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About Dr. Susan Martinelli
Dr Susan Martinelli is a Professor of Anesthesiology at the University of North Carolina at Chapel Hill with her clinical specialty in cardiothoracic anesthesiology. She is passionate about resident education and serves as the Associate Residency Program Director. She is also interested in physician wellbeing with research interests in the flipped classroom in residency education and finding ways to include family and friends into wellness programming. You can follow her on Twitter @DrSusieUNC
? Interviewer: Omar M. Khateeb, Director of Growth at Potrero Medical
? Interviewee: Dr. Susan Martinelli
Khateeb: Hi, everyone. I’m Omar M. Khateeb, the director of growth over at Potrero Medical and we are in Chicago for the Society of Cardiac Anesthesiology. I got a chance to catch up with. Dr. Susan Martinelli right after her panel discussion. Dr., thanks for joining us.
Martinelli: Thanks for having me.
Khateeb: Absolutely. As regards the panel that you were on and you had to talk before coming here, could you share the title of that talk?
Martinelli: I don’t remember the exact title, but it was essentially looking at burnouts in cardiac anesthesiologists specifically, but more general in physicians as a whole.
Khateeb: Interesting. I definitely want to ask you more about that but before I do, as a tradition on this show we’d like to know what got you into medicine. If you can go back to where you grew up in undergrad, walk us through that.
Martinelli: Okay, I grew up in Wisconsin. My father was a physician and I used to spend time with him doing rounds back in the days when there were a lot of in-patients.
He’s an ENT surgeon and I used to run with him at the hospital to see his patients in clinic and do things with him. I even got through one of the operating rooms with him. I was always a science-minded person and I took that and knew that that’s what I wanted to do essentially. I went to undergrad at the University of Wisconsin and medical school there as well with the thought that I was going to do ENT surgery. That’s what I knew best because of what my father did. At that time, we had a mandatory anesthesia rotation in our third year. When I did that rotation, it clicked that this was what my job would be; this is what I need to do.
I was very fortunate that we had that opportunity as students. So I went into anesthesia. I did my residency at the University of North Carolina and I did a Cardiac Anesthesia Fellowship at Duke. Then I went back to UNC on faculty and have been there for 11 years now?which makes me sound really old.
Khateeb: So you just couldn’t deal with being at Duke after being at UNC firsthand, right?
Martinelli: I loved my time at Duke. I have nothing bad to say I when I went over there. I’d already signed on for a job at UNC.
Khateeb: Okay, very nice. You said something clicked. Well, what was it specifically that clicked?
Martinelli: I don’t know, I just felt this instinctive, gut feeling that this was the right thing for me and this is where I wanted to be because when I looked at the ENT stuff, there were things that I wasn’t interested in in the profession. However, anesthesia just felt right. It just seemed like there was this internal sense that this the right thing for me. A
Khateeb: Interesting. Actually, we caught up with one of your co-panelists yesterday?Dr. Perry out of University Minnesota. He talked about this idea of physicians utilizing more of their intuition. I was listening to your panel earlier about physician burnout and someone had mentioned that there’s this martyrdom that comes along with it. About how hard you worked and everything, and it sounds like it’s very ego-driven versus what we intuitively want to do.
You’ve been working hard on physician burnout understanding, so what kind of things have you discovered?
Martinelli: Well, I don’t know that I’ve personally discovered them, but we know as a profession that burnout is a huge issue for physicians. And not only physicians, but throughout medical students training all the way up to practice. There have been reports that show among the physician population in the United States, at least burnout is almost at about 50%. So, this is something that I think is becoming more recognized as an issue, which is fantastic. There’s been more education on it. The next step with it is how to combat it and how to foster wellness for our physicians and medical students.
Khateeb: Where do you start especially in terms of fostering wellness. I know that as someone who directs your residency program, you have young residents who are working very hard to prove themselves and wear it almost as a badge of honor. However, this idea of wellness is important because you have to be able to take care of yourself first before you take care of others, right?
Martinelli: Yeah.
Khateeb: So where does the start in that education?
Martinelli: It should start way before we get them. It should start in the beginning of medical school. And I think now it is required to be incorporated into medical school training. It certainly is a requirement to have it be part of residency training. However, I think a huge start to it is education. We’re all evidence-based thinkers and we need to show evidence that this is a problem and there are real consequences with it.
So, it’s not just that you don’t feel well as a human and as a physician but there are real consequences that go along with it. There are higher rates of depression and anxiety. There are higher rates of suicidal ideation. There are poor patient outcomes.
We’ve shown over and over again that physicians who are burned out have more medical errors. It affects us. Substance abuse, suicide, and all these things are all wrapped up around burnout. So, if we can start that education process early and continue it on, if we can get buy-in from the stakeholders (our leadership) and then start to work on having this culture where we can talk about it and where we work to improve the overall wellness of our physicians, that’s the next step on how to make things better for our providers to recognize and accept that this is an issue.
Khateeb: Why this long? Why did it take until this year or at least the last couple of years for this to really become a topic of interest?
Martinelli: I think it has been for a while. There’s been work done on this. One of the big studies that surveyed for prevalence of burnout, work-life and balance issues had the first survey done in 2011. So this is not a new topic. I think there’s been more recognition of it. I don’t know if that’s because there’s more understanding that there are detrimental consequences as a result of it or maybe it’s because it’s now mandated by places. However, it’s not new.
I don’t think it’s even in the duration where it’s starting to be studied. I don’t suspect that that’s when it started. I suspect it’s been happening and hadn’t been recognized or defined prior to that.
Khateeb: Not just in medicine but in anything, when it comes to modifying behavior, it’s easy to always talk about it. But sometimes, forcing those behaviors to happen is where it becomes very tricky. As you know, with medical students and residents the idea of taking time for yourself and focusing on what else is talked about, a lot of people don’t do it.
So, how have you been able to find ways to modify the behavior and change the perception of this with your residents?
Martinelli: I think our residents have easily bought into this. I don’t think they’re the ones who need the shift in the mind frame. I think, if anybody, it’s the folks who have been around longer and don’t accept it as a problem. It’s those who think it’s always been the way it is, those folks who think you’re weak if you can’t just keep working. It’s those who say why would you need to leave the O.R.? If you had a death in the O.R., just put your head down and keep going back to work. The folks with that mindset are not our residents and our medical students. And so, I don’t think there’s much need of a push to tell them this is an issue and to try to work on it. I think they have bought in and are open to modifications.
Hopefully some of that is starting in medical school. So, when they come to us that’s already entrained in their thought process. It is hard to implement though, right? Residents are busy.
They have not only their clinical work, but also exams that they’re studying for. They have quality improvement projects and research projects are working on. Overall, they’re studying and learning about what it is that we’re doing. For them to find time to fit that in can be difficult.
When I meet with them, I try to let them know that I suggest that you come up with a list of priorities that’s outside of medicine and you rank them. You may not have room in your schedule to do all of those things all the time, but you need to figure out what your highest priority is. Whether that be spending time with your significant other, going to the gym, listening to music or playing music. Whatever it is in your life that keeps you human, you need to figure out how you’re going to fit that in.
You do recognize that you may not be able to do all five of those things, but you need to at least be doing the top one or two. This is my perspective.
Khateeb: You mentioned earlier that the residents are all open to this but sometimes, depending on the program you might have the wrong person at the head who doesn’t agree with this type of change in medicine.
Medicine is very conservative, it has a very strong history and culture and sometimes breaking or changing culture is very painful. What do you do about influencing your peers and colleagues who are the heads of residency programs but feel that this wellness stuff is kind of a joke? Who feel that we all got through it before and this is part of the training?
Martinelli: I think the biggest thing is education because again, we’re all scientists at heart. So, if we can show the evidence that there are so many consequences to this, including financial consequences, consequences to patient safety and also consequences to physician safety it’s going to be easier. If we can show the data that there are real effects of this, then I think it’s much easier for folks to take that in and say, “Okay, we have to do something about this”.
I have to say that I am super fortunate because at my program, our chairman is so supportive of this. He thinks it’s a really important issue. We’re very lucky that we have as much support as we could ask for in developing this program and helping our physicians.
Khateeb: Fantastic. In terms of the adoption of wellness programs and this type of education specifically for residents, do you feel that throughout the US it varies depending on the region? Or is it the same across the board?
Martinelli: I don’t know the answer to that. I haven’t talked to folks specifically or seen any surveys or data that shows if it’s site-specific. I would guess that maybe some of the traditionally more hardcore malignant programs maybe would have a harder time adopting some of this than others, but that would only be speculation.
Khateeb: You mentioned a lot of evidence and data. Can you walk us through some of that evidence? What was being seen in training programs that made people say, “We really have a problem here and we did we need to address this”?
Martinelli: It’s not specific to training programs. I think some of it is that there are certain validated scales that measure burnouts and a stock burnout inventory is one of them. There are scales that measure depression and you can simply ask about suicide ideation. So, by surveying residents and practicing physicians, you can get a scope of the issue from that. However, one of the hardest hits is that the folks who are more burned-out tend to have more medical errors and this has been shown over and over again.
A lot of these are self-reported. In my perspective, I’ve had a medical error versus something that can be audited. I’ve only seen one study that looked at pediatric residents that had audited medication errors and they were linked to residents who had a higher rate of depression. Other than that, it’s been shown in Internal Medicine residents multiple times over, anesthesiology residents as well as practicing surgeons, that those physicians who are burned out have more self-reported medication errors or medical errors.
There’s a study that was done on physicians overall and all specialties across the United States and those who were burned, had significant fatigue or had recent suicidal ideation had significantly more self-reported major medical errors.
Khateeb: What makes a resident depressed? I’m sure that’s a multivariate problem and there’s a lot of different answers; but in your opinion and your experience, what you usually tips off residents to be depressed and suicidal?
Martinelli: I don’t have the answer to that. I think depression is a medical disease process.
Some of it is biochemical?I think, and some I’m sure are situational. Unfortunately, our residents go through situational life events that are very difficult while they’re still in the midst of this very difficult time in their life for training as well. I think it’s very individually based and I’m not a psychiatrist, so I don’t know that I can really answer what would make a resident depressed.
I can tell you things that I think contribute to burn out in the physician population; not necessarily residents alone, but just overall.
Khateeb: Yes, please.
Martinelli: As physicians, and as anesthesiologist specifically, we see high acuity patients.
We see folks who are so sick. Some folks don’t do well and there’s this societal belief that when you go to the doctor and have surgery, you’re going to have a good outcome and that’s not always the case. This doesn’t mean that something was done wrong or there was a mistake made but not everybody has a good outcome and that’s really hard to manage.
People make mistakes because we’re all humans. So there are medication errors. There are mistakes and sometimes our mistakes harm people and that’s a really heavy burden to carry. We have little control over our schedule even more so, from a resident standpoint.
The idea of being respected and appreciated for what we do is not as prevalent in the field of anesthesiology as it is for?in my belief?surgery or medicine. This is because when you come to us as anesthesiologists, you don’t know who we are. You didn’t come because of me; you came because of the surgeon and I’m just kind of there. Generally speaking, people don’t know what we do in order to fully appreciate what we do.
Then there’s all the maintenance of certification for practicing physicians and for residents where they obtain a certification; and for medical students getting into the residency. So there are all these other things such as paperwork and bureaucratic things that go along with it, too.
Khateeb: You made a very good point that, for example, in the O.R. the surgeon’s usually the poster child for what’s happening. But I was speaking with Dr. Perry and he made a good point that anesthesiologists are one of the few physicians in the hospital who literally span across the hospital for all kinds of procedures. Also, Dr. Gordon Moorewood who’s actually very interested in the business model of healthcare, mentioned that anesthesiologists are probably the best people to really observe and start helping healthcare move away from fee-for-service to essentially producing the final product that people pay for. This is because they observe all the systems and processes in the hospital.
In your training as an anesthesiologist, you were in a variety of different procedures and departments. What was it about Cardiac Anesthesiology that got you to go into it? Is it a very interesting niche area?
Martinelli: The same thing is that probably, they do more burnout in the area. The ability that I could take care of the sickest of the sick patients was very appealing to me because as a trainee, those were some of the most intimidating patient encounters. When folks come and there are multiple pressors, intubators and all of these mechanical devices that support and keep them alive, and all of a sudden, they’re my responsibility.
To have extra training, knowledge, support and comfort in taking care of that patient population was very appealing to me. I think the surgeries and procedural skills that we participate in are what keep it going. There’s this great back and forth between a cardiac surgeon and a cardiac anesthesiologist because there has to be really good communication in order to be successful.
It’s certainly a high adrenaline environment and I guess I find that appealing most days.
Khateeb: Yeah. I can appreciate what you’re describing. I got to spend some time in some cardiac cases. I’ve been in a lot of surgeries before but being in a cardiac case is like something I’ve never seen. First, when I’m walking in, I have to keep my head down and make sure I don’t trip over anything and I also have to look up, so I don’t hit anything with my head. I very much likened it to a grand symphony because you have the perfusion team, the anesthesiologist, and the surgeons. It’s really quite a unique environment.
What are some keys to being successful in an environment like that for young anesthesiologists just getting started?
Martinelli: I think it’s huge to foster teamwork and relationships with the folks that you’re working with. That’s sometimes hard for a resident who rotates through four months to come into that environment when everybody else knows each other and knows how each other works. However, I think that’s one of the things that makes it successful; that you’re empowered to speak up when you have a concern and that you have this continual dialogue with the perfusionist, the surgeon, and with the nurses.
There’s this back and forth and this trust of your team members. I think that’s the biggest thing that helps us to be successful in that environment.
Khateeb: You mentioned being able to speak up. With this old culture of medicine being very hierarchical?for good reasons?and this idea of wellness coming into place, do you feel that residents will be empowered to be a little braver and speak up and not harbor the fear of shame when they do that?
Martinelli: I hope so. We work on that and I think we have a pretty good culture for that at our institution. In addition, I try to role model for the residents that what we do is important and that our voice is just as important as everybody else’s voice in the room and in order to keep our patient safe, you have to be participating in that.
I think our residents do a really good job with that but we’re also fortunate because we have really good camaraderie in our room and a very good open teamwork. We don’t have a surgeon who doesn’t listen to what our thoughts are. You know, the sort of old stereotypical surgeons who would be throwing something or yelling. We just don’t have that, and I think that’s important.
I hope that were my residents end up, they don’t have that environment. And if they do, I hope we give them the strength and the courage to use their voice and to speak up for the patients. I think they will.
Khateeb: Absolutely. As someone who’s really been pioneering this with the residents in your program, and of course role modeling it in the last few years that you’ve been doing this, have you learned anything about yourself? Have you learned anything that surprised you perhaps about the process, the program and residents?
Martinelli: I feel like I’ve changed and grown a lot over my time as an attending and as a resident and fellow as well. I have found my voice and I’ve been able to stand up for myself and for my patients. I’ve come down a little bit from them and I’ve also been able to step back and let other people say stuff that I don’t agree with or pick battles.
I don’t know if others don’t agree but I’ve become a little bit more patient with folks and I have a better ability to see other perspectives?I hope. I think it’s a never-ending learning process for all of us. I don’t know if that answered your question.
Khateeb: No, no. It absolutely did. You said that you learned a lot about yourself and your crew. Did anything surprise you? Or did anything enlighten you in a way where you said “Wow, I didn’t know that!”?
Martinelli: Well, I had certain mentors along the way. They gave me tips to be able to try to make decisions and to stand up be strong and hold my spot. However, it’s more or less been like this path that is easier to see looking back than when I was doing it.
Khateeb: It’s always easier to connect the dots looking back, right?
Martinelli: Yeah. Without any major huge defining moments, I do think that when I became a mom it allowed me to step back and put things into a better perspective. Whether that’s right or wrong I don’t know, but I think, for me, that gave me a better open-minded perspective on things in general.
Khateeb: I do want to get a little clinical with you. Having spent more time in this industry, in my company, one of the things we focus on is Acute Kidney Injury. It’s this sort of a black box of a disease that not a lot of people know about up until recently. I know that you authored a paper about acute renal failure, but can you share some things about being a cardiac anesthesiologist in terms of how you look at the function of the kidney and how it affects your job?
Martinelli: That paper was a long time ago. [Laughs]
Khateeb: I know. Don’t worry about that. I think it was back in 2009 or 2010. I don’t remember things I wrote a year ago.
Martinelli: Yeah, so I can’t tell you the specifics about that unfortunately, but Acute Kidney Injury is a huge deal for us because we talk about it with our patients when we put them on a pulmonary bypass. The bypass machine can affect folks’ kidneys and so we do things to try to protect the kidneys when they’re on bypass. We have a lot of folks who are in renal failure when they come to us, so we monitor urine output closely. We speak with the perfusionist and sometimes, we use ultrafiltration with the pump for our cases, but I certainly am no expert on AKI.
Khateeb: I don’t even remember learning about Acute Kidney Injury in medical school and when I saw the epidemiology behind and realized that hundreds of thousands of people die from it in every house, I said: “How come nobody really knew about this?”
The best answer that I’ve been getting from people is “If you can’t really do anything about it, why talk about it?”
Fortunately, I guess more data and technology is coming out to hopefully provide support in understanding that. For cardiac anesthesiology, what are some of the ways that try and monitor it? Because unfortunately, with the old ways where there was nothing that captured data automatically.
So how do you best monitor it and how does that inform your decisions?
Martinelli: I don’t know that we have a great monitor. We monitor our urine output in the operating room, and we take that into account with the general volume that we give to the patient if we are in a position where we can make those decisions.
We use it along with our laboratory data to try to figure out how much more volume that we need to give as part of the picture. But I don’t know if I’m going to be able to give you a whole lot beyond that.
Khateeb: No. No, that’s perfectly fine. At least you know for the medical students and residents that are listening, is it correct to look at urine output as an indicator or may be a tip-off of what’s happening upstream with cardiac output?
Martinelli: Maybe. In our cardiac O.R.s, it’s a lot more complex than that because when we’re on bypass, the perfusionists are a huge player on the amount of volume that we give. So, we do look at that and use that in conjunction with transesophageal echocardiography to try to figure out the volume status of a patient. However, it’s kind of this whole dance and game where it’s a piece to the puzzle. In the cardiac O.R.s, actual urine output may be less of the piece than in some of the other rooms.
It’s harder to use that as a great indicator of where we are as far as volume status is concerned. However, we look at the big picture. We talk with our perfusionists, we look at the heart in the field, we look at the volume status on the echo, we look at the cardiac output on our monitor; our pulse pressure variation and all those things come into play.
Khateeb: I asked a cardiac anesthesiology at a hospital that what are some of the things that usually keep a cardiac anesthesiologist up at night? I haven’t had that much interaction up until this meeting with them and he mentioned Acute Kidney Injury, bleeding and heart failure.
Is that correct? Would that be the same for you or does vary depending on the cases?
Martinelli: When you say up at night do you mean like literally up at night doing cases? Or do you mean what we worry about a patient?
Khateeb: Yeah, what are you worried about?
Martinelli: If I’m thinking about my cases for the next day, among what I’m worried about, bleeding is huge, coagulopathy is huge, cardiac function is huge. Ability to obtain access in folks is sometimes worrisome from my standpoint, especially folks who are have chronic kidney disease and hemodialysis. Those folks are notoriously more difficult to find lines for.
The significance of the case is also a factor. If it’s a redo case, that is always just more concerning to me?a redo chest, than a virgin chest. Honestly, for me kidney injury is not on the top of my worry list.
Khateeb: The things you mentioned are pretty bigger. [Laughs]
Martinelli: Yeah.
Khateeb: The SCA meeting has been really fantastic with great sessions. I’ve been really impressed with the depth and volume of it. I think a lot of physicians and not even just cardiac anesthesiologist should consider attending this meeting. Of the sessions you’ve been in, are there any topics or sessions that really stood that you enjoyed and learned a lot from?
Martinelli: Unfortunately, I came from another meeting. I just got in yesterday and the only thing that I really was able to attend was the best abstracts because one of my residents got chosen for that.
Khateeb: Oh great! Well, what was their abstract on?
Martinelli: Theirs was doing erector spinae blocks for post-op pain for sternotomies. They were able to show that folks who got the blocks?the SP blocks?had a decreased requirement for narcotics than their peers. So, I think it’s interesting. I think they’re going to keep working on it and it may make a big difference for folks going forward.
Khateeb: Absolutely. And definitely, the unfortunate thing is that here in the US, opioid narcotic cases are a big problem. Just within the last month or so, there have been a lot of allegations and trials going on with big pharma and the use of these opioid narcotics, when in reality you don’t need much. So, that’s been really interesting. About your panel today, how did how did that go?
Martinelli: I hope it went. Well, the feedback was good. My part of it was to give what the problem is and the state of where we’re at right now. So I went over some of the data and evidence of why this is an issue and started to get briefly into ways to try to promote wellness and to combat burnout. However, I didn’t have the opportunity to really talk about some of the stuff that we’re working on at UNC because that wasn’t the goal of the panel.
Khateeb: What are some things you guys are working on?
Martinelli: One of the biggest things that I’m hopeful will make a difference is that we’ve been doing this family day program. Back in April 2017, we did it for all clinicians in our entire department. We brought family members or support persons essentially. It could be a best friend, siblings, significant other, parents or whoever is a support person in your life. We actually, for that one, did a kids track and an adult track. We brought them in and did some different simulation experiences with them to give them a sense of what we did. I really enjoyed it as I was able to bring my kids and I think they got a lot out of it.
We got fantastic feedback from it and so we adjusted it a little bit for August of 2017, specifically for our new CA1 residents. It was adults only for that, but we encouraged them to bring their support persons and we taught both the residents and the support persons together about wellness, burnout and substance abuse. We also talked about what resources we have at UNC. Then we did the adult simulation track with them.
I think it’s going really well. I’m really excited about it. We’re about to embark on a multi-institutional study with the CA1 program to hopefully demonstrate that we really are making a difference as far as decreasing burnout and improving wellness of communication for our residents goes.
Khateeb: That’s fantastic. All residents are adults but a lot of times changing behavior is hard. So, the idea of bringing a spouse or support person to educate them on how to look for the signs is incredibly helpful. Are you the first program to do something like this? I haven’t heard of this before.
Martinelli: We’re the first folks who have published on it. The only thing we saw in the medical literature at all was something early in medical school that was an attempt at something like this, but nothing has been published. So, you know, I don’t know. I know we have published a couple things and I’ve heard other people saying that they’re doing it based on some of the stuff that we’ve done which is great.
The goals are both to teach about wellness and burnout signs as well things to be on the lookout for. However, it’s also to give this common ground on what it is that we do so that support persons have a better understanding, because anesthesia is not something that the lay people understand. I don’t think really at all.
So, if you can build this foundation and give the scaffolding of what it is that we do, then when you come home having had a really awesome accomplishment or a really bad day and you want to have that conversation with your support person, they have some basis of what you’re talking about.
Khateeb: Interesting.
Martinelli: It’s a goal, anyway.
Khateeb: Do you feel like part of the development of these wellness programs and curriculums is also finding ways to educate the people who are in the lives of these residents and physicians, such that if the resident or physician isn’t strong enough or interested enough to recognize these signs, the people around who care about could recognize them and help them get the help that they need?
Martinelli: I think that the support persons will frequently be the first ones that recognize issues because, especially for new residents who we maybe don’t know as well, it may be harder for us to pick up on some of the signs that might be more subtle. However, if there are changes at home or in those relationships, we’ve empowered those support people to reach out to us if they have concerns, hoping that the intervention can occur much earlier.
Khateeb: Thank you for spending some time with us. Before we let you go, we have just a couple of more questions. One is for the physicians and medical professionals who are listening to this program, if they’re interested to learn more about the wellness programs that UNC offers are there any resources, papers or sites you can point them to?
Martinelli: For what we’re doing we did publish something. I am happy to discuss with anybody if they want to reach out to me via email or whatever. We can have conversations.
Khateeb: I’ll leave your contact information in the show notes.
Martinelli: Other than that, I don’t know of a specific site, but I think there’s a lot of stuff going on and we need to share what we’re doing so that it’s easier to adapt their program into our institution. It would be great if there was an open forum. I think it’s important to study this work and publish this work so that we can use evidence-based methods just like we would with anything else.
Khateeb: Absolutely. Then comes my final question, and you gave me a nice segue into it. Talking about an open forum, I heard that you just got on Twitter.
Martinelli: I just got on Twitter yesterday.
Khateeb: That’s fantastic.
Martinelli: Thank you.
Khateeb: Does it feel like it’s a big deal?
Martinelli: Well, I don’t know how to use it yet.
Khateeb: Ah, you will don’t worry.
Martinelli: Okay.
Khateeb: The nephrologists are quite a group on Twitter. It’s really unbelievable. They have their own Twitter universe.
Martinelli: I probably will not be joining there.
Khateeb: [Laughs] Do you know your Twitter handle off the top of your head?
Martinelli: Yes.
Khateeb: Yes! What is it?
Martinelli: It’s @Dr.SusieUNC.
Khateeb: Perfect. I’ll make sure to leave that in the show notes. Doctor, thank you so much for spending some time with us. We really appreciate it.
Martinelli: Thank you. Thanks for having me.