainly been criticism of the healthcare field of being slow to adopt it. I think what's also really nice is recognizing that now that we kind of were forced to do it, the adoption has actually been very, very fast and people aren't using it very well. There are two interesting elements there. One is there are two huge policy changes that happened last month that I would actually say or groundbreaking in the history of medicine period. And I think that this is a, you know, silver lining of COVID. And what we've had to do in response to it, one is that Medicare is now paying for telehealth visits where they weren't before. And so, you know, I mentioned there's sort of criticism of, oh, why is medicine been so slow to adopt telehealth.
BF: Is that for telehealth mental or telehealth in general?
NV: Actually, in general, and it was happening that the policy was to change Medicare reimbursement period across the board for all issues and so that that helped make if Medicare is paying for it that not only makes the whole that whole segment open, but that insurance really follows whatever Medicare is going to say they'll do. Right?
BF: Is that temporary or permanent?
NV: So right now, it's temporary. But that's actually something that we are, you know, I think the associate clinicians and everyone really myself want to see continue because it really needs to stay that way. And I hope that this was just a push, but that now, with the financial incentive in place, providers will respond if the financial incentive was there, right. But if you're not getting paid to do tele visits, then, of course, you're not going to do tele visits. But if it gets paid, and if it gets paid at the same rate as an in-person visit, then it really increases access to folks who wouldn't be able to come in or are sick and other ways and getting to the doctor's office is difficult. So what that was one big policy change, I think, was great. And that will set us up for success moving forward in order to you know, when we think of it that we've talked about suicide in order to prevent things like suicide from happening increasing access is the easiest first thing that we can do. And so something like that is huge. The second thing, policy change that happened that also relates to access is eliminating state boundaries. So for example, you know, I'm here, I'm licensed in California in New York. And so I can only see people who are in California in New York. And so when we look, there's an incredible discrepancy between the population of providers with the overall population. I'm from a small town in West Virginia, that's where I grew up. And like, you can just like the complete opposite of being here in the Bay Area, right. And so we need to be able to really think about our resources as a country and be able to share resources broadly like, you know, American, or Native American reservations or rural areas or places like that, where they need the care. So that's the second thing that has been changed for the time that this is a public health crisis. That's the one that I don't know if it will get changed back. I think Medicare will likely continue. I worry that the state medical associations will push for that to return to how it was but I hope that some people can really work together to either to have some level.
BF: A dissolution maybe or compromise or makeup that I think it's $350 billion in licensing revenue that they will pay that fee. So I believe it's I mean, it's nice to have that quality control, but I think the conversation has to be around work. We make up that, you know, where to what, what other things can they do to be useful? Right. So I think it's sort of not asked like, should it be, but it should be where should you know not? Should it be and should we have these states ensure we maintain the 350 billion dollars, but how do we redeploy those people to make them useful?
NV: Perfect, perfect phrasing. Yeah, how to redeploy and that's how we increase access across the board.
BF: Right. So then going back to so those are some of the preventative things that we have the telehealth which is a big piece of it, which is going to in maybe some of these devices,
That are really monitoring people 24 seven, where you can actually have alerts to psychiatrists, and they can have input or they can be. So we do have a lot of preventative measures in place. But I want to go back to what you said about this lag period. And there was an article, we talked about it last week and the podcast for the future of mental behavioral health. We talked about this silent pandemic approaching, which is a mental health pandemic, and you talked about the lag, it's coming. It's imminent. And in the case of I guess, was it the depression it was two to three years they hit the suicidal peak. So why is there that lag when we are adjusting? I understand it's, it's tough to adjust, things aren't going to be the same. But why is it the case that it takes six months and if we're, if we if society knows that it's going to six months, it's gonna you're gonna
To hit a breaking point or a year, you're going to hit a breaking point, maybe it's good for us to understand. What is it that you have seen in other crises? Six months after it sort of calms down? And what are those signs? Why can't we help ourselves from getting into those mental health anxious points?
NV; Yeah. So I just want to clarify so you know, why, even after the kind of worst of the crisis is over, why is there then a delayed peak? And what we see on the mental health side of things?
NV: Yeah. So, one, one, you know, I think folks are trying to study this and come up with an answer. I don't know that we have a clear answer for why that is. Right. Now, there's certainly a number of hypotheses and kind of, Oh, you know, this, this sort of makes sense. And I think that part of it is, you know, unlike a physical disease or even like an infectious disease, where it happens and it's, it's their mental health diseases do evolve over time, and get better and worse as their different triggers. And when we think about mental health, we think of this combination of biological, psychological, and social environmental elements that lead to the disease getting to where it is as well as kind of worsening and getting better and worse. And so I think that when there is this initial insult, like what's just happening right now or like the Great Depression, that is a huge blow certainly that affects everything from you know, substance use depression, but a lot of times the ramifications that actually happened later on down the line, right. So if you imagine losing your job, for example, you know, there certainly are a subset of people who lose their job and they would then feel suicidal and might act on it in that moment or in the few days or weeks after it. But then if we think if we take a step back and realize, okay, you've lost your job, maybe you know, there is you are resilient and you have family around that. Try to help or you're able to get on to your get on unemployment for a little bit. And then you try, you fight and you know, you try to get better. But then six months later, the unemployment has run up, or you've now been spending six months applying for jobs and you're not getting anything. And so I think, you know, is like related to both probably substance use depression and suicide, the hopelessness or the difficulties that people face, it's sort of like you have this one big injury, but then more and more things come as time progresses right and, and, and personal relationships start to break down. And initially there is a big sense especially when we go through a disaster like this of people really coming together to try to help each other. Right and we're seeing that now it's been. It's actually been heartwarming to see the wonderful things that are coming out and how people are doing anything, they can't help each other. That also happened a month ago right now, I think even a month later, people are the strain that we are all feeling strain that
To go for some folks were able to, to turn that into love and giving and gratitude that now is starting to become more strained. And you can imagine six months from now or a year from now, when stuff starts to return to normal in some ways, that initial like, peak of giving and helping others goes away. And so then those extra like sensitive support that folks might have, they no longer get. And now it's like you're all alone. Right? And I think when you look at things like when someone dies, for example, and that like a lot of friends and family are helping them in those first days and weeks after a passing of a loved one, and then they people talk about how when it comes to grief and stuff that the real loneliness happens three months later, or six months later, when all no one's bringing meals over or no one's calling, you know. And so I think this is very similar to that. And when we look at suicide, substance, depression, all of those are reactions to these other things happening, right, you're lonely, you don't have a job and so use increasing substance use feels like. The only answer, right you're self medicating for what's going on or you're feeling a sense of hopelessness get that much worse. So I think that's why there is this lag because there Melton mountain mental health is so multifaceted, where it's not just the disease or that one insult. There's biological elements, the, you know, the job, the relationships, your relationship with yourself, your housing, all of those, and how that factors in.
BF: And it's kind of hard to ask the community, your community to be there and be accessible. At some point. It's, that's not entirely the answer to make everyone make all of you accessible six months from now. And I think one of the, I guess, if we're preparing for that, you almost have to ask yourself is the type of treatment we're providing going to be useful or the types of is it? Is it CBT is it great gratitude is it you know, is there I know Headspace has this new protocol called weathering the storm. So it's not for later, it's from now. But it almost seems that there is a new type of package or service that you could be thinking about, where it's sort of six months after the storm, you know, what are the things? What should we be doing as, as a community, your community, and what should we be offering? or What should we be, you know, teaching, and it almost seems like we've already seen this happen before. So we should have a playbook over the next year or 18 months to figure out how to help people be on their own. And a lot of it is really just teaching them how to fish, right, teaching them how to be on their own. And are there conversations around that in terms of not just being there, but sort of preparing them for six months to 18 months from now?
NV: Yeah, I think that now what I'm hearing is still a little bit more in that we're responding to the crisis and trying to put all the resources into that. I think that probably even just in the last few days or weeks, exactly this discussion that you're talking about has started to come about. And I imagine that in the coming weeks, that's what's really going to grow once that kind of sense of Okay, you know, the curve is flattening. We're out of that concerning range. Now, let's think about how we prepare ourselves. And so, so it is starting to happen. And, you know, on one level, I really love that you bring up like, you know, we have treatments that work. And I think that a lot of people in terms of when we look at the general public, don't yet don't still see that there's a lot there's still an enormous amount of stigma and misunderstanding, like miss misinformation out there. Fake News, if you will, you know, in terms of mental health. And so, the, what I think we need moving forward is actually the same stuff that we've needed historically, but it's like now there's this extra push to do it. And the first is education, or stigma. I mean, I think that mixed up sort of like stigma to education of saying, Look you know, you not only need to get help, you can get help, there are treatments that will make people better. And that actually makes me want to bring up something. One of the things that I think has been the, again, probably the I wouldn't about the policy stuff, the other silver lining of this entire experience, I have never heard the word anxiety mentioned as frequently as as high. But by so many high profile people and publications, as I have in the past month, like the New York Times, every single day, I go to New York Times calm and there is some article addressing anxiety right from May 15 onwards or March 15 onwards. That never happened before and the fact that that word is out there and being used and that anyone is willing to now say I am anxious. I think that's really really huge for the entire field of life of decreasing stigma and saying and acknowledging I am struggling, I want help. I need help. How do I get that help?
Look at mental health, I think that those first three things have, I am struggling, I need help I want help, those were not actually a big part of the discussion, right. And so I do think that has already started to change. And I hope that that only continues to change. I think it's on our part as psychiatrists as well as the broader community, to really encourage that discussion to continue where it's okay and safe to say, I am struggling in these ways. And then make it really easy to be able to access help, right from everything from being able to you know, do a little self diagnostic to realize Wait a second, like I might be suicidal or like the amount of alcohol I'm drinking is not in the poor and teeny like, yeah, this is fun zone, but I actually like, you know, doing too much. And so and then making it really easy to get that care and you're talking about, you know, can we make, even if we clone psychiatrists and like, you know, 10 x the number of my colleagues and I weren't, that's still not really going to solve the problem because we do need to think about the scalable things that can be done to address this things like even peer to peer interventions. And exactly as you said, How do we teach people how to fish right? where a lot of the things like CBT and gratitude and mindfulness and, and self care, and even things like you know, exercise and nutrition, like getting outside in nature, these are the basic things that actually help everyone across the board, teaching these in a really easy digestible format, that's actually going to make a much bigger difference.
BF: So um, so a couple of things I want to talk about some antidepressants, because that's been somewhat of a go-to, but now living in an age of a lot of new behavioral technologies that could be changing and that these new medical devices and behavioral software could be the new antidepressants. So that's one but the quit but something that even mentioned that we've talked about quite a bit but you being in the industry, of studying The Human Condition for a long time and probably seeing this change in the way people are addressing their own struggles and their own anxiety. So it sounds like you have been treating people who for a long time would never be able to say that they could never say I'm struggling, I'm depressed. And I also am seeing more people able to come out and admit these things that they're struggling with. Why do you think and why do you think as a society, we have created this, this sort of negativity around understanding yourself as a person who does struggle and a person who does get anxious, and what did we do wrong?
NV: Oh, that is that that is a probably billion-dollar question that you know if I don't yet have the answer to but, um, but I think that's, you know, that's exactly what we need to figure out. Like, what Why Why are we here? What happened to get us here? And then more importantly, you know, what, what do we do to change that? I think that it's interesting that I was having a conversation with a colleague just yesterday around what has been so different around this time is that we're what we're recognizing as clinicians learn how to take care of other people. We never learned how to take care of ourselves and it's also never okay to say that we ourselves are struggling, right it's okay to be treating patients who have anxiety or depression but for you yourself as the doctor to have anxiety or depression is not okay. And I think that in some ways that's actually just a reflection of what I mean. Maybe in medicine, it's more, you know, concentrated but I think broadly in society it's still not okay to say I'm struggling, I have anxiety, I have depression or anything. Moreover, then there's an even bigger stigma around medication of I'm you know, I'm at the level of needing to take medication but that stigma is awful. And really hold back progress. I think. Why did we get there? Part of it is I think there is still this sense of wanting to present ourselves in a particular way. And in a way that it seems there's something about the brain where it's like, it's okay to say, I have diabetes and my, you know, my, my different organs are not producing what they should, right. But there's something about the brain where it's harder to say, my brain isn't producing what it should. And I would I actually think comes down to you know, we were talking earlier about biological, psychological and environmental aspects. I think that because personality and who you are, as an individual is so tied to your brain and how you're thinking, but it's really difficult to separate who I am, conceptually as a person and the self from these biological, hormonal, electrical, you know, elements that actually make up the brain. And if we think about something like cancer, you can separate I have breast cancer or I have Prostate cancer from who I am as a person, right? Like cancer is something that happened to you or an or it's in an organ versus when it comes to mental health pathology, there's this sense of I am wrong or I don't feel good. And so that relationship with the self is very, very different where other things you can hide like there's this organ versus I think with mental health, it's like, that's me. And that I think is where this sense of identity and everything comes into play where then it's like, if you say, I'm sick, there's something wrong with me as a person, and not just that I have this disease.
BF: Right, right. I guess we all have to take sort of ontological classes about understanding who we are as human beings and and spend more time with that but maybe this time it we who are spending time. And that could be somewhat of an answer if people start thinking about their own human nature and that's a good thing. Actually not trying to be so successful thinking about the material world but actually thinking about who they are. And maybe that could be an answer backing, talking about the antidepressants because you're you incubated 16 startups at the Innovation Lab, I've worked with dozens and dozens of startups, many in the digital health field that are creating digital therapeutics, a number of now we have access through via telehealth or via games or online apps that can deliver some of these programs in a timely fashion were and they're replacing antidepressants and most a lot of the startups that I'm speaking with today in these days are trying to do that and get FDA approval, what type of any, any come to mind in terms of these new innovations and what is the appetite over there at your within your organization. For these new innovations that don't have FDA approval yet but could very well address say some of you know, unintended consequences of antidepressants, whether it's you know, the addiction or some other things. So what's your feeling about these new innovations and what's the appetite there for adopting them?
NV: I'm likely a little biased given that but you know, my lab is for innovation entrepreneurship and technology but I love all for it all for it to do hundred percent. I love them but to take a step back why I love them is one you know, I do want to really say especially knowing that you know, people will be hearing this medication works. Medication is like life changing for some people. Some people certainly also take medication and it doesn't work or they take medication and side effects but mental health medications are actually no different from medications for, you know, allergies or or high blood pressure like that. All these things help enormously. And when we think as I said before, when we think about what makes up mental health and the presentation of depression or anxiety, it's biological, psychological and environmental. And so then when we think about treatment, medications, address the biological side of things. And then there are a multitude of treatments that can help address the psychological and environmental side. And so in an ideal setting, you're addressing all three of these and what's hard about mental health, you know, we don't have blood tests, right? We don't have imaging, like cancer or diabetes or heart disease. And when we think about the combination of biological, psychological and environmental, we know that it's a combination of all three of those that leads to why you are you know, expressing the mental health elements that you are right now, we don't know the breakdown, right? So for me, it might be you know, 5%, biological 50% psychological 40 45% environmental for you, it might be 50% biological 20% psychologic 30% environmental we don't know yet and, you know, clinical interview and stuff, you can start to get it get a sense, right? Like environmental triggers, for example, like I just lost my job or my boyfriend just broke up with me right, those things are certainly environmental psychological. Um, but I say that because when we think about how to optimize treatment, we think about all those three areas we think about the biological, the psychological, and the environmental. So medication is tremendously important and wonderful for some people. And it needs to continue to be a part of the discussion because it can do enormously well. And then in addition, what many of these digital health tools are doing that you're talking about our tremendous improvements in the biological, psychological, and environmental side of things, right. So on the psychological front, teaching you cognitive behavioral therapy techniques that are very evidence-based and help everything from, you know, from depression through substance use, and you know, everything and even like psychosis. There's You know, there are elements of CBT For psychosis, so being able to teach that and make that really, really accessible, such that you can take it, learn it and do it yourself. And even more importantly, do it in the moment. Like, if we look at traditional therapy, it's just like once a week in the doctor's office for an hour type of thing. That's, that's fine. But when you really struggle is like when you're out of the doctor's office and in the middle of things. And so to be able to have an app that can help you in those moments, or give you those digestible little pieces of treatment to help you really to help make it a part of your lifestyle, and not just a quote treatment. I think that's a tremendous gift that these apps are able to offer. And then even as it's like, you know, the environmental side thinking about things like gratitude and mindfulness and, and even exercise and all these things, these lifestyle changes that are enormously beneficial for mental health. The apps do a phenomenal job of that and they're able to, you know, one of the phrases we always say is meet people where they are. That is one of the overarching philosophies of how we treat people meet, meet them where they are. And this is both figurative and literal. And I think the apps do that, right. Like, literally, you know, you have your phone with you, every moment of the day, I still sleep with my phone, which I know I'm not supposed to do, but it's my bed companion. And and so like, you know, never in history, never in the history of medicine or mankind have we had a tool like that that is always with us. 24 seven. So if anything, if something like that can deliver education or notifications or treatments, or you know, anything like that, or even be a communication platform, it's it's really unprecedented, as I said, in the way that we've ever delivered therapy or treatments before. So I think that there's enormous, the enormous potential there. And I'm just really excited about it. And you mentioned the FDA approval, I think that you know, for some entities, they've gone through that process that that's great. Not everyone needs to but what is really important is that even if you're not going through the FDA approval process, to do at least some studies to try to understand how effective your product Is and not make assumptions. For example, there are a lot of companies I think that quote are evidence based. Like they say, oh CBT is evidence-based and we're using CBT. Therefore, our product is evidence based. And that's not actually the case. So I think that making doing even small trials, right, it doesn't need to be a placebo control a gold standard, but even something to understand what's working, why and then make changes accordingly is going to be really important to ensure the quality moving forward.
BF: Okay, Nina, thank you so much. We're going to wrap it up there because that's been about 40 minutes, I think. 3040 minutes. No, it's wonderful, wonderful. And we're going to continue having these discussions. I have so much more to talk about, particularly around the innovation with these new innovative products, maybe some wearables, and some, some objective biomarkers for diagnostics and treatments. I would love to talk about it. There's a number of companies that I'm looking at that are really doing some innovative things in that space. So thank you so much for taking this time. Good luck out there. Being on the frontline yourself being mated with so many people who need your help to talk to them, hopefully not off the ledge, but to at least talk with them. And thank you for what you're doing with the community. Thank you and thank you. This podcast is awesome. As I've already failed, I just really look forward to continuing the discussion. Thank you. I've been speaking to Dr. Nina Besson, I'm Bambi Francisco Roizen.
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